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By Kirsti A. Dyer, MD, MS, FAAETS
Whatever it is that I have lost (or must give up) I must grieve. If I do not do my grieving about the old hurts and insults, then, when I am faced with a here and now grief experience, I will end up having to dredge up all that old energy along with the current experience. On a daily basis, medical students, residents, physicians and other healthcare providers care for patients who are experiencing a life challenge or have experienced various losses; yet we may be completely unaware that our patient has been significantly impacted by a loss and is grieving. These include the loss of body image, loss of body function, loss of mental function, loss of health through various illnesses or disease, loss of sexual function, loss of plans, hopes and dreams for the future and loss of independence. Physicians and healthcare providers may also inflict loss on patients with medications, treatments and surgical procedures. Many of the losses faced in medicine evoke a grief response. Therefore it is important that we learn to recognize the signs and symptoms of the normal grief response to distinguish grief from medical disorders and enable the proper diagnosis. Treating those suffering from loss, without being aware of the grief response can have detrimental affects on medical diagnoses, treatment plans and therapeutic responses. Understanding Loss & Grief Loss--the disappearance of something cherished by an individual i.e. person or property--is a byproduct of living. Most people have experienced some type of personal or professional loss at some point in their life. There are also many losses that occur during "routine" medical diagnoses or procedures resulting in a patient grieving in addition to his or her medical diagnosis. This is particularly true if the patient is adjusting to being diagnosed with a life-threatening or terminal illness, a chronic medical condition, the loss of a limb or a breast, the loss of a child, the loss of mobility, hearing, sight etc. Many times these losses are never publicly announced or acknowledged such as the case of a miscarriage or abortion, death of a relative by suicide or various types of physical or emotional abuse. Instead the person endures very private sorrows that can impact his/her health and well being. Grief is the normal reaction to a loss. During this process the grieving person may experience significant and subtle changes that can impact his/her physical, emotional, mental, behavioral and spiritual health thereby compromising overall well being. Experiencing a loss or a life challenging upsets the normal balance and reduces a person's energy. Therefore, grieving is the highly energy requiring process a person goes through while restoring the balance and energy in his or her life. Grieving losses is an important step for restoring balance, because, according to Elaine Childs-Gowell, if we don't grieve the old losses, when faced with a new loss, we will have to use our energy to face the past as well as the current loss. The Impact of Grief on a Person's Well Being Health is the optimal state of well being--being well physically, emotionally, spiritually and mentally. Wellness is considered to be the state in which the physical, emotional, mental, and spiritual dimensions are balanced so that energy is used effectively. Although grief and wellness seem unrelated, unrecognized acute loss or unresolved grief can mimic various medical conditions, lead to illness and a decline in wellness. A grieving person may experience a variety of somatic complaints: fatigue, insomnia, pain, gastro-intestinal symptoms, chest pressure, palpitations, stomach pains, backaches, panic attacks, increased anxiety or a generalized feeling of not being quite right. These symptoms may be due to a medical disorder or a grief response following a loss. Potentially serious medical complaints require a through evaluation to exclude serious medical disorders before a grief response or depression can be diagnosed. Loss and the resulting grief response can impact a person’s mental and behavioral wellness. Repressed, unrecognized or unresolved grief can cause personal anguish, increased anxiety, multiple physical complaints, functional impairment, strained relationships, marital discord, disrupted sleep, impaired childhood, increased substance abuse—tobacco, alcohol, drugs, tranquilizers; clinical depression, and an increased mortality from heart disease and suicide. The death of a spouse has been shown to negatively impact the health of the surviving bereaved spouse, including increasing the risk of death. Studies have shown that bereavement—grief following a death--can also lead to an increased mortality from ischemic heart disease, the development of high blood pressure, depression of the immune system, and increased depressive and anxiety disorders including post traumatic stress disorder. In order to enhance our patients' well being, we need to recognize the role that loss and grief may play in a current medical diagnoses or conditions. We also should determine the patient's past losses, life challenges or experiences, which can still impact the person's health and affecting his or her overall wellness. Distinguishing between Grief and Depression During a normal grief response, a person may experience symptoms of distress or depression. This overlap between grief and depression makes it challenging for practitioners to determine if a person is experiencing a grief response or true clinical depression. The accompanying table summarizes the key characteristics of grief and depression to help you distinguish between these two related but distinctive conditions.
Distinguishing Grief and Depression
Taking a Loss History Current or prior losses are not typically screened for when asking a patient’s medical history. Some of these losses include the loss of body image, loss of body parts, loss of bodily functions, loss of sexual function, loss of health, loss of freedom, loss of access to health care, loss of control, loss of independence, and loss of hopes and dreams for the future. These losses can result in an acute grief response that can mimic different medical conditions. A loss history may also reveal contributing factors for many patients with multiple medical complaints. By asking the right questions, a healthcare provider may uncover losses that are impacting the patient's health and well being. Additional questions can be asked to determine coping strategies use by the patient in the past and can be helpful in revealing how the person has handled prior losses and indicate how he/she might handle future loss(es).
A loss history can be included as a routine part of a history and physical questionnaire and updated at follow-up appointments. The patients major losses can be listed either chronologically or by importance. All major types of losses should be included current and distant:
When to Consider Medication Providers need to resist the temptation to prescribe a sedative to "fix" an acute grief response, frequently viewed as a "problem." Unfortunately, medications, including antidepressants, are often over-prescribed in managing grief as something to do. Instead healthcare providers can offer the grieving person is his/her presence (or the presence of another sympathetic listener)--the ability to sit with and be a witness to the grief response. They can also remind the person some of the basic coping strategies listed below. Prescribing medication should only be considered if the grief response is an extreme case of hyperarousal, progresses to complicated grief, depression or Post Traumatic Stress Disorder. If this is the case then medication may be appropriate along with additional formal counseling. The ongoing use of medications is generally not indicated in the treatment of grief; it should be the exception rather than the rule. Anxiolytic agents may be useful during the initial phase of shock and hyperarousal. However, prolonged use of benzodiazepines to treat the symptoms of grief can promote and intensify denial preventing the affective and cognitive processing of the loss, thus prolonging the grief response. Unless the person has true symptoms of clinical depression, antidepressants may not be helpful in managing grief. Coping with Life's Challenges Following a sudden loss, death or tragic event, it is important for the grieving person to remember to take care of him/herself. Focusing on the basis survival needs for the body is especially needed during time of stress and uncertainty:
Conclusion Failing to identify a grief response to loss may result in a poor response to therapy because the correct diagnosis (grief) was not make and underlying etiology for the patient's symptoms was never identified. If the grief response is not identified, the patient may not receive the support needed to help him or her cope with the life changing events. Taking a loss history may help the practitioner to identify and correctly diagnosing a grief response. This in turn can help the practitioner to educate the patient that their symptoms may be related to the life challenge, which then helps the patient to process the change, integrate the loss, begin living again and restore balance, energy and well being. Resource available on request. Kirsti A. Dyer, MD, MS, FAAETS, FACW, NCBF, CWS Internal Medicine Physician - on Hiatus for Childcare Adult Medicine, Life Change and Wellness Specialist Nationally Certified Bereavement Facilitator Certified Wellness Specialist Journey of Hearts, The Violet Heart. Dr. Dyer can be reached at griefdoc@journeyofhearts.org
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