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1/Pathological Grief: Diagnosis and Explanation VeM#i** ^

MARDI J. HOROWITZ, MD, GEORGE A. BONANNO, PHD, AND ARE HOLEN, MD

Pathological grief deserves a place in the diagnostic nomenclature. Because posttraumatic stress disorderrequires an event beyond the range of usual experience and bereavement is virtually a universal experience,a new diagnosis of signs and symptoms precipitated by a loss event is needed. Many varieties of pathologicalgrief have been noted in clinical research studies, and multiple diagnoses of pathological grief would makeresearch difficult. The authors advance a solution in a personality-based explanation of abnormal responsesto loss events; this allows for a single diagnosis of pathological grief.

The authors also present a predictive model to partially explain pathological grief by antecedent traitcombinations. The hypothesis is that persons with a preloss combination of both contradictions in relationalschemas about the deceased and tendencies toward excessive control to stifle unwanted affect will tend tohave unsuccessful processes of mourning. Types of contradictions and overcontrol may vary, yieldingpersonality-based varieties of response within a single diagnostic category.Key words: bereavement, diagnosis, emotion, grief, schema.

The addition of posttraumatic stress disorder(PTSD) to the diagnostic nomenclature was an ad-vance in the study of stress response syndromes (1).Although the PTSD diagnosis facilitated research onthe consequences of unusual and catastrophic stres-sors such as war and disasters, there are still clinicaland research problems in trying to understand mal-adaptive responses to loss. One root cause is DSM-III's criterion that the stressor event be "outside therange of usual human experience." Bereavement ispart of the usual range of human experience. None-theless, it may be shockingly stressful for the personwho sustains the full impact of the loss. Responsesmay include intrusion and denial symptoms ofPTSD. To allow better recognition of psychopathol-ogy precipitated by loss, we suggest the establish-ment of a pathological grief disorder diagnosis ormodification of the PTSD stressor criteria to includebereavement as a stressor that can incite a disorderin predisposed persons.

In discussions on how to form DSM-IV, severaltheorists, such as Beverly Raphael and her col-leagues, have suggested diagnoses of multiple cate-gories of pathological grief (2). Multiple categorieswould complicate nosology and make research morecomplex. In this paper, we take the position that by

From the Langley Porter Psychiatric Institute, University ofCalifornia, San Francisco.

Address reprint requests to: Mardi J. Horowitz, M.D., UCSF,Langley Porter Psychiatric Institute, Center for the Study ofNeuroses, 401 Parnassus Avenue, Box 37-B, San Francisco, CA94143.

Received for publication August 5, 1992; revision receivedNovember 17, 1992

considering certain personality-based explanationsof symptom formation, a single set of criteria can bedeveloped, and a single diagnostic categoryachieved. Specifically, we address personality interms of enduring but contradictory internalizedviews or schemas of self as related to other, as wellas habitual styles of defensive overcontrol that pre-vent resolution of such contradictions.

BACKGROUND

PTSD became a part of the descriptive categoriesof DSM-III in 1980 and was grouped as an AnxietyDisorder. The reason for such a grouping was tomaintain coherence of prominent symptoms. Peoplewith PTSD often report symptoms of intrusive andanxiety-provoking ideas, worry over loss of control,new phobias plus fear of repetition of the traumaticevent, chronic tension, and hypervigilance (3, 4).The symptoms of intrusion may co-occur with theirseeming opposites: symptoms of denial, disavowal,avoidance, blunting, and numbing. These extremedeflections to "too much" and "too little" consciousexperience themselves may occur simultaneouslyor may show a sequence of phases (Figure 1). Thephases can also be defined by specifying the eventcriterion as a bereavement, leading to a differentia-tion of normal and pathological grief that is pre-sented in Table 1.

Some people do not have intrusions and periodsof numbness during their response to serious lifestressors, and many people who do have these ex-periences have them at the same time rather thanin phasic sequences. In addition, people who com-plain of grief and seek professional help often do so

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Psychosomatic Medicine 55:260-273 (1993)

PATHOLOGICAL GRIEF

Intense and prolongedexperiences may becomesymptomatic as follows:

WORKINGTHROUGH

Facing the reality of

Fig. 1. Phases of response after stressor life events. From Horowitz M): Stress Response Syndromes, 2nd Edition. North vale, N], JasonAronson, 1986.

not only because of intense symptoms but also be-cause they recognize an undue prolongation andlack of progression in their personal responses to thestressor event. A model of normal to pathologicalstress responses that includes such observations ispresented in Table 2. It shows (a) resilient responsesduring stress without postevent perturbations, (b) anormal period of stress-event-induced perturbationthat does not warrant diagnostic labeling, and (c) apathological stress response with impaired func-tional capacity and prolonged experience of disturb-ances.

A pathological stress response can take severalforms. There are psychological perturbations, as inpersons who have continuing distortions in thoughtand mood. There can be deflections from ordinaryconscious experience into states in which there areeither intrusive ideas and feelings or omissions ofexpectable ideas and feelings. There are also pro-longed states in which inhibitions so reduce mentalexpressions that the processing of stressful events isnot completed. Nonconscious processing (or ephem-eral moments of consciousness that are not contin-ued or remembered) may occur, leading to sharp

Psychosomatic Medicine 55:260-273 (1993) 261

M. J. HOROWITZ et al.

TABLE 1. Normal and Pathological Grief*

Phases of Reaction Normal Response Pathological Intensification

Outcry

Denial

Intrusion

Working through

Completion

Outcry of emotions withnews of the death andturning for help to othersor isolating self with self-succoring.

Avoidance of reminders, so-cial withdrawal, focusingelsewhere, emotionalnumbing, not thinking ofimplications to self of cer-tain themes.

Intrusive experiences in-cluding recollections ofnegative relationship ex-periences with the de-ceased, bad dreams, re-duced concentration,compulsive enactments.

Recollection of the de-ceased and contempla-tions of self with reducedintrusiveness of memoriesand fantasies, increasedrational acceptance, re-duced numbness andavoidance, more "dosing"of recollections and asense of working itthrough.

Reduction in emotionalswings with a sense of selfcoherence and readinessfor new relationships.Able to experience posi-tive states of mind.

Panic; dissociative reactions;reactive psychoses.

Maladaptive avoidances ofconfronting the implica-tions of the death. Drugor alcohol abuse, counter-phobic frenzy, promiscu-ity, fugue states, phobicavoidance, feeling deador unreal.

Flooding with negative im-ages and emotions, un-controlled ideation, self-impairing compulsivereenactments, night ter-rors, recurrent night-mares, distraught from in-trusion of anger, anxiety,despair, shame or guiltthemes, physiological ex-haustion from hypera-rousal.

Sense that one cannot inte-grate the death with asense of self and contin-ued life. Persistentwarded off themes maymanifest as anxious, de-pressed, enraged, shame-filled or guilty moods, andP5ychophysiological syn-dromes.

Failure to complete mourn-ing may be associatedwith inability to work,create, to feel emotion orpositive states of mind. Inextreme cases, persistingdelusions or bizarre ideasmay occur.

* From Horowitz M), Stinson CH, Fridhandler B, et al: Pathological grief: An intensive case study. Psychiatry, in press.

and unexpected pangs of emotion. These pangs ofemotion have physical sensory components result-ing from increased levels of autonomic nervous sys-tem activation, neurotransmitters, and stress hor-mones. Chronic high levels of stress hormones mayproduce physiological and immune system changesand even lead to enduring structural change in vul-nerable organ systems. For that reason unresolvedgrief may be reflected in bodily perturbations froma variety of psychophysiological and psychosomaticsymptomatologies, perhaps exacerbating preexistingconditions. The enduring effects of unresolved grief

reactions can also include social perturbations.Some persons may be stigmatized by loss, othersmay destroy available social support systems andnot resume social responsibilities.

How a person reacts to a stressor will depend onthe nature of the event, its place in relation tocascades of other events, and its social and physicalenvironmental contexts. How a person reacts willalso depend on how the event and context interactwith the person's preexisting personality structureand style(s) of coping. Personality will affect the typeof experiences formed, the duration of each phase

262 Psychosomatic Medicine 55:260-273 (1993)

PATHOLOGICAL GRIEF

of response, and whether or not adaptive completionof a mourning process is achieved.

Certain personality characteristics might makesubjects respond with turbulent emotions; other per-sonality characteristics might make subjects re-spond by stifling emotional responses. Conse-quently, which phase of stress response led to symp-toms (and so presentation for diagnosis) might vary,depending on the personality features of subjects.These personality differences can be individuallyformulated in clinical work and eventually mightbe included in a multiaxis diagnosis, as Axis II ofDSM-III-R is improved into better defined, empiri-cally derived, and reliably assessed typologies orprototypes.

PERSONALITY FACTORS

How They May Affect Successful orUnsuccessful Processes of Mourning

No generally agreed upon classification of person-ality has yet been achieved in psychology, and thepsychiatric classification of disorders of personalityhas yet to achieve highly reliable descriptive cate-gorization. Nonetheless, clinical research on normaland abnormal responses to stressor life events suchas loss do indicate that the inciting changes do notfall on a blank slate but, rather, on an internalized,enduring, and slowly changing knowledge structure.

Bereavement activates the generalized meaningspertaining to the relationship between self and thelost other, object, or function in life. Bereavementitself casts aspects of personality into a bolder man-ifestation so that features of personality may berendered more recognizable. Among the features sohighlighted are derivatives of the subject's schema-tizations of self and others, as well as habitual stylesof how the subject handles emotional tendencies,especially how he or she tends to express or stiflestrong negative affects. Understanding such aspectsof personality, especially in combinations, can helpus consider the utility of a single diagnosis of path-ological grief, even though various typologies ofgrieving will be found even within such a diagnostic"umbrella," and can help us understand the differ-ence between successful and unsuccessful mourn-ing processes as well as the outcome of such proc-esses in terms of states of normal or pathologicalgrief.

Freud (5) emphasized issues of ambivalence andguilt in pathological, as differentiated from normal,grief. Lindemann (6), Deutsch (7), and Klein (8) also

TABLE 2. Types of Response to Stressor Events

Time

Before event

During event

After event

ResilientResponse

Equilibrium

Emotionalperturba-tion

Equilibrium

Normal StressResponse

Equilibrium

Outcry

Denial phase

Intrusionphase

Combineddenial andintrusion, aworkingthroughphase withreduceddenial andintrusion

Equilibrium

PathologicalStress

Response

Equilibrium(or pre-event tur-bulence)

Prolonged ortoo intenseoutcry

Excessive andprolongeddenial,repression,dissocia-tion

Excessive andprolongedintrusionand flood-

era

Combineddenial andintrusionwithout re-ductionover time

Reschema-tizationinto a path-ologicalequilibrium(e.g., char-acter dis-tortion)

indicated the higher prevalence of rage, and defen-ses against rage leading to somatic changes, in theambivalence and guilt themes that tended to occurmore frequently in pathological than in normal griefreactions. Others indicated the importance of unre-solved dependency themes in uneasy schemas ofattachment as more prevalent in persons clinicallyfound to have pathological grief reactions (9-12).Such variations in configurations before the losscould lead to variations after the loss, which is whysome have suggested different types of pathologicalgrief (2). The variety of antecedent meaning struc-tures about a relationship can be understood, in part,by considering these meaning structures as personschemas.

Person schemas generalize, organize, and retain agreat deal of information about the relative roles andattributes of self and others, and plans for how



EVENTS

CURRENTWORKING MODELOF RELATIONSHIP

ENDURINGSCHEMA OFRELATIONSHIP

ACCORD OF WORKINGAND ENDURING SCHEMAS

EMOTIONAL SYSTEMS

STATES OF MIND

Ordinary RelationsWith Other

Mutuality t

Other

Equilibrium

Calm

News of Deathof Other

Help

HarmedOther

Mismatch

Alarming Rateof Arousal

Fearful Outcry

Fig. 2. Modeling a state shift from calm to alarm. From Horowitz MJ. Person schemas. In Horowitz MJ, (ed), Person Schemas andMaladaptive Interpersonal Patterns. Chicago, University of Chicago Press, 1991.

interactions might occur in sequences (13-20).Mourning is an evolutionary success story: it takessuch schemas of the relationship with the deceasedand modifies or reschematizes them so one can goon living with zest and meaning in spite of the loss,although there is a period of painful transition (21).Attachment bonds are not "forgotten;" the relation-ship lives on in the mind, but habitual proceduresof living are modified to accord to new realities andeven new opportunities through the process of re-schematization (22-28).

Extreme emotions may occur during the resche-matization process, especially during the outcry andintrusive phases of grief if these are experienced.The denial, numbing, and avoidant phases are inpart an effort to ward off these strong feelings. Theemotional responses are due to the social loss in realsituations, and to internal or mental assessments ofthe meanings of the loss both to the self and to otherloved ones. In addition, some important aspects ofthe emotionality that occurs have to do with thedifferences between internalized knowledge struc-ture and external realities, the mismatches betweenexisting but now outmoded schemas and the actualperceptions found in real contexts.

Alarm emotions may occur when enduring and

expected schemas do not accord with new realities.Take for example a period early in bereavement, asshown in Figure 2. Before the news of the death, asubject would feel calm even when apart from theloved one. The current belief, or the current workingmodel of the relationship, to use Bowlby's term, isone of being in an enduring mutual relationship thataccords with the enduring relationship schemas.After news of the other's death, the current workingmodel no longer accords with the enduring schema.The result is a pang of powerful and negative emo-tion. Often, as also shown in Figure 2, the currentmodel may not fully accord with external reality.The deceased may be modeled as harmed and des-perately in need of help. Outcries of fear, helplessexcitement, and despair'may result from the sud-denly recognized discrepancies between the currentworking model, as derived from the news of death,and the as yet unchanged enduring schema of therelationship. Persistence of the schema of the otheras alive can lead to the prolonged and erroneousbelief that the deceased will return (29), as well asto a continued and episodic sense of the presence ofthe deceased (28-30).

Let us repeat for clarity how person schemas relateto grief emotions. A bereaved person's cognitive-


PATHOLOGICAL GRIEF

EVENTS

CURRENTWORKING MODELOF RELATIONSHIP

ENDURINGSCHEMA OFRELATIONSHIP

ACCORD OF WORKINGAND ENDURING SCHEMAS

EMOTIONAL SYSTEMS

STATES OF MIND

Empty Situations Empty Situations

AbsentOther

Mismatch

Alarming Rateof Arousal

Need

AbsentOther

AbsentOther

Match

Equilibrium

Agitated SadnessPoignant Sadness orResignation

Fig. 3. Reduction of Alarm states with development of schema of others as lost. From Horowitz MJ: Person schemas. In Horowitz MJ,(ed), Person Schemas and Maladaptive Interpersonal Patterns. Chicago, University of Chicago Press, 1991.

emotional state changes sharply with the news ofthe death of the loved one. Often the other is viewedas if harmed rather than dead. The emotional re-sponse is intense and there may be considerableagitation related to helplessness. As mentioned,there are alarm emotions, the sharp surges of inter-rupting affect, that occur when enduring schemasdo not match well with current working cognitivemodels of what is happening "now." There is a rapidincrease in arousal resulting in the outcry phases asindicated in Figure 1 and Table 1. Various types ofarousal activate different brain areas and functions.Different types of peripheral autonomic nervous sys-tem, endocrine, and immune system responses re-sult. These lead to bodily sensations and changes,and hence to social as well as individual psycholog-ical appraisals and reactions to bodily changes.Worry for the self as well as the other may occur asa response to perceived bodily changes.

After a time, repetitions of the fact that the otheris lost forge a schematization of the self, longing forand needing but not finding the other. Gradually,upon reminders of the loss, this tendency to enterstates of agitated sadness becomes a tendency tohave states of poignant sadness and resignation. Thisshift in the emotional intensity of alarm reactions

indicates to the bereaved person a progress inmourning. This simplified model of working throughand reschematization is shown in Figure 3.

The revision of existing schematic structures re-quires both some awareness of the inability of pre-viously held knowledge structures to account fornew information, and time to develop new meaningstructures. Yet we often avoid repetitions of suchawareness and cling to existing beliefs even in theface of obvious incongruities (18, 31). This is largelya product of the important role played by schemasin most aspects of our daily lives. We rely on thesecondensed knowledge structures to maintain a senseof the world as safe and predictable (32). Periods ofchange in these knowledge structures, above andbeyond all the searing pain of the loss itself, makethe world and the emotional self feel less in control.

Alarm reactions are themselves anxiety provok-ing, leading to secondary pathological effects, and,speculatively, physical ones. Alarm reactions in-clude the intense bodily responses that lead to strongphysical sensations such as startle-induced muscu-lar contractions, palpitations, or gastrointestinalspasms. The autonomic nervous system physiologyis associated with emotional pangs in a way that isprobably extensive but this has never been fully

Psychosomatic Medicine 55:260-273 (1993} 265


worked out. The repetition of many alarm reactionscould have psychosomatic consequences from com-plex combinations of peripheral neurological, en-docrine, and immunological system responses to al-terations in the brain. There are probably cyclesinvolving cortisone-releasing hormone (CRH),ACTH, cortisol, and epinephrine, with feedbackloops through blood circulation back to the activityof cells in the hypothalamus, limbic system, andtemporal lobe cortex. These feedback loops mayreadjust levels of CRH and similar substances. Con-stant repetition of pangs could prevent CRH reduc-tion and so inhibit reciprocally the production ofrestorative hormones such as growth hormones. Theenduring structure of these interactive systemscould be affected.

The process of psychological reschematization canreduce emotional pangs, but it is usually slow.Mourning takes months or years rather than days.Schemas developed and maintained over long pe-riods of time facilitate information processing bybecoming relatively "automated" and by operatingoutside of conscious awareness (33, 34). By virtue oftheir repeated activation, however, long-held sche-matic representations tend to assimilate rather thanaccommodate (35) new information. They are, thus,less easily revised and up-dated and, in some cases,may be adhered to rigidly (18, 31]. The schematicrepresentations of marital partners and members ofthe nuclear family generally exemplify such auto-mated knowledge structures.

The person's ability to revise schematic represen-tations during mourning depends to some extentupon the degree of ambivalence or schematic con-tradiction in that person's relationship to the de-ceased prior to the loss. The official glossary ofpsychoanalytic terms (36) defines ambivalence as"the simultaneous existence of opposite feelings,attitudes, and tendencies toward another person,thing, or situation." Ambivalence is virtually uni-versal; it is noteworthy as a clinical phenomenononly when contradictory feelings or tendencies be-come so strong that they cannot be integrated (15,37) or when they are experienced as intolerable (38).In the language of schema theory, a highly ambiva-lent relationship would indicate a preexisting statein which one organized set of beliefs is not readilyaccommodated to another related body of informa-tion. Contradictory and nonintegrated relationalschemas would exist. The mourning process is oneof review of a relationship and would activate thesecontradictory schemas. When very discrepant sche-mas were activated, the mismatch would lead to

especially powerful and distressing pangs of emo-tion.

The representation of an ambivalent relationship,then, should prove to be even less flexible in accom-modating to the loss of the other. Consistent withthis hypothesis, ambivalent feelings toward the de-ceased (psychological dependency, guilt, anger) havebeen cited as a major factor in pathological griefreactions (26, 28, 30). Yet, although ambivalent rep-resentations will be perhaps more difficult to rec-oncile, the presence of ambivalence alone would notnecessarily prohibit reassessment and revision ofschematic representations. As already mentioned,we propose that the reconciliation of unresolved orconflicted representations of the deceased will bemore difficult for individuals who habitually avoidpainful topics, and contrary thoughts and emotionsthat feel alarming and difficult to control. Suchindividuals would be less able to identify contradic-tory beliefs and, consequently, less able to adjusttheir expectations of life, explore new behaviors, orto find new meanings.

Anxiety and Cognitive Avoidance

Consider the experience of excessive anxiety, acommon feature of bereavement, particularly in theearly months following the loss. The death of aspouse or important family member can often instillin the survivor a profound sense of "aloneness"accompanied by marked insecurities as well as re-alistic fears, such as those related to financial hard-ship (39). A portion of any bereaved sample, how-ever, will tend to exhibit more severe anxiety states.These individuals also tend to evidence a previoushistory of anxious states of mind (25, 40). Thus,individuals prone to the chronic experience of anx-iety are mostly likely to exhibit excessive anxietyduring bereavement.

Chronically anxious individuals in a variety ofpopulations have been associated with "cognitiveavoidance" (41)—the avoidance of extended or pro-longed processing of threatening information (42,43). The individuals prone to experience excessiveanxiety during grief, then, could also be expected toavoid contemplation of the emotional implicationsof the loss to the self. They should be less able toprocess the meaning of the loss and, as we areproposing, should tend to exhibit more severe griefreactions. A number of studies have demonstratedthe concordance of excessive anxiety with severe(31, 32) or prolonged (44, 45) grief responses. Inaddition, consistent with our proposal, the data from


PATHOLOGICAL GRIEF

several studies has shown a relationship betweenexcessive anxiety, severe grief, and the inability toreconcile and review the representations of the de-ceased (45, 46).

Avoidant Personality Styles

Avoidant information processing has also beenassessed as a habitual "coping" style in a variety ofnormal personality dimensions. While personality isoften cited as a likely predictor of grief outcome,these dimensions have not been investigated in be-reavement research. One such group that mighthave difficulty adjusting to a loss are individualsidentified by questionnaire as "information blun-ters" (47, 48). In one study blunters and their coun-terparts, information monitors, were confrontedwith low probability electric shocks and given thechoice of listening to an information channel aboutthe shocks of distracting themselves with music.Blunters spent more time listening to the musicchannel (48). In a study of combat-related PTSD (49),blunters responded in a manner similar to chroni-cally anxious individuals. They self-reported moresymptoms and greater problems in social function-ing, and had higher levels of intrusions and avoid-ance on the Impact of Event Scale (50).

A different group of individuals identified byquestionnaire and associated with avoidant infor-mation processing have been labeled "repressors"(51). Repressors comprise about 20 to 25% of a nor-mal population and have been the object of consid-erable study (52-54). They consistently exhibit thebehavioral signs of avoidance (51, 55) and demon-strate poor memory for emotional events (56-58).Yet, the repressor and information blunter measuresappear to assess different personality dimensions(59, 60). Furthermore, repressors differ from chron-ically anxious individuals in that they appear toavoid the "experience" of anxiety (61). Individualssuffering from anxiety disorders report elevatedanxiety and exhibit heightened physiologicalarousal in response to stressful laboratory situations(41, 62). Repressors also exhibit heightened arousalin response to laboratory-induced threat but, in con-trast to anxious individuals, they do not report acorresponding increase in anxiety (51, 63, 64).

Attention and Control Processes

The difference between the cognitive avoidanceutilized by many anxious individuals and the re-

duced conscious experience (or reports of) anxietydemonstrated with repressors has been understoodin terms of each type of person's habitual style ofregulating attention and so the nature of their on-going conscious awareness (61, 65, 66). The roleplayed by attention in self-regulation is sometimesviewed on a continuum from an internal focus to-ward the self to an external focus toward the envi-ronment (61, 67, 68). The focus of attention inwardlyintensifies negative-affective states (e.g., 69, 70) andleads to an increase in the activation of self-relevantinformation derived from schemas of self (e.g., 71,72). Although self-focused attention is considered anessential element of normal self-regulatory proc-esses (61, 68, 71), it is actively avoided when, forexample, it would lead to a negative emotional statebecause the dominant current self schema is dis-crepant from a desired self schema and a wished forstate (73), or when responsive emotions become ex-cessive and intolerable (74). These conditions holdan obvious similarity to the features of the mourningprocess described on the preceding pages.

The experience of anxiety has long been associ-ated with excessive self-focused attention (61, 68,71, 75-77). Self-focused attention appears to mani-fest in anxious individuals as a "priming" towardthe perception of anxiety-related information (78-80). Such an anxiety-related "vigilance" seems tofurther heighten arousal which, in turn, leads anx-ious individuals to inhibit any further processing ofthe threatening information (41, 81).

We propose that these same processes are opera-tive in pathologically grieved individuals when theyexperience excessive anxiety or other negative-sig-nal affects. The characteristic "vigilance" to threathas been observed in overly anxious, bereaved in-dividuals (40). The resulting arousal-vigilance se-quence should then minimize any prolonged self-reflection and exacerbate symptoms. Accordingly, itis not surprising that acute-anxiety states early inbereavement predict prolonged anxiety at laterstages (39, 40).

Repressors, on the other hand, have been associ-ated with the opposite of self-focused attention, whatBonanno and Singer (61) have referred to as "percep-tual cognition"—a lessened self-consciousness, ac-companied by a global and superficial attention tothe external environment which is easily and fre-quently shifted from one object to another. Such aminimization or absence of self-focused attentionshould result in a lessened experience of negativeaffect and less accessible self-schema. Consistentwith this line of theory, it is not surprising thatrepressors do not show the selective vigilance to



EXTERNALSITUATION

STRUCTURESAND PROCESSES

CONSCIOUSEXPERIENCES

Internal working model-of external situationmatches schemas ofself and other(s)

iInternal working modelof new externalsituation does notmatch schemas of selfand other(s) ]_

Well being

Emotional alarms

iiRegulation

tomodulate emotion

ILIII

| Supports ) » Reassesses situation' ' < to revise schemas

Modified repertoire ofschemas of self andother(s) matches newexternal situation andopportunities

IInii

Emotional-relationalefforts at restoration;trial and practice ofnew behaviors andrecognitions; possibleturbulence requiringendurance and hope

Well being (completionof normal grief)

Fig. 4. Successful mourning.

negative stimuli typically exhibited in anxiety states(55, 82). Repressors also distract themselves morereadily than do other individuals (55) and appear tomore efficiently dissociate the experience of exces-sive arousal or unpleasant feelings (63, 64).

Given these characteristics, bereaved repressorswould not be likely to exhibit anxiety-related symp-toms during the initial phases of grief. It is possiblethat they may be especially prone, however, to thelater development of symptoms, or "delayed grief"(26, 28, 30, 46). Repressors could also be expected toexhibit signs of strong grief reactions indirectly as,for example, psychosomatic complaints or night-mares, and to exhibit avoidant or escapist imagery.

To recapitulate, we have suggested that personsmay have many different types of person schemasfor organizing belief and behaviors in relation to thedeceased, and the self as related to the deceased.People with many contradictions and discrepancieswithin these person schemas or internalized objectrelationships would be more likely to have strongnegative emotions while processing and reschema-tizing all the implications surrounding the loss and

the life of the self after the loss. The more contra-dictions, the more turbulent the emotionality duringsuch processing. There would be different types ofemotionality and different ideational preoccupa-tions depending on the different aspects of contra-dictions and qualities of ambivalence. At the sametime persons would vary in how they habituallyused processes of control to reduce emotionality.There would be different styles of overcontrollingemotionality, that is, different ways of reducing neg-ative emotional states of mind to such an extent thatreschematization opportunities are impaired by ex-cessive avoidance of processing the ideas and feel-ings that would lead to the reschematization. Nei-ther factor alone would lead to pathological grief,but contradictions (of any kind) and overcontrol (ofany kind) in combination would yield such an un-successful mourning process that pathological out-comes and prolongations would occur.

This theory is given graphic form in Figures 4 and5, and provides an explanatory basis for how path-ological grief might contain different patterns ofideational, emotional, and behavioral content, and


PATHOLOGICAL GRIEF

EXTERNALSITUATION

STRUCTURESAND PROCESSES

CONSCIOUSEXPERIENCES

Internal working —models of externalsituations are unstabledue to contradictoryschemes of serf andother(s)

Approach-avoiddilemmas, problems inrelating, and contusionsor contradictions infeelings

Internal working modelof new externalsituation does notmatch schemas of selfand others; activationof latent contradictoryschemas I

Emotional alarms,severe moods, frozenstates

Overcontrolto avoid dreadedemotional states

{ Inhibited or distorted —I information processing• prevents reassessmentsI of situations and

modification of schemas(and walls off support)

Repertoire of schemasremains contradictory -and does not matchnew external situationand opportunities

Compulsive repetitionsand negative emotionalrecognition thatbehaviors areinappropriate,excessive numbing orflooding of emotion

More severe dilemmas,symptoms, problems, orextreme avoidances(pathological grief)

Fig. 5. Unsuccessful mourning.

yet have a common enough form that a single diag-nostic entity could be defined for nosological andresearch purposes.

DIAGNOSIS OF PATHOLOGICAL GRIEF

The polythetic criteria of DSM-III-R makes it pos-sible and reasonable to include different expressionsof psychopathology which share common featureswithin the same diagnostic entity. In addition, froma research point of view, a single diagnostic catego-rization of pathological grief offers methodologicaladvantages over any more complex set of typologiessuch as acute, chronic, delayed, or stifled grief. Pop-ulation samples can be smaller if there is one ratherthan many entities to consider.

As in PTSD, the first criterion for such a diagnosisis the evocative event—the loss of an object or afunction that for the person has had an enduringimportance as an "attachment" of the self. The lossmay be of a spouse, a child, or another significant

person. The loss may be of a body part, a bodilyfunction, or even one's personal status, position, orpossessions. Unlike the stressor in PTSD, such a lossdoes not have to be out of the ordinary range ofexperience. On the contrary, at some point in life,losses of this kind are likely to happen to everyone.

Beyond the stressor event criterion, the criteriafor the diagnosis of pathological grief encompassthree categories of symptom-related features: intru-sions, avoidance, and dysfunctional adaption. Thesecriteria are shown in Table 3. Intrusions includerecurring, unbidden, and uncontrollable consciousexperiences, such as haunting thoughts and hard todispel images, including memories, images, dreams,and most especially nightmares.

A difference between traumatic reactions to ac-cidents, disasters, or violence and pathological griefmay be found in the manner in which the intrusionsare experienced. Individuals suffering from PTSDmay feel out of control because they cannot avoidimages that repeat the traumatic perceptions; theserepresent a kind of hypermnesia or an excessiveactivity of memory. Similar intrusions may occur in



TABLE 3. Diagnostic Criteria for Pathological Grief

Criteria Description

A. Stressor Loss of a significant otherB. Intrusion 1. Occurrence of distressing, intrusive images,

ideas, memories, recurrent dreams, or night-mares; the mind is flooded with emotionswithout a sense of reduction in intensity.

2. Illusions or pseudohallucinations. The mindis "haunted" by a sense of presence of thedeceased without a sense of reduction inintensity.

C. Denial 1. Maladaptive reduction in or avoidance ofcontemplation in thought, communication,or actions of some important topics relatedto the loss.

2. Having an implicit relationship for more than6 months with the deceased as if alive; keep-ing the belongings of the deceased exactlyor completely as before.

D. Failure to adapt 1. Inability to resume work or responsibilitiesat home beyond 1 month after the loss.

2. Barriers to forming new relationships be-yond 13 months after the loss.

3. Exhaustion, excessive fatigue, or somaticsymptoms having a direct temporal relationto the loss event and persisting beyond 1month after the loss.

* General rule for the diagnosis of pathological grief: The personmust meet criterion A, and in addition needs to display at least onemanifestation within all of the classes from B to D. It also is possibleto diagnose pathological grief if only one of the criteria from B toD is present to a highly maladaptive degree.

pathological grief response. Yet a considerable por-tion, of the intrusions may arise in relation to mem-ories or images that serve as essentially positive andtemporarily comforting portrayals of the deceasedas still alive. Such ephemeral comforts result, how-ever, in a repeated intrusive realization of the voidor absence of the lost object and constitute a painfulreminder of the present that is devoid of the lostobject. There is a 'trauma of contrast' between whatwas and what is. The survivor is tormented byexposure to the present now schematized to consistof an excruciating emptiness and in sharp contrastwith the absorptions in 'good' memories of the past.

A further distinction of pathological grief reac-tions from the experience of shock-induced PTSD isthat some pathologically grieving individuals preferby choice to indulge tenaciously in the 'good' mem-ories or images of the past over such an extendedperiod of time that it becomes an obstacle to theirreorientation in life. Despite the untoward conse-quences, such an avoidant dwelling on the past maybe experienced as an appealing relief and a comfortand as a solitary source of gratification.

Positive memories of the deceased are often in-

flated by idealized fantasies or selective forgettingof negative features. In such instances the giving upof the lost object usually is associated with strongand overwhelming emotions, and may for this rea-son be avoided. Such manifestations would appearto reflect the combination of contradictory sche-matic representations and the overcontrol of emo-tional experience discussed earlier.

The maladaptive component of this phenomenonis manifest in the inability to make decisions inaccord with the here-and-now reality. Pangs of fear,sorrow, rage, shame, or guilt may emerge. The per-son constantly feels close to loss of control; intensemotoric emotional responses and startle reactionsare easily triggered by any factual or symbolic re-minder of the deceased.

A variety of escape-from-death images, illusionsand pseudohallucinations, may be entrenched insocially accepted and promoted systems related todeath issues. These include ideas of reincarnation,communication with the spirit world, and the prom-ise of life after death. When and if these notions arespiritual beliefs and acts of faith, they are beyondthe scope of diagnosis. No established belief system,irrational as it appears, can be a criterion of a dis-order. In order to assess the avoidant criterion for apathological grief diagnosis, functional impairmentmust be assessed in relation to shared beliefs heldby a surrounding group of affiliated individuals orsocial network. For a diagnosis to be made theremust be functional impairment in addition to irra-tional beliefs or intrusive images.

Cultural schemas and social belief systems forhow a person is to behave in bereavement will relateto the question of whether or not a functional im-pairment is present. In some cultural contexts, forexample, widows or widowers may be expected toremain celibate and to avoid the experience of anew love. In most western cultures, by contrast,mourning is viewed as a relatively brief, finite phaseof experience with a completion. After the mourningperiod, the person is expected to resume relating toothers in a normal manner. If a bereaved person'sexperience is dominated by rigid social beliefs aboutthe mourning process, there may be a failure toadequately comprehend the personal meaning of theloss and to revise the schematized representationsof self with intimate others.

A premature attempt to replace the lost personmay lead to perplexed and awkward states of mind.If the person has not yet revised their role-relation-ship models to accommodate anyone other than thedeceased, they may experience uneasiness, intenseguilt, or even panic (15, 21). The confusion engen-


PATHOLOGICAL GRIEF

dered by a "new" social obligation to a new othermay also motivate avoidant or escapist coping mech-anisms.

In pathological grief, avoidance may also manifestbehaviorally in the form of staying away from placesor people that are reminders of the deceased. Anenduring dissociated state of mind, with elements ofdepersonalization or derealization may be observed.Avoidance may also be expressed through indulg-ence in excessive activity, or hypomania.

Prolonged dysfunctional or maladaptive behaviorwill be evident in an individual's relationship towork, in the general manner in which responsibili-ties are carried out, and in social relationships. Inthe work sphere the person may have a curtailedability to complete projects, to concentrate, or main-tain a daily routine. Like PTSD patients, pathologicalgrief cases occasionally have a dismaying sense of aforeshortened future. More common is the feeling ofbeing on hold. In the social realm, pathologicallygrieving individuals appear to be unable to give asmuch as before to children, relatives, or closefriends. More clearly pronounced are the problemsreflected in the ability to approach to a new intimaterelationship.

Once formed, the person may encounter substan-tial problems in maintaining or deepening the newrelationship out of guilt toward the deceased. Guiltis sometimes especially prominent when the persondiscovers new qualities or joys in a relationshipcompared with the previous relationship with thedeceased.

Differential Diagnosis

Pathological grief can be diagnosed by a set ofseparate and distinct criteria that are independent

of those used for a diagnosis of Major DepressiveDisorder. In a study now underway, analysis of someof the early subjects has shown a high level ofinterrater reliability for the diagnosis of pathologicalgrief by criterion as shown in Table 3. Preliminarydiagnosis of this sample shows that there are personswho, after a spousal bereavement, have signs andsymptoms that warrant the diagnosis of major de-pressive disorder without other Axis I diagnoses,other subjects who warrant the diagnosis of bothmajor depressive disorder and pathological grief,and subjects who do not have the symptoms thatwould warrant a diagnosis of major depressive dis-order but who do warrant the diagnosis of patholog-ical grief. The proportion of subjects found in allthree categories indicates the need for an additionaldiagnosis.

Because of the criteria in the diagnosis of posttrau-matic stress disorder, many persons who have per-sisting intrusive and denial-numbing-type symp-toms without the signs and symptoms of major de-pressive disorder after a loss are given a diagnosis ofadjustment disorder, possibly only within the timeframe of 6 months. Unfortunately adjustment dis-order is a time-limited and diffuse entity, inadequateto problems of either research or clinical work. Onealternative possibility to our suggestion of a patho-logical grief diagnosis would be to modify the stres-sor event criterion of the posttraumatic stress dis-orders to continue emphasizing the intrusive anddenial-type symptoms as found in DSM-III-R as wellas to add some proposed diagnostic criterion forpathological grief in Table 3.

This paper is based on research supported by theJohn D. and Catherine T. MacArthur Foundation'sHealth Program through funding of its Program onConscious and Unconscious Mental Processes.

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