How do we tell the difference between normal grief, complicated grief, and depression?

M. Katherine Shear, MD, program director for Columbia University's Center for Complicated Grief and Sidney Zisook, MD, distinguished professor and director, Department of Psychiatry at the University of California San Diego, La Jolla, discussed this with Medscape’s Ronald W. Pies, MD.

Adapted from a Medscape article published online at http://www.medscape.com/viewarticle/836977?src=wnl_edit_specol&uac=90700DY

 Dr. Shear began by noting that there are things the general public calls” depression” ranging from “genuinely benign everyday blues” to severe, long-lasting feelings that impair our ability to function. Sadness which is not recurrent, lasts only a month or two, and does not include feelings of worthlessness or suicidal ideas may not fit the diagnosis of clinical depression.

To describe a true clinical depression, Dr. Shear quoted from Infinite Jest, by David Foster Wallace: “It is a level of psychic pain wholly incompatible with human life as we know it. . . It is a sense of poisoning that pervades the self at the self's most elementary levels.”

"Bereavement" is the situation of having experienced the death of someone close, not the response to the loss. "Grief" is the response to loss, not simply an emotion. The word "grief" is a simple shorthand for a complex, multifaceted experience that changes over time and varies from loss to loss.

Grief can be considered as the form love takes when someone we lose someone we love. Like other forms of love, grief can be an avenue for personal change and growth which often entails reevaluation of one's self-concept, and revising expectations and predictions of self and others, especially the deceased.

Acute grief is the initial response to a painful loss that usually entails painful emotions; a sense of disbelief about the finality of the loss; preoccupation with thoughts, images, and memories of the deceased; and an inclination to social withdrawal. Longing, yearning, and sorrow are the most prominent emotions, often accompanied by a sense of disbelief even though the bereaved person knows that their loved one has died.

Dr Pies: Kathy, what about the notion that people can and should "get over" grief?

Dr Shear: As Wortman and Silver[2] have argued, return to a prior state after a significant loss does not occur. Another [misconception] is the idea that successful adaptation means "letting go" or "saying goodbye" in order to "move on."

Adaptation entails understanding the meaning of the finality and consequences of the loss and re-envisioning life goals and plans. As adaptation progresses, the frequency and intensity of grief symptoms attenuate.

As time passes, the disbelief wanes; acute grief is reshaped, and its dominance subsides. As the finality and consequences of the loss are understood, grief is integrated into memory systems, and ways are discovered to use this relationship to foster continued psychological growth.

Grief is not a single emotion, but rather contains a compendium of emotions, both negative and positive. Yearning and sorrow are the emotions that define grief. In addition, almost everyone experiences some anxiety, guilt, anger, or shame in response to a significant loss.

Most grieving people are anxious about the meaning of the loss, the experience of grief, or the shape of the future without their deceased loved one. Some people are afraid that they will never stop feeling wrenching pain, anxious about whether they can ever be happy again, or whether they can ever feel comfortable with themselves without the person they lost.

Many bereaved people experience some remorse or guilt about how they treated their loved one. Many feel some survivor guilt because they get to live and enjoy life when the person they loved can no longer do this.

Anger is also common. It is easy to feel cheated, to think it is unfair that the person died, or that someone failed in caring for the person who died. Sometimes anger is directed toward the person who died.

Overall, many complex and varying emotional, cognitive, and behavioral changes are entailed in making the adaptation needed to come to terms with the loss and to re-envision the future after bereavement.

 The process of adaptation to a death has been described by Bowlby as one in which we must change a mental model. However important this is, change is resisted. Bowlby asserts that our minds mercifully move toward and away from acknowledging the painful reality, providing bouts of grief interspersed with periods of respite. In other words, adaptation typically progresses in fits and starts, in which we oscillate between confronting and reflecting on painful information about the loss, and then setting it aside.

Dr Pies: What about complicated grief, Kathy? What context does that occur in?

Dr Shear: Sometimes, maladaptive feelings, thoughts, or behaviors can get a foothold during grief. A person might become caught up in troubling thoughts about the circumstances or consequences of the death, or about aspects of their relationship with the deceasedComplicated grief occurs when something interferes with learning that is the core process of healing. The result is a situation in which the bereaved person seems "stuck" in acute grief, trying to deal with the complications that block acceptance and adaptation to the loss.

Complicated grief is at the high end of the grief spectrum in both intensity and duration. People with complicated grief are often caught up in ruminations, avoidance, or maladaptive proximity-seeking. 

Complicated grief ruminations are usually focused on counterfactual accounts of the death—for example, "If only I had made him go to the doctor sooner" or "If only I had not left the room right before she died."

With complicated grief, avoidance can be specific, in which the survivor is focused on not wanting to confront reminders of the person who died. 

On the other hand, people with complicated grief can also be desperate to feel close to their deceased loved one. They may spend hours looking at photos, touching or smelling their clothes, or daydreaming about times they were together. This proximity-seeking is usually pleasurable, but on until the person "wakes up" and remembers that the person is gone.

Dr Zisook noted that it is important to recognize a Major Depressive Episode when it occurs in a recently bereaved person who is still actively grieving."

Here are several important differentiating factors:

1. The key feeling in grief is a sense of emptiness and loss whereas the key feeling in depression is an inability to anticipate happiness or pleasure.

2. In simple grief the sadness tends to decrease in and occurs in waves that are associated with thoughts or reminders of the deceased—so-called "pangs of grief." With a Major Depressive Episode, (MDE) the sadness is more persistent and not tied to specific thoughts or preoccupations.

3• In grief, the pain may be accompanied by positive emotions, such as humor, relief, and warmth in the closeness with significant others. In contrast, when a MDE also is present it leaves no room for warmth, joy, or humor.

4. Thoughts and memories of the deceased predominate in grief. When the grief is accompanied by a coexisting MDE, thoughts also are focused on oneself being bad, undeserving, or unworthy

5. In grief, self-esteem is generally preserved, but where there is MDE, thoughts of worthlessness and self-loathing also are common. Grieving individuals often feel supported and comforted by friends and relatives sharing time and conveying condolences. This is less true of those with an MDE.In grief, thoughts of death or dying are generally focused on the deceased and possibly about joining them. In those suffering from an MDE, thoughts may be more focused on ending one's life because of feeling that the world would be better off without them.