Normal Grief Research Articles

DSM‐5 grief scorecard: Assessment and outcomes of proposals to pathologize grief

Where does grief stand diagnostically, now that the dust has settled and the DSM-5 has been approved? The DSM-5 Task Force considered an unprecedented series of proposals to identify grief-related mental disorders where now there are assumed to be normal variations. The proposals taken together had the potential to transform psychiatry's conceptualization of grief and the clinician's response to bereaved patients. Targets for pathologization included both depressive symptoms during grief and grief itself – the yearning, disbelief, and other experiences distinctive of grief. Four grief-related proposals made it to the final leg of the DSM-5 revision process, a major event in itself. Here I review the proposals, assess their validity, and present the Task Force's final decisions, providing an overview of the status of grief post-DSM-5.

‘Understanding it makes it normal’: is it a reasoning fallacy or not?

In 1973, P. Meehl drew attention to the fact that some clinicians tend to interpret the otherwise clear symptomatic behaviour of their patients as 'normal' if they are given a plausible causal story of patients' behaviours. He claimed that this way of thinking is, in fact, fallacious and gave the alleged fallacy the 'catchy' name 'understanding it makes it normal'. Thirty years later, the cognitive psychologists W.K. Ahn, L. Novick and N. Kim questioned the fallacy status of 'understanding it makes it normal' by arguing that this way of reasoning is not only quite common among clinicians but that it is in fact rational. The controversy over whether 'understanding it makes it normal' is a reasoning fallacy or not is still unresolved and this is evident from the recent discussion about the proposed removal of the 'normal grief' exclusion criterion for Major Depressive Disorder from DSM-5. This paper proposes an analysis of what stands behind the two opposing claims about 'understanding it makes it normal'. The analysis builds on the distinction between validity and utility of psychiatric diagnoses and reaches the following conclusions: (1) the fallacy claim is consistent with the assumption that the psychiatric diagnoses are valid descriptions of real mental disorders; (2) the non-fallacy claim is consistent with the opposite assumption that current psychiatric diagnoses are not valid but only useful descriptions and their utility varies across different contexts; (3) if we agree that there is not enough evidence for the validity of the diagnostic categories embedded in DSM-4 and ICD-10, we should also agree that the behaviour of those mental health professionals who change their diagnoses under the influence of the causal context is rational; (4) nevertheless, the 'understanding it makes it normal' reasoning strategy should be considered a bias insofar as it takes into account only part of the causal context: the causes of the symptoms but not what they themselves might cause. The neglect of the latter might have dramatic negative consequences in clinical practice. In addition, some recent studies suggest that this bias probably has cultural roots.

The New Crisis in Confidence in Psychiatric Diagnosis

The New Crisis in Confidence in Psychiatric Diagnosis

A Pilot Study of Physiological Reactivity in Children and Maternal Figures Who Lost Relatives in a Terrorist Attack

Trauma is thought to interfere with normal grief by superimposing symptoms of posttraumatic stress disorder. This exploratory pilot study examined the association between traumatic grief and objectively measured physiological reactivity to a trauma interview in 13 children who lost relatives in the Oklahoma City bombing as well as a potential link between children and their maternal figures in physiological reactivity. Although the authors found no association between posttraumatic stress and objectively measured physiological reactivity among children, they found significant differences in objectively measured reactivity associated with loss and grief. Children who lost “close” relatives evidenced greater objectively measured reactivity than those who lost “distant” relatives. For the most part, children with higher levels of grief evidenced greater objectively measured reactivity than those with lower levels of grief. The most interesting of the findings was the parallel pattern in objectively measured physiological reactivity between children and their maternal figures along with a positive association between children's objectively measured physiological reactivity and maternal figures’ self-reported physiological reactivity. Research using larger representative samples studied early and over time is indicated to determine the potential significance of these findings.

Finding Light in the Dark: Suggestions for Dealing With a Patient’s Death

Back to table of contents Previous article Next article Residents’ ForumFull AccessFinding Light in the Dark: Suggestions for Dealing With a Patient’s DeathDavid Buxton, M.D., and Arshya Vahabzadeh, M.D.David BuxtonSearch for more papers by this author, M.D., and Arshya VahabzadehSearch for more papers by this author, M.D.Published Online:5 Apr 2013https://doi.org/10.1176/appi.pn.2013.4a4AbstractWoody Allen once stated, “I am not afraid of death, I just don’t want to be there when it happens.” Many residents and physicians relate to this sentiment as the death of our patients from suicide, accidents, or chronic illness is our worst fear as an outcome. In fact, our medical training emphasized this idea as we focused on lifesaving measures, with little attention focused on the end of life. Furthermore, as psychiatrists, death is constantly on our minds as we screen for suicidal ideation in our interactions with patients.Unfortunately, as trainees, we will not be guarded from exposure to death. Research has shown that over 60 percent of residents will encounter suicide during their training. As residents who have had firsthand experience and witnessed our colleagues struggle with this monumental event, we felt it important to suggest a few pearls to help during this process.“Don’t worry alone.” It seems to be such a basic concept of training, but when a patient dies, it is essential to seek out guidance. Training directors, supervisors, mentors, and colleagues are there to help in times of stress. They can provide support, share personal experiences, and create a space for you to discuss your feelings. When you are ready, these individuals can also review your documentation, direct you regarding possible legal implications, and help you understand any mistakes from a medical perspective so that you can learn from the case.“Stay healthy.” As residents, our schedules are incredibly hectic as we balance service obligations and our personal lives. The stress of a loss can add another burden to our already filled plate. It is imperative that you ensure you are getting enough sleep, eating well, and taking time to relax. Some residents have chosen to take time off from work, which can have its advantages and disadvantages, both of which should be discussed with a supervisor. “It’s Normal.” After any loss or death of a person we know, there is a period of normal grief. As physicians we can have feelings of responsibility and guilt and may replay what we could have, should have, or would have done differently. We may also be stirred by this death and reflect back to other losses in our lives, which may augment our feelings about this loss. Trainees should be aware that it will take time to get back into the swing of things and should hesitate before diagnosing feelings as pathologic. “What now?” Residents may feel a strong desire to reach out to family members of their patients after a death. What should I say to them? Should I contact them through an e-mail, letter, phone call, or meeting? Should I go to the funeral or wake? These questions are very complex, so each case needs to be examined on an individual basis. Trainees should discuss all options with their supervisors to get guidance and be aware that this contact may have positive or negative effects in the medical-legal sphere. “Search for Meaning.” After any death, we have a tendency to search for meaning in the tragedy. One may find solace in the questions of why did this happen to this patient or why did it happen to me by finding different outlets to process it. Some residents have taken time to lecture on the topic to help other trainees prepare for or deal with a patient dying, while others have written about their experience. Trainees should also consider finding a way to say goodbye to their patients, which could include privately visiting a gravesite, lighting a candle, etc., to achieve closure.The death of a patient can be a scary and startling experience, but is very likely to occur during your professional career. As residents, we can feel alone in the dark on how to react and move forward, but we need to take advantage of our training status by seeking help from mentors and other opportunities for support. Loss can have different effects on each of us, but we need to make sure to take care of ourselves so we can take care of others. ■David Buxton, M.D., is a first-year fellow at the MGH/McLean Child and Adolescent Psychiatry Department. Arshya Vahabzadeh, M.D., is a PGY-3 psychiatry resident at Emory University and a 2013 Laughlin Fellow. ISSUES NewArchived

APA Approves Final DSM-5, Due in May After 6-Year Revision

The American Psychiatric Association has finalized its restructuring of the Diagnostic and Statistical Manual of Mental Disorders, clearing the way for publication of the fifth edition of the DSM in May 2013 and cementing some controversial changes. On Dec. 1, the APA's Board of Trustees approved the final diagnostic criteria, which had been developed by a task force of clinicians and researchers over the last 6 years. The document now will undergo final editing before being published by American Psychiatric Publishing. “We have sought to be very conservative in our approach to revising DSM-5,” Dr. David J. Kupfer, chair of the DSM-5 Task Force, said in a statement. “Our work has been aimed at more accurately defining mental disorders that have a real impact on people's lives, not expanding the scope of psychiatry.” One change that drew the ire of critics is the removal of the bereavement exclusion. Under the DSM-IV, the exclusion was used to describe people who experienced depressive symptoms lasting less than 2 months after the death of a loved one. Instead, the text of the DSM-5 will include notes clarifying the differences between grief and depression. The APA said the change is intended to reflect the recognition that bereavement is a significant psychological stressor that can precipitate a major depressive episode after the death of a loved one. But during the drafting of the DSM-5, the proposal was ridiculed by some opponents who said that removing the exclusion could lead clinicians to diagnose major depressive disorder in people experiencing brief periods of normal grief. Another proposal that was especially controversial during drafting of DSM-5 was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions, delusional ideas, hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability. But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5's Psychotic Disorders Work Group opted to put the new diagnosis in an appendix for diagnoses in need of research. In comments made before the APA board's approval of the new draft, Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to people who were simply “quirky.” Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, also in earlier comments, said that several proposals in the pending DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said the manual would elevate “temper tantrums” to disruptive mood dysregulation disorder. Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend. The DSM-5 also will include some new disorders, including excoriation (skin picking) disorder and hoarding disorder. Binge eating disorder will be moved out of the DSM-IV's Appendix B, used for diagnoses requiring further study, and into the main manual. Posttraumatic stress disorder (PTSD) will be made part of a new chapter on Trauma- and Stressor-Related Disorders in the DSM-5. There will be a greater focus on the behavioral symptoms associated with PTSD, according to the APA. Many areas will remain relatively unchanged. The categorical model and criteria for the 10 personality disorders in the DSM-IV will remain the same in the new manual. However, to encourage further study on how personality disorders can be diagnosed, the DSM-5 will include a separate section with new trait-specific methodology.

DSM‐5and Bereavement: The Loss of Normal Grief?

The mood disorder work group has proposed to eliminate the bereavement exclusion criterion from the diagnosis of major depression in the 5th edition of theAmerican Psychiatric Association's (2012)Diagnostic and Statistical Manual of Mental Disorders. The proposal would break tradition with the long‐held distinction between depression and normal bereavement. This article reviews the development of the bereavement exclusion, discusses evidence for and against the proposal, and offers some relevant implications for counselors in light of the research on depression and bereavement.

Effect of optimism/pessimism attitude on depression and coping strategies

Depression is a word used by mental health professional to refer an illness or group of illness called mood disorder. Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. It's impossible to escape life's ups and downs. Feeling unhappy or sad in response to disappointment, loss, frustration or a medical condition is normal. Many people use the word to explain these kinds of feelings, but that is really situational depression, which is a normal reaction to events around us. Clinical depression, though, overwhelms and engulfs your day to day life, interfering with your ability to work, study, eat, sleep, and have fun. It is unrelenting, with little if any relief. True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period of it.There is a difference, however, between a normal grief reaction and one that is disabling or unrelenting. While there's no set timetable for grieving, if it doesn't let up over time or extinguishes all signs of joy laughing at a good joke, brightening in response to a hug, appreciating a beautiful sunsetit may be depression. Brown and Haris (1978) reported that depression increases with the age due to several factors of day today life like burden of responsibility, sleeping problems, declining health etc.Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events.There are many different ways of coping but they all involve making some change in input-output relationships. Thus some methods of coping involve changing, controlling and even avoiding certain inputs, whether the problem is attacked by working on inputs that in internal processes or outputs, it will be one of the two major ways of adjustingdefensive coping or direct coping. Defensive coping involves protecting oneself by getting away from threatening inputs. Direct coping involves meeting challenges head on. Coping with stress may begin with the occurrence of a stressful even, during exposure to stressor and finally after it has taken places. However, successful coping with stress should depend on a number of factors such as individual attitude, perception of life stress and suffering and personal skills, capability of problem solving and decision making. Raju, Rohini, and Naga (2008) revealed that among the old age people 21.3% of them were severely depressed and diabetes is experienced mostly by the elderly whose age is between 70-80 years. The severely depressed older adults were suffering with blood pressure and asthma. The mildly depressed older adult's experiences suicidal tendencies, hearing problems, loneliness, diabetes and problem with the eyes.Sahu, (2007) found gender differences on life stress and significant negative relationship between life stress and coping was observed. It was also extended for males but this relationship was not found significant for females. Folkman, S. and Lazarus, R.S (1980) evaluated age difference in the use of problem focused coping and emotion focused coping among individuals aged 45 to 64. The younger group was found to use emotion focused approach more i.e. they used more of accepting responsibility, distancing more than o lder group.Considering the above facts the present study was undertaken to observe the Optimists and Pessimists on Depression and Coping strategies.Hypotheses of the studyTo achieve the main objective of the study following hypothesis are framed;* Optimists will have significantly low level of Depression as compared to Pessimists and its dimensions.* Optimists and pessimists will differ significantly on the tendency of using Coping Strategies and its dimensions.MethodParticipantsThe total sample was consisted of 255 optimists and 191 pessimists subjects. …

Measuring Grief and Depression in Seriously Ill Outpatients Using the Palliative Grief Depression Scale

Almost all persons experience grief when faced with a serious illness.1,2 The grief experienced by seriously ill patients often manifests as physical symptoms (insomnia, loss of appetite, etc.) and emotional, social, spiritual, cognitive, and behavioral changes through which a person attempts to resolve or adjust to the losses imposed by the serious illness. Depression, while common in seriously ill patients, is neither a normal nor a universal phenomenon.3 Depression is underdiagnosed in seriously ill patients, though the prevalence is high. In a recent meta-analysis4 which reviewed 70 studies with 10,071 individuals across 14 countries in oncological, hematological, and palliative care settings, the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM)-defined major depression was 14.9% (range: 12/2%–17.7%); for DSM-defined minor depression, 19.2% (9.1%–31.9%); and for all types of depression, 20.7% (12.9%–29.8%). Persistent dysphoria, anhedonia, a sense of hopelessness, helplessness, worthlessness, and an active and persistent desire for an early death could be manifestations of depression2,3 in seriously ill patients. Depression, when present, significantly diminishes the quality of life of these patients and likely complicates the presentation and optimal palliation of other distressing symptoms such as pain and fatigue. Distinguishing between grief and depression in seriously ill patients is vitally important, as the treatments differ.3 Normal grief, an adaptive process, often responds well to counseling and ongoing support. In contrast, depression is a pathological state causing significant distress and needs to be treated with a combination of nonpharmacological and pharmacological modalities. If diagnosed and treated appropriately, depression can be palliated effectively in seriously ill patients.5 Differentiating grief from depression in seriously ill patients Differentiating between grief and depression2,3 is especially challenging in a seriously ill patient population due to the following reasons: (1) grief and depression share common symptoms and may coexist; (2) many of the somatic symptoms traditionally used to diagnose depression (appetite, weight and libido changes, loss of energy, insomnia) may be present as a part of the serious illness process or due to grief; (3) the affective changes used to identify depression (sadness, crying) are also seen in grief; (4) there is a common misperception that depression is a universal and normal phenomenon in a seriously ill population. Thus clinicians may fail to routinely screen these patients for clinical depression. Therefore there is a great need for a robust instrument that will aid in measuring grief and distinguish it from depression in a seriously ill population.

Fallacious reasoning in the argument to eliminate the major depression bereavement exclusion in DSM‐5

Fallacious reasoning in the argument to eliminate the major depression bereavement exclusion in DSM‐5

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5?

The proposed changes to DSM-5 will create new categories of mental disorder (referred to here generically as Prolonged Grief Disorder'' [PGD]) to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief (e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness). The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: (1) PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; (2) PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; (3) PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; (4) PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and (5) PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.

Recurrence of Depression After Bereavement-Related Depression

The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (≤ 2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920-928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

Recent Data Lead to Shift in PTSD Criteria

Recent Data Lead to Shift in PTSD Criteria

Grief reactions in dementia carers: a systematic review

Supporting dementia carers is an identified target of the UK government, yet we know little about such family carers' grief before and after the death of the person with dementia for whom they care. We systematically review the existing literature on characteristics, prevalence, predictors and associations of grief in dementia carers before and after death. We searched electronic databases and found 31 publications meeting predetermined criteria. Grief in dementia carers, which may be normal or complicated, is a complex reaction to losses occurring before and after death. Carers experience anticipatory grief as multiple losses for themselves (companionship, personal freedom and control) and the person with dementia. Anticipation and ambiguity about the future, anger, frustration and guilt are core features. Anticipatory grief is greatest in moderate to severe stage dementia and spouse carers, especially when the person with dementia is institutionalised. There was poor quality evidence about the prevalence of grief; studies reported anticipatory grief between 47% and 71%, and complicated grief after death is estimated around 20%. Carer depression increases with anticipatory grief. Being a spouse carer and being depressed are the strongest predictors of complicated and normal grief after death. Grief in dementia carers can be expected; however, those at risk of distressing anticipatory and complicated grief may be identified and targeted for intervention when necessary. Higher quality research from a wider range of samples and countries is needed to explore this complex and emergent topic.

‘That Weeping Constellation’: Navigating Loss in ‘Memoirs of Textured Recovery’

In The Year of Magical Thinking, Joan Didion laments the absence of any significant body of literature that will help her through her grief. I propose that the grief memoir fills this gap left by professional literature of bereavement and itself contributes to a community of mourners missing from contemporary grief practices as identified by Sandra Gilbert and Darian Leader. This genre, new to literary analysis, provides a fertile ground for the discussion of recent literary and psychoanalytic analyses of mourning that have resisted the neat split Freud draws between normal and pathological grief. My chosen texts deliberately complicate ‘packaged and frozen’ (Ellmann qtd. in Payne, Horn and Relf 78) notions of recovery while honouring what Jenny Diski calls the ‘texture of experience.’ As such, I am essentially identifying a sub-genre of the grief memoir, which I call ‘memoirs of textured recovery.’ What sets them apart is the performance of complex ‘recovered’ selves that show how ‘recovery,’ ambiguous and shifting in nature, calls for more complicated theories of mourning able to accommodate an understanding of grief not in terms of Freud's absolute recovery nor Tennyson's ‘loss forever new’ (Laura Tanner), but rather a space located somewhere in between.

Living with grief

Living with grief

Dealing with Our Losses: When Our Work Hits Home (513)

1.Review literature regarding how health care providers can deal with death and serious illness on a regular basis and maintain purpose and avoid burnout.2.Discuss strategies for dealing with and preventing burnout in hospice and palliative medicine.3.Explore possible means to dealing with our own personal losses, in the midst of ministering to the needs of our patients. Twenty-five years have passed since Balfour Mount's “Dealing with Our Losses” highlighted the relationship between loss, stress, and clinical performance in field of oncology. In the years that have followed, the field of hospice and palliative medicine (HPM) has blossomed and become a viable career option, both for seasoned professionals pursuing a second career and newer providers coming right out of training. Evidence suggests that burnout may result from dealing repeatedly with suffering, death, and loss--a reality of our profession. While scant literature has surfaced regarding burnout in HPM professionals, it has been suggested that narrative is a major avenue for dealing with suffering and loss. The telling of the story and the opportunity share feelings and responses to situations with others appears to be valuable for HPM providers; the process being more cathartic than any potential outcome. Unfortunately, one loss all HPM providers will invariably encounter is personal loss--often in the form of death of a loved one. Positively, this may serve as the motivation to become an HPM professional or a source of ongoing professional satisfaction. Negatively, personal loss may affect interactions with HPM patients or intensify normal grief associated with patient loss. How HPM providers process their own losses may indeed impact how their patients are cared for, perhaps even more than in other fields. The goal of this session is to explore collectively--audience and presenters--how our personal and professional stories may impact the care of our patients. We will discuss how to incorporate personal experiences appropriately, without allowing them to unfairly shape our practice. Lastly, we will explore strategies on how to “insulate oneself” from the repeated suffering witnessed as HPM providers, leveraging individual coping strategies, in an effort to promote sustainability and improve patient care.

Bereavement and Depression: Possible Changes to the Diagnostic and Statistical Manual of Mental Disorders: A Report from the Scientific Advisory Committee of the Association for Death Education and Counseling

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is being revised. A proposed revision hotly debated is to remove what is known as the exclusionary criterion and allow clinicians to diagnose a person with a major depressive episode within the early days and weeks following a death. The Executive Committee of the Association for Death Education and Counseling (ADEC) commissioned its Scientific Advisory Committee (SAC) to examine the debate over removing the exclusionary criterion and provide a written report. The DSM-IV-TR classifies bereavement as a clinical condition that is not a mental disorder. The exclusionary criterion states that within the first 2 months of the onset of bereavement a person should not be diagnosed as having major depression unless certain symptoms not characteristic of a normal grief reaction are present. We note these symptoms when discussing the exclusionary criterion. In the report we identify the features that comprise the exclusionary criterion, examine reasons (including research conclusions and clinical concerns) given for retaining and for eliminating the exclusionary criterion, offer extensive comments from experienced licensed clinicians about the issues involved, discuss diagnostic and treatment implications, and offer specific recommendations for ADEC to implement.

Bereavement care in primary care: a systematic literature review and narrative synthesis.

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited. To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them. design systematic literature review. Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes. Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to 'medicalise' normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people. A small number of studies were identified, most of which were > 10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.

Concepts and Controversies in Grief and Loss

Although grief is a universal experience, the ways in which it occurs are not universally agreed upon. In fact, there is considerable controversy about the "normal" duration of grief, its expected outcome, and its course. Although most grieving adults will achieve a sense of normalcy at some point, others seem not to do so. Continuing impairment by grief raises a question: Is the experience qualitatively different from normal grief or is it different only in degree? This article discusses grief conceptualizations, including that of complicated grief, and approaches to grief counseling.