Bereavement is normal but some people's grief can seem more traumatic than others, and can become difficult to resolve. The term 'pathological' bereavement is sometimes applied to people who are unable to work through their grief.
This type of bereavement may include prolonged grieving, severe reactive depression with or without suicidal ideation, excessive feelings of guilt and converting emotional conflicts into psychosomatic symptoms. Predictors include the type of relationship with the deceased person and personality traits or experiences of the bereaved.
Recognising the signs of abnormal grieving is important but remember not to get over-involved in the case
There are many factors that can lead to complications for pathological bereavement. For example, the timing may be sudden or there may have been prolonged expectation of death. The death may have involved violence, such as crime, suicide, or even loss of the body.
Other factors include exposure to media attention, multiple losses, previous bereavement or mental health problems, deaths of children, little support from family, prolonged investigations or problems affecting completion of the funeral.
Also be aware of the effect of family grieving on children who may need particular attention from experienced services.
Bereavement reactions differ in intensity and expression from person to person. This is influenced by personal and cultural experiences and cannot be easily judged as appropriate or inappropriate in simple terms.
Stages of bereavement
The typical sequence of a bereavement reaction is considered to be: initial shock (with numbness and disbelief); denial and searching; depression, apathy or despair; guilt, anger or blame and finally acceptance.
But this is not a linear process. People may move through it in a different order or several times. The phases can each take days, weeks or several months each. Becoming stuck in one stage without further progress may indicate a problem.
The patient might experience initial agitation, restlessness, disrupted autonomic nervous system functions and spells of searching for the lost person, which might be intense shortly after the bereavement.
It is not uncommon to see temporary anxiety, hypochondria (regarding their own health or the health of others), phobias and paranoia or obsessive compulsive behaviour.
Certain feelings may cause guilt if they seem socially unacceptable, for example a sense of relief or even freedom at the bereavement.
In an attempt to find a meaning or explanation for the death, a bereaved person may look for mistakes made on somebody's part - including themselves or other people, such as healthcare professionals.
There might be a phase of mild auditory or visual hallucinations or misinterpretations; for example the voice of the deceased or seeing their face in a crowd or on television. This can be frightening for the bereaved but reassurance and explanation will help.
Being proactive as a GP can be an important part of preventing abnormal bereavement and demonstrates your competence and openness to talk about these problems.
Warning signs for abnormal grieving include idealisation of the dead person, denial of the death, self-neglect, prolonged functional impairment, impulses for sudden radical changes (moving house or starting a new relationship), a sense of intense and stereotypical bereavement reactions, or the use of drugs or alcohol or displaying antisocial behaviour.
Managing the patient
The GP's job is to identify these signs early, to act on them and to ensure follow up at about six months after the death to check the situation again.
Occasionally obvious signs for psychiatric problems develop, such as psychotic features or post-traumatic stress disorder, which will need specialist input.
Be aware of the different time frames people will need to grieve. If a person has not completed the essential parts of the process, any withdrawal of attention or support provided may affect them quite badly.
Some people may seem to not want to stop grieving. This could be due to a perceived expectation of themselves or their social and cultural peer-group. It is a difficult task to redefine oneself and adjust to new roles and responsibilities. This can be only partially facilitated by the GP, who could suggest a bereavement counselling service.
Similarly, if the death has considerable implications on social and financial situation of the bereaved, this may need to be addressed by the relevant agencies in the community.
Ensure that significant bereavements are coded on the notes of the closest relatives and communicated with colleagues in the practice if this is necessary. Anniversaries or reminders of the trauma can destabilise the patient dramatically.
Medical treatment is not usually needed. The evidence for the temporary use of benzodiazepines is mixed and they may, if not used carefully, induce dependency.
It might be tempting to get over-involved in the case and forget to set reasonable professional limits. Being there for bereaved people in times of need is an important part of being a GP, but it must be balanced in terms of your own requirements and the attention you are giving other patients.
Dr Jacobi is a salaried GP in York
- This topic falls under section 2 of the GP curriculum 'The General Practice Consultation', www.RCGP-curriculum.org.uk
Learning points - Helping bereaved patients
1. Pathological bereavement may include prolonged grieving, severe reactive depression and excessive feelings of guilt.
2. Bereavement reactions may differ from person to person - beware of the differing time frames patients will need.
3. Denial, self-neglect or antisocial behaviour may be signs of abnormal grieving.
4. It may be necessary to refer the patient to specialist services or for local bereavement counselling.
5. Remember to set professional limits and not become over-involved in the case.
- CRUSE bereavement counselling: www.crusebereavementcare.org.uk
- National Association of Bereavement Services (020) 7709 9090
- Survivors of bereavement by suicide: www.uk-sobs.org.uk