Death and Bereavement

Attachment and Loss in Children

According to Bowlby’s theory of attachment, children are predisposed at birth to form attachments with others. Over the first 2 years of life, they form attachments with their primary caregiver.

Separation from a child can lead to the following:

• Protest (usually seen during short-term separation, e.g., up to 2 weeks)
  • Crying, screaming, and clinging when parents leave
  • Anger toward parent upon return
• Despair
  • Protesting stops
  • Despondency and sadness
  • Child appears calmer but may be withdrawn and disinterested
• Detachment
  • If separation continues, the child will start to engage with others but will reject caregiver and remain angry
  • Indifference upon caregiver’s return

Mourning and Loss in Adults

Adults who are bereaved or are mourning the loss of a loved one also go through a period of adjustment. People move back and forth through the stages of adjustment (Kübler-Ross).

Not everyone passes through all stages or reaches adequate adjustment.

Table 3-4. Normal Grief vs. Depression

Normal Grief	Depression
Normal up to 1 year	After 1 year, sooner if symptoms severe
Crying, decreased libido, weight loss, insomnia	Same but more severe
Longing, wish to see loved one, may think they hear or see loved one in a crowd (illusion)	Abnormal overidentification, personality change
Loss of other	Loss of self
Suicidal ideation is rare	Suicidal ideation is common
Self-limited, usually <6 months	Symptoms do not stop (may persist for years)
Antidepressants not helpful	Antidepressants helpful

Recall Question

1. Which of the following patients matches with the appropriate screening test at the appropriate age?

   1. Breast cancer screening in women age <40
      
   2. Lung cancer screening in male smokers age >35 with low-dose CT
   3. Colorectal cancer screening in men age >50
      
   4. Abdominal aortic aneurysm screening in female smokers age 65–75
      
   5. All of the above are correct

Answer: C