Motivation and emotion/Book/2015/Grief and health

Overview
Grief is a painful emotion which can greatly impact our lives and functioning. It has the potential to affect the physical and psychological health of individuals, both positively and negatively (Tomita & Kitamura, 2002). This chapter will present an understanding of grief, the underlying processes of grief, and its potential impact on physical and psychological health.

What is grief?
Grief is a natural human reaction to loss (Archer, 1998). It is the anguish experienced upon separation from something which an individual had formed an emotional bond with (Hall, 2011). Although it is often the case, grief is not a reaction that is limited to death; it can also be a response to the loss or separation from any important person, relationship, or situation in life (Archer, 1998).

Grief is a universal emotion; however, the symptoms and intensity as well as the manner in which it manifests can vary greatly between individuals, religions, and cultures (Hall, 1998). It is a multifaceted phenomenon which can affect the physical, emotional, cognitive, behavioural, and spiritual states of those who experience it (Hall, 2011).

"Grief is not a disorder, a disease, or a sign of weakness. It is an emotional, physical, and spiritual necessity, the price you pay for love. The only cure for grief is to grieve. - Earl Grollman"

Why grief occurs


To understand why grief occurs and why it is a vital part of physical and psychological health, it is necessary to first understand the roots of the phenomenon in terms of attachment. Psychologist, John Bowlby, proposed that attachment occurs as an adaptive behaviour which comes about in infancy (Field, 2011).

When alarmed or endangered, the infant’s behavioural system invokes the need to seek out a caregiver in order to receive safety and security, and in turn, enhance an infant’s chances of survival (Field, 2011). As caregivers provide support and protection for infants, attachment to such figures results in an infant’s distress upon separation from them (Field, 2011). As such, Bowlby thought of grief as a natural facet of the behavioural system, which discourages lengthy separation from a caregiver in infancy and believed that the phenomenon continued into adulthood (Field, 2011). Bowlby proposed that the need for safety and security from primary caregivers, or those figures individuals are attached to, remains present throughout life (Field, 2011).

Types of grief
There are numerous types of grief which are dependent on the situation and circumstances in which the loss has occurred as well as the individual experiencing the emotion (Bonanno & Kaltman, 2001). The strength and type of emotional bond, the manner in which the person died, the presence of life stressors, and the availability of support can all effect the type of grief experienced (Archer, 1998). Individuals are not necessarily restricted to experiencing one particular type of grief and can move between different types (Bonanno & Kaltman, 2001).

Normal Grief: Normal grief symptoms follow a typical pattern and gradually decrease (Singg, 2009). As a result, acceptance and readjustment are able to occur (Singg, 2009). Typically, normal grief lasts for approximately 12 to 18 months but can relapse upon death anniversaries or other important dates (Singg, 2009). These relapses, however, are typically brief in normal grief (Singg, 2009). Anticipatory Grief: This type of grief occurs when the loss is foreseen, such as in cases of debilitating disease or terminal illness (Singg, 2009). Initial grief symptoms or phases occur prior to the death and are characterised by conflicting emotions such as dread of the impending death and hope for closure and an end to the pain or discomfort experienced by the dying as well as those close to the individual (Singg, 2009). The stages of grief experienced prior to the death to do not negate those experienced after the death; it is possible for the process to start again when the individual passes away (Singg, 2009). If prolonged, anticipatory grief can put great strain on physical and psychological health (Singg, 2009).

Disenfranchised Grief: Disenfranchised grief occurs when a loss is experienced but it is not acknowledged by society or considered significant (Singg, 2009). This experience of grief can result in complications which are not present in the normal grieving process (Singg, 2009). These complications can include intensified reactions and emotions as the griever may not be able to talk about or receive support for their loss (Singg, 2009).

Complicated Grief: This type of grief arises when an individual is significantly impaired by the loss beyond six months after the death (Singg, 2009). Complicated grief is characterised by intense and overwhelming symptoms (Jacobs, 1999). This continued impairment is considered a failure to meet the cultural expectations of grief as normal functioning is not able to occur due to the persistence and duration of grief (Jacobs, 1999). Complicated grief can also occur as a results of a disruption in the progression towards acceptance and resolution or no attempt at all (Singg, 2009).

Chronic Grief: When an individual experiences grief which is excessive in duration and fails to come to a satisfactory conclusion, they are said to be experiencing chronic grief (Worden, 1991). Those suffering from chronic grief are aware that they are not making progress and fail to complete tasks involved in the grief process (Worden, 1991). These individuals are not able to move on with life even several years after the loss (Worden, 1991).

Absent or Delayed Grief: This type of grief involves a delay of normal grief symptoms (Singg, 1999). While the individual may have experienced some form of reaction at the time of the loss, what was felt or expressed was not adequate (Worden, 1991). Individuals may behave as though the death did not occur or as though they can get through the loss without showing emotion (Singg, 2009). Delayed grief can be a result of overwhelming feelings at the time of the loss (Worden, 1991). As is often the case with delayed grief, a full grief reaction can occur at a later date when triggered by other types of losses or losses experienced by others (Worden, 1991).

Unanticipated Grief: This type of grief is associated with sudden or traumatic deaths and individuals are not able to experience normal grief reactions to due to the sudden nature of the loss (Singg, 2009). Instead, intense emotions such as bewilderment and depression can take over as those experiencing unanticipated grief think about things such as regrets or loose ends (Singg, 2009). Those suffering from unanticipated grief may feel an intense need to search for meaning (Singg, 2009). This pattern of grief is very uncertain and often leaves individuals feeling vulnerable and out of control (Singg, 2009).

Masked Grief: Masked grief typically involves symptoms and behaviours which seem unrelated to the loss (Worden, 1991). Individuals suffering from masked grief suppress feelings of grief and as such, grief manifests itself in either a masked physical symptom or a maladaptive behaviour (Worden, 1991).

Physical processes of grief


An Austrian physician named Hans Selye proposed a biological explanation of stress response in the human body called the General Adaptation Syndrome (GAS) (Selye, 1950). The GAS proposes that the biological pattern of reaction to stress (i.e, grief) is predictable and involves two systems, the nervous system and the endocrine system (Selye, 1950). The GAS allows the human body to adapt to external stressors and maintain or restore homeostasis (Sullivan, 2009).

In order to maintain homeostasis when under stress, the body uses the endocrine system to release hormones, also known as the fight-or-flight response, which allows the body to address stress in an immediate manner (Selye, 1950). An important observation made by Selye about the GAS is that the human body has biological limits in stress control in that it has a limited supply of energy (Selye, 1950).

The GAS is comprised of three stages (Sullivan, 2009).

Positive affects
Scientific evidence of positive affects of grief on physical health are yet to be explored.

Negative affects
When grief becomes maladaptive, there are numerous negative physical effects which manifest in a variety of ways throughout the human body (Buckley et al., 2012). From a neuroendocrine perspective, there have been several studies which have found that there are elevated levels of blood cortisol during the first few stages of grief (Buckley et al., 2012). As stated earlier, cortisol is a stress hormone which regulates the biological changes which occur in response to a stressor such as grief (Buckley et al., 2012). Hypercortisolemia, or a prolonged excess of cortisol in circulation, results in immune dysfunction which opens individuals up to a wide range of infections (Summers, 2009). Hypercortisolemia can also have a number of adverse biological effects, including muscle wasting and weakening, osteoporosis, cardiovascular disease, high blood pressure, and can lead to the eventual failure of the adrenal glands (Summers, 2009).

Grief can also negatively affect sleep and change sleep patterns (Buckley et al., 2012). Several studies have found significant changes in sleep patterns in grieving individual (Buckley et al., 2012). In a study of Japanese residents, grieving was associated with an increased risk of interrupted sleep and a higher incidence of using hypnotic medication (Doi, Minowa, Okawa, Uchiyama, 2000 as cited in Buckley et al., 2012). Similar studies have also found that grieving individuals reported significantly lower sleep quality and efficiency and worse sleep-reported measures associated with higher levels of depression (Buckley et al., 2012). If left unaddressed, sleep disturbance can become debilitating (Buckley et al., 2012).

There are numerous negative immunological changes associated with grief. At a basic level, long-term grief which remains unresolved has been shown to result in altered immune responses (Buckley et al., 2012). T-lymphocyte cells are the agents of cell-mediated immunity, and there is a reduced proliferation of these cells when grief is experienced (Buckley et al., 2012). Additionally, natural killer (NK) cells, which defend the body against tumours and virally-infected cells, have been found to have reduced activity during grieving (Buckley et al., 2012). Furthermore, a studies have found that high depression scores in grief are associated with an absolute loss of cells which kill cancer called cytotoxic cells (Irwin, Daniels, Bloom, Smith, & Weiner, 1987 as cited in Buckley et al., 2012 ), as well as lower levels of the antibody which identifies and neutralises pathogens called immunoglobin-M  (Buckley et al., 2012). Cells which kill invading bacteria called neutrophils, have increased mobilisation throughout the grieving process (Summers, 2009). Numerous studies have found that the neutrophil count in grieving participants was significantly higher compared to participants who were not grieving (Buckley, Morel-Kopp, & Ward as cited in Buckley et al., 2012). Prolonged presence of neutrophils can increase the risk of damage to healthy tissues due to the highly destructive capacity of the cells (Summers, 2009). Immunological threats are particularly prominent in individuals who have pre-existing illnesses (Arnette, 1996).

Grief has been found to have numerous negative effects on platelet activation and coagulation as well (Buckley et al., 2012). Von Willebrand factor (vWF) is molecule involved in homeostatic regulation (Buckley et al., 2012) Throughout the early weeks of grief, there are increased levels of Von Willebrand factor in the body which is a risk factor for a heart attack (Buckley et al., 2012). At this point in the grieving process, there is also increased platelet activation which also increases the risk of heart attack as activated platelets are involved in thrombosis and most acute coronary occlusions occur as a result of an unstable atherosclerotic plaque and superimposed thrombus function (Buckley et al., 2012).

From a hemodynamic point of view, grief can have many adverse effects. A Cardiovascular Health in Bereavement (CABER) study showed that heart rate was substantially higher in those grieving a recent death compared to the control group (Buckley et al., 2012). The CABER study also found that high levels of anxiety and cortisol were associated with higher heart rate (Buckley et al., 2012). High heart rate has been linked with greater risks for heart attacks, coronary artery plaque rupture, and mortality (Buckley et al., 2012).

Blood pressure has been found to be a significant feature of grief throughout the early months (Buckley et al., 2012). Prigerson, Bierhals, and Kasl’s 1997 study found that traumatic grief symptoms at six months after the death of a spouse predicted higher self-reported blood pressure in a survey of 150 widows (as cited in Buckley et al., 2012). Further negative effects of grief include, but are not limited to, digestions problems and changes in metabolism and respiration (Buckley et al., 2012).

Psychological processes of grief
"For in grief nothing "stays put". One keeps on emerging from a phase but it always recurs. Round and round. Everything repeats. Am I going in circles, or dare I hope I am on a spiral? But if I spiral, am I going up or down it? How often -- will it be for always? -- how often will the vast emptiness astonish me like a complete novelty and make me say 'I never realised my loss till this moment'. The same leg is cut off time after time. - C. S. Lewis, A Grief Observed"

The psychological experience of grief is not a linear process (Kubler-Ross, 1969). While there are recognisable stages of grieving, there are no specific patterns or timelines which are generic for all people and psychological states can vary greatly, occur more than once, or not at all throughout the grieving process (Hall, 2011). In 1969 Swiss psychiatrist Elizabeth Kubler-Ross published the most widely-recognised theory on the stages of grief in her book entitled On Death and Dying (Kubler-Ross, 1969). Kübler-Ross  proposed that there five stages involved in the grieving process; denial, anger, bargaining, depression, and acceptance (Kubler-Ross, 1969).

Denial: Denial is a temporary stage of shock utilised as a defense mechanism when an individual is faced with confronting news (Kubler-Ross, 1969). This reaction allows an individual time to pace the emotions of grief while the mind processes the situation (Kubler-Ross, 1969). Example: “No, it cannot be true. Surely you must mean somebody else!”

Anger:Anger is the next stage of the grieving process. During this stage an individual may feel anything from rage, to resentment, to envy and these strong emotions are often displaced or projected onto those within close proximity such a relatives, friends, and doctors (Kubler-Ross, 1969). Example: “It’s all the doctor’s fault; he didn’t try to save him at all!”

Bargaining:Bargaining is the next stage of Kubler-Ross’ stages of grieving. At this point following a loss, people bargain in attempt to bring the person back or change the situation (Kubler-Ross, 1969). This stage is often associated with guilt felt by the survivors and is accompanied by “What if…” and “If only…” thinking (Kubler-Ross, 1969).Example:“I promise to never get angry or yell at my husband again. Please just let him live!”.

Depression: In the depression stage of the grieving process, the reality and finality of the situation sinks in as the griever realises that no amount of denial, anger, or bargaining will change the situation (Hall, 2011). At this point, a sense of great loss and deep sadness is experienced (Kubler-Ross, 1969).Example:“The person I loved most in the world is gone, what is there left to live for?”

Acceptance: The final stage of Kubler-Ross’ model is acceptance. Having worked through the four previous stages, the griever accepts the situation and is able to make some sort of peace with the loss (Kubler-Ross, 1969). At this point, the griever is ready to accommodate themselves into a life without the person they lost (Kubler-Ross, 1969). Example:“Even though he was a big part of my life and I will always love him, my dad is gone and it’s going to be okay”.

Positive effects
Although grief is often associated with negative effects, it does have several positive psychological effects. A healthy grieving process allows individuals to adjust gradually to life without a person (Calhoun Tedeschi, Cann, & Hanks, 2010). It can also free up energy invested in negative emotions throughout the grieving process; until giving is complete, the energy cannot be successfully reinvested elsewhere (Calhoun et al., 2010).

Research has found that grieving can result in a positive change in self-perception due to the emotional growth a person goes through in the grieving process (Calhoun et al., 2010). Grief can also enable people to feel more experienced about life and to build confidence to deal with similar situations in the future (Calhoun et al., 2010). Psychologically, grief can have a positive effect by allowing the deepening of relationships with others, it can change peoples’ philosophy of life, and give a new appreciation for life (Calhoun et al., 2010).

Negative effects
There are numerous negative psychological effects associated with grief which can change depending on the stage of grief an individual is experiencing; the list below covers the main affects but it is not exhaustive. Grief can be influenced by many factors and is an individual experience and as such, so are the negative psychological effects (Beem et al., 1999).

Anger is not only a stage of the grieving process but it is also a negative psychological effect of grief which can be experienced intermittently (Beem et al., 1999). Anger and hostility are symptoms of separation distress (Beem et al., 1999). These emotions are used as an alternative way of resisting the loss that feels unacceptable to the mind (Beem et al., 1999). This anger can be physical or verbal manifestations or expressed through facial expressions (Beem et al., 1999).

Anxiety is the fear or unease about the unknown and it can take many forms as a negative psychological effect of grief (Beem et al., 1999). It can manifest as panic, restlessness, tension, nervousness, inability to sleep, nightmares, excitability, or a feeling of a lack of control (Beem et al., 1999). Anxiety is often associated with high arousal and the inability to focus (Burton, Westen, & Kowalski, 2009). These symptoms can often leave individuals psychologically exhausted (Burton et al., 2009).

Depression can often look like grief itself, however it is a more persistent manifestation of the grief symptoms (Beem et al., 1999). Depression as a psychological effect of grief is characterised by constant despair and emptiness with a loss of interest in aspects of life which once held great importance to the individual (Burton et al., 2009). People suffering from depression as a symptom of grief struggle to feel pleasure or joy and may experience low self-esteem and exaggerated guilt about the situation (Beem et al, 1999). Sigmund Freud distinguished depression from grief by noting that depressed individuals turn their energy into an attack on the self rather than integrating loved ones who are now gone (Fiorini, Bokanowski, & Lekowicz, 2009).

Guilt is a very powerful negative psychological effect of grief. The reasons for feeling guilty about a death can range from general thoughts of not doing enough, to specific acts, or lack thereof, which may have influenced the outcome of the situation (Beem et al., 1999). Unrelenting feelings of guilt can transform from psychological emotions to physical action, for example self-harm Beem et al., 1999). Self-harm can bring about physical pain in an attempt to mask the psychological pain of the death (Burton et al., 2009).

Summary
Grief is a natural human reaction to the loss or separation from something which an individual had formed an emotional bond with. While it can have some positive effects on physical and psychological health, evidence thus far suggests grief is a highly taxing emotion, which tends to have many detrimental effects on health.

Physically, the body goes through the General Adaptive Syndrome process upon feeling grief which helps the body to adapt to the stressor and maintain homeostasis. While there are some positive physical affects of grief, the negative affects are far more abundant. Grief can have a negative impact on neuroendocrine function, the immune system, sleep patterns, platelets and coagulation, the heart, and blood pressure.

Psychologically, there is no typical timeline for grief, however there are five stages which are generally worked through during the grieving process; these stages are denial, anger, bargaining, depression, and acceptance. Grief can have some positive effects on psychological health including a positive change in self-perception, improved life confidence, and a new appreciation for life. However, if it becomes maladaptive there are serious negative psychological affects including prolonged anxiety, anger, depression, and guilt.

It is important to understand the anatomy of grief as well as the underlying impacts on physical and psychological health so that we are able to understand the process and support ourselves/others who go through it.