Health Impacts of Grief
Grief—A Significant Public Health Issue
The primary task of the public health community is to promote health and prevent disease. Identifying factors that affect the health and well-being of individuals or populations is necessary to reduce the risk of ill health. This is especially relevant for bereaved individuals who experience significant stress after the loss of someone or something significant in their lives. Epidemiological studies have uncovered a significant correlation between grief and ill health (Doka, 2016), and though pinpointing cause and effect within those relationships has been problematic,1 research does help us to better understand the health impacts of what is considered “normal grief” and more complex, debilitating grief commonly termed “complicated grief” (Prigerson et al., 2009).2
It is important to acknowledge that loss and grief are universal human experiences, with individual reactions expressed through emotions, behaviors, and thought processes. In other words, grief can be experienced emotionally, physically, cognitively, and spiritually (Doka, 2016). Common emotional expressions of grief include sadness, yearning, loneliness, guilt, anger, and possibly shame and isolation. Physical manifestations can include headaches, muscular aches, menstrual irregularities, fatigue, chest pains, tightness in the throat or chest, abdominal pain, shortness of breath, weakness and oversensitivity to stimuli, or sexual dysfunction. Common psychological manifestations of grief can include increased rates of depression and anxiety, but irritability, anger, disorientation, or inability to concentrate can also be evident (Prigerson et al., 1997). Socially, grief can cause mourners to lose interest in daily routines and familiar activities, which may lead to withdrawal from family and friends. Spiritually, grief can cause us to question our belief systems, and at times, shakes the very foundation of our faith.
And yet, there are some discernible patterns in how the bereaved generally respond to grief.
Patterns of Grief Response
Some time ago, Parkes (1998) observed that the moment of death (or hearing that death of a loved one has occurred) typically causes great distress in an individual—but that in Western society that distress is quickly repressed and followed by a kind of emotional numbness that can last hours to several days. Parkes referred to this as the first phase of grieving. Second-phase grieving involves intense feelings of pining accompanied by intense intermittent anxiety. Appetite and weight are lost, concentration and short-term memory are reduced, and the bereaved person often becomes irritable and depressed. This usually gives way to third-phase grieving, marked by disorganization and despair. Weight is usually recovered after 3–4 months, and sexual and social appetites generally return, with overall recovery after about two years.
Other researchers have conceptualized response to grief as ranging from minimal psychological disruption (equated with resilience) (Bonanno and Kaltman, 2001), to acute grief lasting 1–2 years (Mancini and Bonanno, 2006), to severe and debilitating grief (sometimes life threatening) lasting longer than two years. This latter response is referred to as complicated grief (Prigerson et al., 1995) or prolonged grief disorder (PGD) (Prigerson et al., 2009). Another view is that grief response exists on a continuum, where resilient individuals regain psychological equilibrium fairly quickly after a loss (Bonanno and Kaltman, 2001), to somewhere in the middle where moderate distress is experienced in the form of shock, anguish or sadness, but over time the bereaved adapt to the loss. At the far end of the spectrum is protracted grieving, where the bereaved experiences profound separation distress, emotionally disturbing memories of the deceased, emptiness and meaninglessness, and an overall inability to accept the loss (Holland et al., 2009).
Serious Health Impacts and Risk Factors
Unfortunately, complicated grief can lead to serious medical, psychological, and psychiatric impacts3 (Lichtenthal, Cruess, and Prigerson, 2004). But even “uncomplicated” grief can have serious health impacts. Physiological impacts can include impairment of the immune response system, increased adrenocortical activity, serum prolactin, increased growth hormone, psychosomatic disorders, and increased mortality from heart disease (especially in elderly widowers). Parkes (1998) discovered that about one-quarter of widows (and widowers) experience clinical depression and anxiety during the first year of bereavement. He also found increased rates of cardiovascular disease and impaired immune system, which he believed influenced the onset of disease such as cancer (Parkes, Benjamin, and Fitzgerald, 1969). More recent research has confirmed that widows have poorer physical health and greater weight loss over a three-year period following the death of their spouse (Wilcox et al., 2003) than other women. As well, widows who experience traumatic grief have been found to be at even greater risk of cancer or heart attack (Chen, et al., 1999).
When Prigerson et al. (1997) examined the longer-term health impacts of complicated grief, she found that the presence of traumatic grief symptoms approximately six months after the death of a spouse predicted negative health outcomes such as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. Prigerson concluded that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors, but “it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction” (1997, p. 616).” Interestingly, Prigerson et al.’s research also identified that certain precipitating factors appeared to be associated with traumatic grief, including compulsive care giving, excessive dependency, and defensive separation (Prigerson et al., 1997).
Other research has confirmed additional risk factors that correlate with complicated grief. They include insecure attachment, negative interpretations of grief reactions, lack of meaning, lack of preparedness for death, a perception that the loved one suffered before death, low social support, care giver burden, and some history of psychopathology (Burke and Neimeyer, 2014). The most predictive factors have been found to be low levels of social support, avoidant/anxious/insecure attachment style, discovering the body (in the case of violent death), being a spouse or a parent of the deceased, high levels of pre-death marital dependency, and high levels of neuroticism. Burke and Neimeyer (2014) concluded that:
Inasmuch as CG [complicated grief] is conceptualized as an attachment-based disorder, with symptomatology indicative of separation distress and preoccupation with the deceased, it is understanding that mourners who are vulnerable to feeling abandoned and alone,4 who suffer from excessive anxiety or obsession, and who lose a security-enhancing- or care-providing relationship, under conditions of minimal support, and perhaps in circumstances that leave them struggling with post-traumatic imagery, would be especially prone to the development of CG. (p. 15)
It is not surprising that these individuals often turn to consciousness suppressors, such as alcohol and tranquilizers,5,6 to help them cope with grief. A recent Harvard Medical School report7 noted a dramatic increase in mental health disorders between 1996 and 2006—doubling among adults age 65 and older. During that same time period, rates of psychotropic medication use also increased by about the same percentage (Novotney, 2009). As DiGiacomo et al. pointed out in 2013, “The feminization of ageing and an increasing number of older women living alone with multiple chronic conditions represent significant challenges to health services and societal support systems. Older women’s transition to widowhood signals concomitant health transitions and multidimensional support needs.” Research confirms that the combination of comorbidities, polypharmacy, and risk behaviors influencing medication management can have a serious and adverse effect on health events.
Conversely, monitoring factors such as social and psychological supports to assist women in their quest to find meaning in the loss they have experienced8 has been found to help mourners adapt to the life changes that loss causes (Neimeyer, Burke, Mackay, and van Dyke-Stringer, 2009). Bereaved individuals’ efforts to make sense of loss appear to be a strong positive predictor of subsequent well-being (e.g., interest, excitement, accomplishment in life).9
Addressing Grief in Healthy Ways
Working through grief is not an easy task. It takes courage and it is hard work. Because it is hard work, a woman experiencing grief is usually physically exhausted and vulnerable to disease and illness—the result of insomnia, stress, poor dietary habits, and lack of adequate exercise. She is psychologically drained by the emotions of grief, which include sadness, anger, guilt, and anxiety, resulting in depression and low self-esteem. Social isolation is also a real problem—the necessity of moving away from familiar social settings and friends due to employment or the need to upgrade education, for example. These things can compound the loneliness and hollowness felt when a significant relationship ends.
Successful recovery from loss and grief is best achieved when recovery efforts involve intertwining physical, psychological, and social components into a regular routine associated with the basic activities of daily living. A return to order in one’s life is essential, and strict adherence to a healthy routine must encompass proper diet, adequate rest, and exercise.
Diet
Meals should be eaten at regular times every day. The atmosphere at mealtime should be peaceful and relaxed to avoid overstressing the body during digestion. Fast foods, take-outs, and drive-thru dinners are not conducive to healthful living, especially when the high-fat, high-caloric food is opened and digested in front of the television set. Two meals per day are adequate for most individuals, with perhaps one or two healthy snacks such as fresh fruit or low-fat yogurt. Large meals should be avoided because of the lethargic effect, which zaps energy and increases feelings of fatigue, compounding the problem of depression.
Skipping meals should be avoided. The yo-yo effect of high and low levels of blood glucose adds unnecessary stress at this crucial time of recovering from grief. The way to maintain a constant level of glucose and its effect is to eat meals high in complex carbohydrates (whole grain cereals, potatoes, pasta, rice, and beans). An added advantage of eating complex carbohydrates is that these foods also contain dietary fiber, which assures intestinal health and efficient elimination. It also may prevent colon cancer and can aid in lowering blood cholesterol levels essential in the prevention of cardiovascular disease. (As mentioned, these diseases have been associated with grief distress [Parkes and Prigerson, 1989].) Protein consumption is also important in a balanced diet, but the amount should be limited to low-fat varieties such as chicken; fish; or, if vegetarian, beans. Red meat should be avoided due to its high fat content. Some fat in the diet is necessary, but required amounts are far lower than the typical American diet includes. For some women, loss of appetite and weight loss occurs during bereavement. For others, the stress associated with grief’s emotions lead to overeating and weight gain. Therefore, caloric intake should be individually calculated in conjunction with an exercise plan.
Exercise
It is well known that the death of a loved one can cause the stress level in a bereaved person to be extremely high, and without proper care this can lead to serious health problems. Anxiety and stress related to finances, housing, loneliness, guilt, children’s education, and a myriad of other issues surface quickly after a death, and the bereaved person needs to focus on relieving stressful feelings in order to successfully cope with his or her loss. Unfortunately, this can be a long process for many, and it can be a never-ending one for others.
Tranquilizers are a common method used by physicians to relieve anxiety and stress, but they are not always beneficial to the bereaved because they delay the grieving process. Physicians and mental health professionals alike are beginning to recommend exercise to their patients to improve mood (Hays, 2009). (A positive byproduct is that exercise also helps to reduce weight and lower cholesterol.)
A number of research studies highlight the effectiveness of short-term aerobic exercise to reduce anxiety sensitivity (Broman-Fulks and Storey, 2008; Smits et al., 2008; Strohle et al., 2009). And, participation in a program of strenuous aerobic exercise has been shown to be effective in reducing depression (McCann and Holmes, 1984). This is especially relevant for the bereaved because depression is a natural consequence of loss.
Exercise has also been found to be equally effective to antidepressants for treatment of depression, particularly in older persons (Blumenthal et al., 1999). Greater reductions in anxiety have been reported for exercise groups than for groups receiving other forms of anxiety-reducing treatments (Wipfli, Rethorst, and Landers, 2008). Even in the short term, people who exercise report that they feel better (Weir, 2011).
To reiterate, exercise serves as an antidepressant and offers resistance to physiological and emotional consequences of psychological stressors, including anxiety (Salmon, 2001). Exercise is therapeutic and has many physiological and psychological benefits, including self-mastery and social integration. It is often the first step in lifestyle modification for the prevention and management of chronic disease (Anderson and Shivakumar, 2013), for which the bereaved are at risk because of sedentary lifestyles that depression can precipitate.
In 2002 the U.S. Department of Health and Human Services reported that regular exercise significantly reduces causes of mortality by up to 30 percent for men and women across all age groups and racial/ethnic categories. The Centers for Disease Control and Prevention recommends 30 minutes of moderate- to high-intensity exercise for at least five days a week for all healthy individuals.10 Several epidemiological studies have shown that exercise improves one’s self-esteem and sense of well-being, slows rates of age-related memory and cognitive decline, and reduces signs of depressive and anxiety symptoms. As well, exercise offers a protective factor against the development of mental disorders (van Minnen, Hendriks, and Olff, 2010). Physical exercise can positively impact cognitive functioning and may represent an effective strategy to improve memory in those who have begun to experience cognitive decline (Nagamatsu et al., 2013). These findings are all relevant to the increasing population of widows reflected in the baby boomer bulge.
One type of exercise that has received much attention in enhancing psychological well-being is running (Ekkekakis, 1995). Running has been shown to have a positive effect on depression, nervousness, inability to sleep, and inability to cope with the environment (Griest et al., 1978). Physicians, psychiatrists, and psychologists are beginning to support running as a method of treatment. In his book The Joy of Running (2013), psychiatrist Kostrubala, MD, reported that in conversations with runners who run short, long, and medium distances, running done in a particular manner is a natural form of psychotherapy. Kostrubala discussed the occurrence of an “altered state of consciousness” during which runners experience a euphoric “runner’s high.” Anderson and Shivakumar (2013) reported similar findings linking the positive effects of running on specific psychological and emotional states: depression, anxiety, and self-esteem—all potential problem areas with the bereaved. The consensus among veteran runners is that running is relaxing and reduces tension. It helps to take one’s mind off problems by distracting, and the positive effects of running are sustained long after the run is over. What is more, running increases respiratory efficiency, muscle tone, and blood volume, and helps with weight control; moreover, in comparison to other therapies, is inexpensive and time efficient.
Another popular exercise that has been found to be beneficial to the bereaved is yoga. Yoga can improve overall physical fitness, strength, flexibility, and lung capacity while reducing heart rate, blood pressure, and back pain. It also strengthens social attachments, reduces stress, and relieves anxiety, depression, and insomnia. Yoga is being used with post-traumatic stress disorder (Novotney, 2009) and is a proven strategy to benefit mental health. It enhances resilience and improves mind–body awareness and is a natural and readily available approach to maintaining wellness and treating mental health issues (Novotney, 2009). Yoga appears to modulate stress response systems and decrease physiological arousal (reducing heart rate, lowering blood pressure, and easing respiration). As well, there is indication that yoga helps to increase heart rate variability, an indicator of the body’s ability to respond to stress more flexibly (Harvard Health Publications, 2009).
Rest
The mind and body require rest. Different individuals participate in various activities that encourage relaxation (including meditation or massage), but sleep is most basic to mind and body relaxation. The amount of sleep needed is an individual requirement, averaging between six and eight hours per night. Setting up a routine of rest and activity means a period of trial and error. The importance of regularity in sleep patterns cannot be overemphasized for the bereaved. Sleeping late in the morning after a late night does not guarantee adequate rest. To function at an optimum level, the mind and body must be maintained with a balance of nutrition, exercise, and rest. Again, exercise, rather than medications, is a preferred choice to support good sleep.
Psychological Well-Being
The importance of psychological well-being cannot be underestimated in the grieving process. The support of a psychiatrist or psychologist may be helpful to listen to and ascertain the level of support appropriate in the bereaved’s situation. Widow-to-widow programs and divorce groups, for example, can have a positive effect on the bereaved’s grieving process.
One finding that may seem surprising is humor as a wellness strategy for the bereaved. Research indicates that recently widowed women (and men) rated humor and happiness as being very important in their daily lives, and that following the death of their spouse, they were experiencing these emotions at higher levels than they expected (Lund et al., 2008). Being involved in social interactions that create and promote happiness, are enormously beneficial to the bereaved.
Conclusion
Progressing through grief can be a starting point for the bereaved to develop new positive lifestyle habits, a new outlook on life, and active self-realization and self-fulfillment. Controlling factors such as diet, exercise, sleep, and connection or reconnection to family, friends, and community may be the first steps to regaining control of one’s life rather than passively accepting the feelings of helplessness and depression that can lead to serious physical, emotional, and psychological problems. Although it is not easy, the bereaved do have an opportunity to lead happy, healthy, and fulfilled lives by drawing on their own inner strengths and resources as well as the support of caring others around them, to learn “how to be and act in a world transformed by loss” (Attig, 2011, p. viii).
Controlling the basic aspects of one’s life, such as what we eat, how we spend our free time, and how we look, contribute greatly to our overall sense of self-esteem, which often controls our psychological and emotional well-being. Rather than letting eating habits become destructive or letting physical tension build up, a sensible diet and sustained program of exercise can lead to physical and emotional stability. A person who is in control of her own life on every level is happier and more fulfilled than a person who feels manipulated by a sense of fate. A person who may have been living passively previous to loss may be shocked into having to assume more control over her own life. Although it may seem counterintuitive, loss and grief can be tremendous opportunities for relearning both our world and ourselves.
Notes
1. Establishing causal effect is difficult because of the complexities of human behavior and circumstances of individuals prior to their loss; compounding this difficulty is the difficulty as well of tracking these same individuals over the long term; thus the lack of availability of pre–post data.
2. Prigerson et al. (2009) identified that criteria for prolonged grief disorder (PGD) included in the DSM-IV or ICD-10 can enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.
3. Prolonged grief includes symptoms that have been found to be conceptually linked to depression and several other comorbidities (Schaal, 2015).
4. Other research supports this conclusion. Older adults with long mental health histories, and perhaps multiple previous losses, may also be at considerable risk of complicated grief (Shah and Meeks, 2012).
5. It has been commonly accepted that women who were too socially dependent on their deceased spouses often had greater adjustment problems than women who were not (Lopata, 1973, 1979).
6. In general, grief interventions and treatment targeted for improving depression have been found ineffective in dealing with complicated grief (Shah and Meeks, 2012).
7. Harvard Health Publications (2009), Health Affairs, 28(3) May/June, http://www.health.harvard.edu/mentalextra.
8. The concept of widows developing new identities is not a new one (Lopata, 1979) and has been supported in counseling and therapy approaches since the 1980s (e.g., Worden, 1982).
9. Narrative therapies and processes have also been found to offer opportunity for both continuity and change (Romanoff, 2001). Spiritual beliefs in God’s existence have also been found to be related to less grief (Easterling et al., 2000).
10. Many organizations across the United States support exercise (e.g., Hospice Caring Project of Santa Cruz County–Center for Grief and Loss, Mayo Clinic).