Unresolved Grief

The boundaries between normal or uncomplicated grief and pathological mourning are not always clear. The distinction, however, is clinically significant, as “normal” grief is considered self-limited, relatively benign, and not amenable to psychotherapeutic intervention, whereas pathological grief is associated with enormous social, psychological, and medical morbidity (1) and may warrant intensive intervention (2-8). This paper summarizes the relevant bereavement literature with a particular emphasis on the author's own research efforts to better demarcate “normal” from pathological bereavement.

Beginning with Freud's “Mourning and Melancholia” (9), several descriptions of normative grief and bereavement have appeared in the psychiatric literature over the past century. Freud identified four distinguishing features of “normal” mourning: a profoundly painful dejection, the loss of the capacity to adopt new love objects, the inhibition of activity or turning away from activity not connected with thoughts of the loved person, and the loss of interest in the outside world insofar as it does not recall the deceased. Furthermore, Freud distinguished mourning from melancholia by the absence of ambivalent feelings about the deceased and significant disturbances in self-esteem in mourning. Reporting on observations of 101 survivors of the Coconut Grove fire in Boston, Eric Lindemann (10) subsequently defined five characteristics “pathognomonic” of grief: somatic distress, preoccupation with images of the deceased, guilt, hostility, and loss of customary patterns of conduct. To these he added a sixth, shown by patients who border on pathological reactions, namely, the appearance of traits of the deceased in the behavior of the bereaved (identification phenomena).

Building on Freud and Lindemann's work, Engel (11) proposed that grief was a disease state with a predictable course and specific symptoms. Focusing primarily on psychopathological symptoms, Clayton (12) subsequently