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Grief and bereavement: what psychiatrists need to know
Open accessAbstract
THIS REVIEW COVERS FOUR AREAS OF CLINICAL IMPORTANCE TO PRACTICING PSYCHIATRISTS: a) symptoms and course of uncomplicated (normal) grief; b) differential diagnosis, clinical characteristics and treatment of complicated grief; c) differential diagnosis, clinical characteristics and treatment of grief-related major depression; and d) psychiatrists' reactions to patient suicides. Psychiatrists often are ill prepared to identify complicated grief and grief-related major depression, and may not always be trained to identify or provide the most appropriate course of treatment. Both conditions overlap with symptoms found in ordinary, uncomplicated grief, and often are written off as "normal" with the faulty assumption that time, strength of character and the natural support system will heal. While uncomplicated grief may be extremely painful, disruptive and consuming, it is usually tolerable and self-limited and does not require formal treatment. However, both complicated grief and grief-related major depression can be persistent and gravely disabling, can dramatically interfere with function and quality of life, and may even be life threatening in the absence of treatment; and both usually respond to targeted psychiatric interventions. In addition, patient suicide has been reported as one of the most frequent and stressful crises experienced by health providers, and psychiatrists are not immune to complicated grief or grief-related depression when they, themselves, become survivors. Thus, it is essential for psychiatrists to recognize their own vulnerabilities to the personal assaults that often accompany such losses, not only for their own mental health and well-being, but also to provide the most sensitive and enlightened care to their patients.
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“Furthermore, in comparison with existing treatments for MDD and PTSD, PGD appears uniquely responsive to grief-specific treatments (Shear et al., 2005;Zisook and Shear, 2009).”
From The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis (2020) · cites this paper as Zisook and Shear, 2009
Experimental — accuracy not yet measuredIn the citing paper
“Hallucinations and visions of the deceased person are often experienced in both Western and Eastern populations (Zisook and Shear, 2009; Shimizu et al., 2017)”
From The assessment of grief in refugees and post-conflict survivors: a narrative review of etic and emic research (2018) · cites this paper as Zisook and Shear, 2009
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“Around the same time as the refinement of the PGD-2009 criteria, Shear and colleagues built on the earlier conceptualization of disordered grief as CG and proposed important mechanisms for the behavioural and biological aetiology (Shear et al., 2007; Zisook & Shear, 2009).”
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“…grief reactions and process are highly variable and the intensity and duration of grief is influenced by many factors (Parkes, 1965; Rando, 1984; Zisook & Shear, 2009); however, the findings of this study suggest that migratory grief experience may be an especially important factor that social…”
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“Nevertheless, nowadays we still cannot predict whether or not a subject may develop CG, MDD or PTSD in the wake of a loss (Bonanno and Kaltman, 2001; Zisook and Shear, 2009).”
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“One of the major developments in the argument for eliminating the exclusion, offered by Zisook and Shear (2009) and later by Pies and Zisook (2010a, 2010c), was the claim that intense grief and major depressive disorder are distinct and distinguishable conditions.”
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“Healthy and adaptive people typically find the uncontrollable emotionality of acute grief disconcerting or even shameful or frightening (Zisook & Shear, 2009).”
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“Generally, bereaved individuals have to pass through a long-term grieving process until they accept an adjustment to a life without their loved ones, which may take up to 4 years in Taiwanese individuals (Tseng, Petrie, & LeonGonzalez, 2017; Zisook & Shear, 2009).”
BackgroundMedical students’ experience of personal loss: incidence and implications
Whyte, R., Quince, T. A., BENSON, J. A., Wood, D., & Barclay, S. I. G. (2013) · BMC Medical Education · doi:10.1186/1472-6920-13-36 · Cited by 39
“Bereavement is a stressful life event with short and longterm effects on physical and mental health [1-6].”
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Mauro, C., Shear, M. K., Reynolds, C. F., Simon, N. M., Zisook, S., Skritskaya, N. A., Wang, Y., Lebowitz, B. D., Duan, N., First, M. B., et al. (2016) · Psychological Medicine · doi:10.1017/s0033291716002749 · Cited by 37
“Grief is not a mental disorder and most people adapt to loss and regain the capacity to function effectively in the world (Zisook & Shear, 2009).”
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“Failure to assimilate and integrate the losses from the patient’s death into a new life without the deceased may result in complicated grief (i.e., prolonged and unresolved grief) (Zisook & Shear, 2009).”
Online Memorialization and Grief After Suicide
Krysinska, K. E., & Andriessen, K. (2015) · OMEGA - Journal of Death and Dying · doi:10.1177/0030222814568276 · Cited by 36
“The expressions of love, sadness, and missing the deceased, as well as the yearning to be reunited with the deceased and gratitude for knowing him or her, seem to reflect grief reactions shared by the bereaved regardless of the type of loss (Shuchter & Zisook, 1993; Zisook & Shear, 2009).”
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“Integration of the loss tends to be very difficult for these people and they may experience ongoing emotional suffering [4] which interrupts social, occupational, and physical functioning [5, 6].”
BackgroundSanderson, E. A. M., Humphreys, S. K., Walker, F., Harris, D., Carduff, E., McPeake, J. M., Boyd, K. J., Pattison, N. A., & Lone, N. (2022) · PLoS ONE · doi:10.1371/journal.pone.0264971 · Cited by 36
“Most individuals adapt to their loss and can integrate back into their life, often within a few months after the death [1].”
BackgroundHopf, D., Eckstein, M., Aguilar‐Raab, C., Warth, M., & Ditzen, B. (2020) · Journal of Neuroendocrinology · doi:10.1111/jne.12887 · Cited by 44
“N/n per group (% female) Age (mean/ range or SD) Cortisol diurnal pattern Ong et al (2012)90 Cross-sectional: in average 17.5 months post-loss Bereaved (1) vs non-bereaved (2) Spouse N = 44 n (1) = 22 (86) 65.8 (48-80) None Salivary cortisol Assessment times: three to 6 months after questionnaire assessment on four su…”
BackgroundInfluentialIn one’s own time: Contesting the temporality and linearity of bereavement
Kenny, K., Broom, A. F., Kirby, E. R., & Ridge, D. (2017) · Health An Interdisciplinary Journal for the Social Study of Health Illness and Medicine · doi:10.1177/1363459317724854 · Cited by 34
Danışman, I. G., Yalçınay-İnan, M., & Yiğit, İ. (2017) · Journal of Psychosocial Oncology · doi:10.1080/07347332.2017.1340389 · Cited by 32
“Although often regarded as a normal reaction triggered by the perceived losses experienced by an individual,(7) grief also has the potential to progress into a disabling condition.(9) According to Prigerson and Maciejewski,(10)”
BackgroundCOVID-19 Suicide Survivors—A Hidden Grieving Population
Pinto, S., Soares, J., Silva, A., Curral, R., & Coelho, R. C. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.626807 · Cited by 34
“Nowadays, grief is described as a two stage process, comprehending acute and integrated grief (72) (see for review).”
BackgroundWhat causes grief in dementia caregivers?
Warchoł-Biedermann, K., Mojs, E. H., Gregersen, R., Maibom, K., Millán-Calentí, J. C., & Maseda, A. (2014) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2014.05.013 · Cited by 32
“Some authors suggested intensified grief could be a prelude to complicated grief or depression in susceptible individuals (Frank, 2008; Givens et al., 2011; Marwit & Meuser, 2005; Peterson, 2006; Zisook & Shear, 2009).”
BackgroundDell’Osso, L., Carmassi, C., Corsi, M., Pergentini, I., Socci, C., Maremmani, A. G. I., & Perugi, G. (2011) · Annals of General Psychiatry · doi:10.1186/1744-859x-10-29 · Cited by 30
“Complicated grief (CG) is identified by symptoms of both separation and traumatic distress [4,5,9,10] which are distinctive from other Axis I mental disorders, primarily major depression (MD) [11-15].”
BackgroundInterconception Care for Couples After Perinatal Loss
Moore, T., Parrish, H., & Black, B. (2011) · The Journal of Perinatal & Neonatal Nursing · doi:10.1097/jpn.0b013e3182071a08 · Cited by 32
“that honor the deceased, or by keeping memories alive in other ways.(3) Because grief responses and experiences are highly”
BackgroundInfluentialBolton, J. M., Au, W., Walld, R., Chateau, D. G., Martens, P. J., Leslie, W. D., Enns, M. W., & Sareen, J. (2013) · American Journal of Epidemiology · doi:10.1093/aje/kwt247 · Cited by 31
Are psychiatrists an endangered species?
Maj, M. (2010) · World Psychiatry · doi:10.1002/j.2051-5545.2010.tb00253.x · Cited by 34
Skantharajah, N., Barrie, C., Baxter, S., Borja, M. C., Butters, A., Dudgeon, D., Haque, A., Mahmood, I., Mirhosseini, M., Mirza, R., et al. (2021) · Journal of Palliative Care · doi:10.1177/08258597211052269 · Cited by 25
“Although grief and bereavement are often used interchangeably, research suggests that the former be thought of as a process while the latter be considered a period of time during which grief is experienced.(4,5) Mourning is another term that is closely related to grief and bereavement, but can be uniquely defined as t…”
BackgroundDodd, A., Guerin, S., Delaney, S. M., & Dodd, P. (2017) · Patient Education and Counseling · doi:10.1016/j.pec.2017.03.010 · Cited by 28
Hospital-Based Interventions to Address Provider Grief: A Narrative Review
Yazdan, R., Corey, K., Messer, S. J., Kim, E. H., Roberts, K. E., Selwyn, P. A., & Weinberger, A. H. (2023) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2023.03.001 · Cited by 29
ElTohamy, A., Hyun, S., Macaranas, A. R., Chen, J. A., Stevens, C., & Liu, C. H. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.07.022 · Cited by 33
“Bereavement is a normal response to loss and should not be disabling nor should it cause significant dysfunction as would be seen in severe psychological distress (Zisook and Shear, 2009).”
Impact of Death by Suicide of Patients on Thai Psychiatrists
Thomyangkoon, P., & Leenaars, A. A. (2008) · Suicide and Life-Threatening Behavior · doi:10.1521/suli.2008.38.6.728 · Cited by 32
Grief Symptoms Promote Inflammation During Acute Stress Among Bereaved Spouses
Brown, R. L., LeRoy, A. S., Chen, M. A., Suchting, R., Jaremka, L. M., Liu, J., Heijnen, C. J., & Fagundes, C. P. (2022) · Psychological Science · doi:10.1177/09567976211059502 · Cited by 30
“…more aggressively to future acute stress (similar effects have been found in previous studies of depression; Fagundes et al., 2013; Pace et al., 2006), During bereavement, symptoms characteristic of either grief or depression (or both) are common (Bonanno et al., 2002; Zisook & Shear, 2009).”
ResultChambers, R. A., & Wallingford, S. C. (2017) · Psychodynamic Psychiatry · doi:10.1521/pdps.2017.45.4.451 · Cited by 29
“In terms of psychotherapies, this means incorporating approaches in the treatment of complicated/pathological grief (Rosner, Pfoh, & Kotoucova, 2011; Wetherell, 2012; Zisook & Shear, 2009) into individual and group psychotherapies for addiction.”
Rostila, M., Mäki, N., & Martikainen, P. (2018) · PLoS ONE · doi:10.1371/journal.pone.0195500 · Cited by 26
The Reproductive Story: Dealing with Miscarriage, Stillbirth, or Other Perinatal Demise
Jaffe, J. (2014) · Springer eBooks · doi:10.1007/978-3-319-05116-1_9 · Cited by 26
Durosini, I., Tarocchi, A., & Aschieri, F. (2017) · Clinical Case Studies · doi:10.1177/1534650117693942 · Cited by 26
“Comorbidity between PCBD and MDD prolongs the duration and increases the severity of depressive symptoms, decreases the level of functioning, and leads to an overall worse prognosis.”
BackgroundInfluentialThe impact of spousal bereavement on hospitalisations: Evidence from the Scottish Longitudinal Study
Tseng, F., Petrie, D., Wang, S., Macduff, C., & Stephen, A. I. (2017) · Health Economics · doi:10.1002/hec.3573 · Cited by 26
“About 10% of the bereaved are estimated to suffer from complicated grief (Zisook and Shear, 2009).”
BackgroundThe Impact of Patient Suicide on the Professional Practice of Swiss Psychiatrists and Psychologists
Gulfi, A., Dransart, D. A. C., Heeb, J., & Gutjahr, E. (2015) · Academic Psychiatry · doi:10.1007/s40596-014-0267-8 · Cited by 26
DSM‐5and Bereavement: The Loss of Normal Grief?
Fox, J., & Jones, K. D. (2013) · Journal of Counseling & Development · doi:10.1002/j.1556-6676.2013.00079.x · Cited by 27
Matthews, L. R., Quinlan, M. G., & Bohle, P. L. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00609 · Cited by 38
“PGD is more likely to develop when the death is relatively recent and due to violent causes (34), and it coexists with depression in up to 50–70 percent of people with PGD (35).”
BackgroundWorden’s task-based approach for supporting people bereaved by COVID-19
Khosravi, M. (2021) · Current Psychology · doi:10.1007/s12144-020-01292-0 · Cited by 25
Demarchi, L., Pawluski, J. L., & Bosch, O. J. (2021) · Peptides · doi:10.1016/j.peptides.2021.170593 · Cited by 26
Johannsen, M., Schlander, C., Farver-Vestergaard, I., Lundorff, M., Wellnitz, K. B., Komischke-Konnerup, K. B., & O'Connor, M. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114683 · Cited by 23
“The majority of bereaved individuals go through a natural mourning process, coping adaptively with the loss over time (Jordan and Litz, 2014; Prigerson et al., 2009; Zisook and Shear, 2009).”
BackgroundAttentional Bias to Reminders of the Deceased as Compared With a Living Attachment in Grieving
Schneck, N., Tu, T., Michel, C. A., Bonanno, G. A., Sajda, P., & Mann, J. J. (2018) · Biological Psychiatry: Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2017.08.003 · Cited by 24
“85) (1,20), which consists of 19 Likert-type items measuring frequency of complicated grief symptoms on a scale of 0 (never) to 4 (always).”
What distinguishes prolonged grief disorder from depression?
Kristensen, P., Dyregrov, K., & Dyregrov, A. (2017) · Tidsskrift for Den norske legeforening · doi:10.4045/tidsskr.16.0629 · Cited by 23
Egerod, I., Kaldan, G., Coombs, M. A., & Mitchell, M. L. (2017) · Intensive and Critical Care Nursing · doi:10.1016/j.iccn.2017.10.003 · Cited by 23
“…grief is a normal, self-limiting reaction to bereavement, complicated grief is where intense, persistent grief lasts for more than six months after the loss, impairing normal psychological, social and daily functioning (Nielsen et al., 2017a; Shear et al., 2011; Zisook and Shear 2009).”
BackgroundCollaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults
Hua, L. L., Alderman, E. M., Chung, R. J., Grubb, L. K., Lee, J. B., Powers, M. E., Upadhya, K. K., & Wallace, S. B. (2021) · PEDIATRICS · doi:10.1542/peds.2021-051486 · Cited by 26
Kučukalić, S., & Kučukalić, A. (2017) · PubMed · Cited by 22
Lisai-Goldstein, Y., & Shaulov, A. (2024) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091241264523 · Cited by 23
“22 When treating dying patients, this motivation may lead to complex emotions, which can manifest in several ways.”
Associations between Predeath and Postdeath Grief in Family Caregivers in Palliative Home Care
Holm, M., Årestedt, K., & Alvariza, A. (2019) · Journal of Palliative Medicine · doi:10.1089/jpm.2019.0026 · Cited by 23
Anticipatory-Vicarious Grief: The Anatomy of a Moral Emotion
Varga, S., & Gallagher, S. (2020) · The Monist · doi:10.1093/monist/onz034 · Cited by 22
“…B to death; A’s grief describes A’s predominantly emotional response to B’s death; while A’s mourning refers more exclusively to A’s behavioral manifestations of grief, which typically include participation in certain communal rituals and customs (for a discussion, see Zisook and Shear [2009]).”
BackgroundKhosravi, M. (2020) · Open Access Macedonian Journal of Medical Sciences · doi:10.3889/oamjms.2020.5502 · Cited by 21
“Table 3: Symptoms of grief under four general categories [3], [25]”
BackgroundInfluentialPre-Loss Grief in Caregivers of Older Adults with Dementia with Lewy Bodies
Park, J., & Galvin, J. E. (2021) · Journal of Alzheimer s Disease · doi:10.3233/jad-210616 · Cited by 20
“Grief is an emotional reaction by caregivers to actual or perceived loss [7].”
Castaldo, A., Lusignani, M., Papini, M., Eleuteri, S., & Matarese, M. (2022) · Journal of Advanced Nursing · doi:10.1111/jan.15195 · Cited by 20
Missed Opportunity: Hospice Care and the Family
Tabler, J., Utz, R., Ellington, L., Reblin, M., Caserta, M. S., Clayton, M. F., & Lund, D. A. (2015) · Journal of Social Work in End-of-Life & Palliative Care · doi:10.1080/15524256.2015.1108896 · Cited by 20
“Finally, to avoid the time period immediately following the loss when grief symptoms are typically most intense (Zisook & Shear, 2009), we only contacted caregivers whose spouse or partner had died at least 3 months prior.”
BackgroundPost-Traumatic Growth and Coping-Strategies of Parents of Children with Disabilities
Sergienko, A. I., & Холмогорова, А. Б. (2019) · Counseling Psychology and Psychotherapy · doi:10.17759/cpp.2019270202 · Cited by 20
Loneliness-based impaired reward system pathway: Theoretical and clinical analysis and application
Wilkialis, L., Rodrigues, N. B., Majeed, A., Lee, Y. L., Lipsitz, O., Gill, H., Tamura, J. K., Nasri, F., Lui, L. M. W., Siegel, A. N., et al. (2021) · Psychiatry Research · doi:10.1016/j.psychres.2021.113800 · Cited by 24
Sekowski, M. M., & Prigerson, H. G. (2021) · British Journal of Clinical Psychology · doi:10.1111/bjc.12344 · Cited by 19
Are Hypnosis and Dissociation Related?New Evidence for a Connection
Cleveland, J. M., Korman, B. M., & Gold, S. N. (2015) · International Journal of Clinical and Experimental Hypnosis · doi:10.1080/00207144.2015.1002691 · Cited by 21
“…the relationship between anxiety and performance; Yerkes & Dodson, 1908) as does depression (in relation to normal bereavement; Clayton, 1974, 2011; Zisook & Shear, 2009), our finding of an association between dissociation and hypnosis suggests that it can have normal or beneficial forms of…”
Background
Metadata
- Authors
- ZISOOK, S., & SHEAR, K.
- Affiliations
- University of California San Diego (US)
- ORCID
- ZISOOK, SIDNEY
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2009-06
- Volume
- 8
- Issue
- 2
- Pages
- 67-74
- ISSN
- 1723-8617 (ISSN-L)
- 2051-5545
- PMC
- PMC2691160
- OpenAlex
- W1495198831
- Semantic Scholar
- 84d101b3e06ad49e4d800b6e58086f4f836be83f
- Cited by
- 451
- References
- 64
- Citations by year
- 2026: 34 · 2025: 48 · 2024: 38 · 2023: 29 · 2022: 40 · 2021: 40 · 2020: 35 · 2019: 25 · 2018: 19 · 2017: 32 · 2016: 17 · 2015: 19 · 2014: 13 · 2013: 15 · 2012: 21
- FWCI
- 16.24
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Social Sciences › Health › Religion, Spirituality, and Psychology
- Keywords
- complicated grief, normal grief, bereavement, suicide, differential diagnosis, grief therapy
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