3.4C – Week 3 – Grief (DSM-5-TR is the focus!)
Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., Carr, D., &
Nesse, R. M. (2002). Resilience to loss and chronic grief: a prospective study from pre-loss to 18-
months post-loss.
The majority of bereavement research focuses on post-loss experiences, leading to a lack of understanding of
diverse grieving trajectories and their predictors. This study examined 205 individuals several years before the
death of their spouse and at 6- and 18-month intervals post-loss. The researchers identified five core
bereavement patterns: common grief, chronic grief, chronic depression, improvement during bereavement, and
resilience. Common grief was uncommon, while resilience was the most frequent pattern. Pre-loss predictors
were investigated for chronic grief and resilience, revealing that chronic grief was associated with pre-loss
dependency, while resilience was linked to pre-loss acceptance of death and a belief in a just world.
The passage makes two main points:
First, it says that some patterns of grief can only The passage also talks about differing views on the
be understood with information from before the absence of distress after a loss, suggesting it might
loss. Second, it explains that not having data indicate denial, grief inhibition, or a lack of attachment.
before the loss makes it hard to figure out why Interestingly, it suggests that the lack of distress might
people react differently to loss. For example, it actually show resilience, a viewpoint often overlooked in
mentions the challenge of telling apart chronic bereavement research. The author proposes that
grief from pre-existing chronic depression (no exploring this link could connect with recent research on
study has distinguished the two). resilience in different life stages and in response to
various life stresses.
Chronic Grief
It is well established that depressed individuals tend to overestimate both the intensity and the number of
previous symptoms of depression. Thus, bereaved pp suffering from chronic grief or depression may similarly
overestimate their prior emotional difficulties. It’s important to distinguish chronic depression from chronic
grief reactions, and that such a distinction be made using actual pre-loss data rather than data collected
retrospectively during bereavement.
The absence of grief: pathology or resilience?
Historically, bereavement theorists have viewed the absence of overt grieving as a sign of psychopathology, as
they found it important to work through the pain of loss. ‘Absent’ grief was seen as denial or inhibition (self-
conscious and unable to act in a natural way), maladaptive (unable to adjust to the environment) in the long
run. Arguments against these are that some pp do not show overt signs of distress because of quick adjustment
following expected loss or because of personality factors that promote an inherent resilience to loss. In fact,
recent studies show that most conjugally (marriage related) bereaved failed to show even mild dysphoria.
Thus, a greater understanding of resilience (instead of psychopathology) is needed.
Delayed Grief and Improved Functioning during bereavement
Delayed grief, the absence of overt signs of grieving means that depression will eventually be manifested as a
delayed reaction, has always been understood as a genuine phenomenon. In each of the 6 analyzed studies,
the % that showed delayed grief (i.e., low initial distress to high distress at a subsequent time point) was
extremely low.
Some pp might actually show improved psychological health after the death of their spouse, theorists have
noted that when a spouse has a serious illness, or when the martial relationship is characterized by high
degrees of stress, the death may provide relief or escape from a chronically stressful situation.
Studies reporting percentages of respondents after the loss of a spouse show a significant minority
experiencing chronic grief reactions.
, These studies only assessed distress Surprisingly, some participants show common, time-limited grief
post-loss, raising the possibility that reactions, but a considerable percentage, and sometimes a
this group consists of two subgroups: majority, display little or no distress after the loss. This latter group
- One subgroup with an intense may also be divided into two subgroups:
reaction to the loss. - A resilient group with minimal distress both before and
- Another subgroup exhibiting after their spouse's death.
elevated distress symptoms - Another subgroup distressed before the loss but improved
both before and after the loss. afterward.
- Participants were initially categorized into low and high pre-loss depression groups.
- Changes in depression were analyzed separately for each group, considering the group's standard
deviation to control for regression to the mean in high-depression participants.
- The study aimed to observe three basic bereavement outcome patterns: common grief, chronic grief,
and absent grief, as seen in previous studies with only post-bereavement data. The expectation was
not to find evidence for delayed grief reactions based on earlier reviewed studies.
- The inclusion of pre-loss depression scores allowed the study to empirically distinguish chronic grief
from chronic depression and identify a stable low depression or resilient pattern from improved
functioning.
- As grief reactions involve symptoms beyond depression, the study also examined the association of
each pattern with other grief symptoms, such as yearning
Pre-loss predictors of divergent reactions to conjugal loss
Bonanno et al. analyzed previous studies to create a set of pre-loss variables that have been associated in
previous work with the chronic and absent grief patterns. Next, this study examined how well these pre-loss
variables predicted the various patterns of grief reaction.
Qualities of the Conjugal Relationship
The literature commonly assumes that chronic grief is a result of conflict in the marital relationship,
ambivalence toward the spouse, or excessive dependency. Chronic grief may be linked to dependency as a
conjugal relationship feature or as a broader personality characteristic.
- Attachment style, specifically the "anxious/ambivalent" or "preoccupied" style, is considered by
researchers as related to intense and prolonged distress following the loss of a loved one.
- Individuals with an anxious/ambivalent attachment style may experience distress and preoccupation
with the relationship even before the loss occurs. Attachment style is also proposed as an
explanation for absent grief, suggesting that bereaved individuals who don't show overt grief may
have been superficially attached to their partner, possibly due to prolonged relationship conflict.
- Individuals with an avoidant or dismissing attachment style tend to limit their emotional
dependence on their relationship partner. As a result, these individuals exhibit relatively little
distress when the relationship comes to an end. Research findings support this idea, showing that
avoidant individuals report less distress compared to others after the termination of a romantic
relationship.
There is a suggestion that chronically depressed or depressed-improved individuals, more than chronically
grieved individuals, may exhibit relationship ambivalence. Emotional distance is mentioned as a
characteristic of people who show little grief after a loss.
Coping Resources
Coping resources play a crucial role in moderating adjustment to stressful life events, including interpersonal
loss.
Personality traits associated with coping efficacy, such as emotional stability (low Neuroticism),
Conscientiousness, Agreeableness, Openness to Experience, introspection tendency, and perceived
confidence in coping, are considered buffers against the destabilizing nature of conjugal loss.
Religious involvement is seen as a coping resource that fosters resilience during bereavement by providing a
stable, shared belief system and social support from the religious community.
Recent factor analytic studies of religious involvement identify two dimensions:
, Meaning (World view)
Finding meaning is considered a fundamental aspect of the grieving process, suggested by numerous
bereavement investigators.
Context
- Losses in the context of serious spousal illness, particularly when intensive caregiving is involved,
may be experienced as relief from chronic stress, leading to improved psychological health during
bereavement.
- Supportive resources, including perceived social support from friends and relatives and instrumental
support (financial resources, help with home and familial responsibilities), are identified as
contextual factors in the bereavement literature.
In the current study, two sets of predictions were formulated regarding the relationship between specific
pre- loss factors and bereavement patterns:
- In addition to the two sets of predictions, the study examined whether factors hypothesized in
bereavement literature as precursors of chronic grief or resilience might be more reliably associated
with chronic depression or depression followed by improvement during bereavement.
- Due to the lack of pre-loss functioning data, chronic grief may be confused with chronic depression,
and resilience may be confused with improved functioning post-loss.
Method
- The study focused on bereaved participants from a sample of 1,532 married individuals in the Detroit area.
- Eligibility criteria for the CLOC study included being English-speaking, married, and having a husband aged 65 or older.
- Baseline interviews were conducted between June 1987 and April 1988.
- Participants who lost a spouse were identified using obituaries and death records, and follow-up interviews were conducted
at 6 and 18 months post-loss.
- Of the 319 widowed respondents, 205 participated in both follow-up interviews. Nonresponse reasons included ill health,
death, or refusal to participate.
- Analyses were based on the 205 widowed individuals (180 women, 25 men) who completed both follow-up interviews.
- Participants who stayed or dropped out did not significantly differ in pre-loss depression.
- The average age of participants at 6 months post-loss was 72 years.
