Grief is usually associated with a catastrophic loss including divorce and losing a job. Grief is the natural response to loss of life, terminal illness or loss of physical function. This extends to the death of a loved one. Accidents, tragedies and disasters will induce grief, but it can also be triggered by shocking personal news such as an infertility diagnosis. Grief is closely associated with mourning.
Grief is not synonymous with sadness or depression although these are frequently symptoms of a person who is grieving. Elisabeth Kübler-Ross identified five stages of grief in On Death and Dying (1969): denial, anger, bargaining, depression and acceptance. Kübler-Ross' stages are not necessary sequential, comprehensive or exclusive. She suggests that people grieving could exhibit other responses and may go through their stages of grief in a different order.
The five stages were based on interviews with more than 500 patients with terminal illnesses. At the fourth stage, the dying patients began to understand the certainty of death and expressed their sadness by being silent, refusing visitors and spending much of the time crying. However, patients also exhibited denial, acting as though nothing was happening. Kübler-Ross suggested that since the denial could not continue indefinitely, patients would substitute sadness for anger and blame. They also sought means to postpone or delay death by bargaining, requesting more time or "another chance." Kübler-Ross considered that patients or their loved ones could stop feeling sadness and depression when they accepted what was happening.
If a person does not respond in the typical way to grief, such as by crying, he or she may feel guilt. However, American clinical psychologist George Bonanno argued that genuine laughter and smiling is a more effective response for coping with the loss than crying or talking about what happened. His research among people who faced major losses indicated persuading people to talk about a loss or to cry undermined their natural resilience.
In 2010, a proposed draft of the Diagnostic and Statistical Manual of Mental Disorders (DSM) V suggested that grief should be included as a major depressive disorder. A common physiological response to a traumatic event is post-traumatic stress disorder (PTSD), which is currently recognized in the DSM IV. The significance of DSM recognition is that unlike lesser expressions of grief, PTSD can be used in medical diagnostics, and prescription treatment and medications can be given. The DSM criteria for PTSD include:
• Exposure to a traumatic event involving (a) loss of physical, sexual or psychological integrity or risk of serious injury or death, to self or others and (b) a response to the event that involved intense fear, horror or helplessness
• Flashbacks, recurring distressing dreams or an intense negative psychological or physiological response to reminders of the trauma
• Persistent avoidance and emotional numbing
• Symptoms of increased arousal not present before, such as difficulty sleeping, anger, lack of concentration or hypervigilance
• Significant impairment of major domains of life activity, such as social relations or occupational activities for more than a month
Similar symptoms occurring for less than 30 days may be diagnosed as acute stress disorder. Studies involving patients with lower levels of grief have identified a change in the activity of the frontal lobe and increased visits to the doctor with symptoms such as abdominal pain and breathing difficulties.
Freud proposed that grief is a process in which loss is resolved through hypercathexis (excessive concentration of desire upon a particular object) followed by gradual decathexis (reduced investment of mental or emotional energy in a person, object or idea) related to internalized bonds of attachment.
While people suffering from grief normally experience short-term anxiety, symptoms of depression or PTSD, some experience acute or chronic depression and may become suicidal. This may last several years or longer, particularly where the grief is unresolved, such as when a soldier is missing in action or where the cause of death of a loved one is never conclusively established.
While acute or chronic responses to grief, such as PTSD, may require medication and therapeutic intervention by a psychiatrist, grief is usually addressed by counseling and, if necessary, psychotherapy. Counseling is typically provided by nurses or a doctor in a medical context. Hospices usually have trained staff to counsel terminally ill residents and their families. Religious and nonreligious officiants providing bereavement services may be trained in bereavement counseling. Responses to public crises such as airplane crashes and terrorist attacks increasingly include counseling for victims, relatives and bystanders. Group counseling is particularly effective since those with common experiences are more likely to empathize with each other, and those who have coped with grief may inspire others who are struggling to do so.