Medical Wellness Archives

Enhancing Well-Being By Understanding Grief & Taking A Loss History

2004: Volume 1, Number 2

Kirsti A. Dyer, MD, MS, FAAETS, FACW, NCBF, CWS

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 lives. Many times these losses are never announced or acknowledged publicly. Instead, the person endures very private sorrows that can impact his/her health and well-being.

Health is the optimal state of wellbeing—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. Experiencing a loss or a life challenge upsets this balance and reduces a person’s energy.

Grief is the normal reaction to a loss. Therefore, grieving is the process a person goes through while restoring his/her balance and energy. 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. Grieving losses is an important step toward 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
Although grief and wellness seem unrelated, unrecognized acute loss or unresolved grief can mimic various medical conditions, lead to illness, and result in a decline in wellness. A grieving person may experience a variety of somatic complaints: fatigue, insomnia, pain, gastrointestinal 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 thorough evaluation to exclude serious medical disorders before a grief response or depression can be diagnosed.

Loss and the resulting grief response can impact a bereaved person’s mental and behavioral well-being. 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 have a negative impact on the health of the surviving bereaved spouse. This includes an increased risk of death.

Studies have shown that bereavement can lead to increased mortality from ischemic heart disease, development of high blood pressure, depression of the immune system, and increased depressive and anxiety disorders, including post traumatic stress disorder.

The Personal and Economic Impact of Loss
Each year, loss and life challenges have an enormous personal impact. In 2000 there were over 2.4 million deaths in the United States. Each individual death is estimated to affect between 8-10 family members resulting in at least 19— 24 million new mourners created each year. Some estimates place this number as high as 30 million.

However, these figures do not include the millions of additional mourners created by the friends, neighbors, colleagues, coworkers, social contacts, students, and others outside the immediate family of those who have died. These numbers also do not include the millions of mourners who have experienced one of myriad of losses other than death or those still grieving a longstanding loss.
 

Loss and the resulting grief response also have a significant economic and societal impact. This is manifested in the high costs of absenteeism, decreases in worker productivity, lower product quality, increases health insurance premiums, escalating social violence, substance abuse among workers, and problems from driving under the influence of drugs or alcohol, including accidents and increase in suicides or suicide attempts. A November 2002 report placed losses in the U. S. linked to grief at more than $75 billion. The study, conducted by the Grief Recovery Institute, included losses from emotional pain ranging from miscarriages to pet loss.

Distinguishing between Grief and Depression
Manifestations of depression and symptoms of distress can be part of a normal grief response to a major loss or prolonged bereavement response, which make it challenging for the practitioner to determine between a grief response and true clinical depression.

The tables below summarize key characteristics of grief and depression to help the practitioner distinguish between these two related but distinctive conditions.

Stress can contribute to depression and may complicate its symptoms. Depression is a major health problem that is commonly underdiagnosed and undertreated. Yet, 80 percent of those with depression can be treated successfully.

Clinical depression is diagnosed if a patient has at least one of these two symptoms every day for 2 weeks or more:

• Feeling sad, blue, or down in the dumps

• Loss of interest in things that were once enjoyable

With at least four of the following, nearly every day:

• Losing or gaining weight

• Feeling tired or having low energy all the time

• Difficulty concentrating or making decisions

• Racing thoughts or slowed thinking

• Feeling worthless or guilty

• Trouble sleeping or sleeping too much

• Thoughts of death or suicide

(Adapted from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

Taking a Loss History
On a daily basis, physicians and other healthcare providers care for patients who are experiencing a life challenge or have experienced various losses; yet they may be completely unaware that the patient is grieving. In order to enhance our patients’ well-being, we need to identify their present and past losses, life challenges, or experiences that can be impacting their
health.

Current or prior losses typically are not included when asking a patient’s medical history. 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 health care provider may uncover losses that are impacting the patient’s health and well-being. Additional questions can determine any coping strategies used by the patient in the past, which can be helpful in revealing how the person has handled prior losses and may indicate how he/she might handle future loss. A loss history can be included as a routine part of a history and physical questionnaire and updated at follow-up appointments.

The patient’s major losses can be listed either chronologically or in order of importance. All major types of losses should be included, both current and distant:

• Deaths

• Divorce

• Loss or impairment of bodily function

• Job losses

• Illnesses—mental and physical, both personal and in the family

• Major moves, relocation

• Other significant losses for the person (e.g., miscarriage, pet loss)

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 basic survival needs of the body is especially necessary during times of stress and uncertainty:

• Take it one hour at a time, one day at a time.

• Maintain a normal routine. Keep up your regular activities.

• Get enough sleep or at least enough rest.

• Regular exercise, even walking, helps relieve stress, tension, and improve your mood.

• Maintain a healthful, balanced diet. Limit high-calorie food, especially junk food and comfort food binges.

• Drink plenty of water.

• Avoid using alcohol, medications, or other drugs to mask pain.

• Talk to others, especially those who have lived through and survived similar experiences. They may provide valuable insights for coping.

• Do things that—and be with people who—comfort, sustain, and recharge.

• Recall coping strategies used to survive past losses. Draw on these inner strengths again.

Conclusion
Failing to identify a grief response to loss may result in a poor response to therapy because the correct diagnosis (grief) was not made, nor was the underlying etiology for the symptoms ever identified. By not identifying the grief response, the patient may not receive the proper support to help him/her cope with a life changing event.

Taking a loss history may help the practitioner identify and diagnose a grief response correctly. Then the practitioner can educate the patient about their symptoms and how they relate to the life challenge, which in turn helps the patient process the change, integrate the loss, begin living again, and restore balance, energy, and well-being.

Resources available on request.

Contact Dr. Dyer at griefdoc@journeyofhearts.org.