Kids don’t like being called kids but they’ll proudly tell you their precise age. Adults too, prefer to define themselves rather than have a label stuck on them. As an adult and former kid, maybe this is why I’m getting bored of the word grief.
There’s more going on with me than grief and grief too has more going on inside it.
To find out if there are more precise words or a wider variety of labels to choose from, I emailed Dr Sidney Zisook of the University of California. I wanted to know if doctors and researchers who study grief, use more than the one catch-all word, and how they separate out grief from things like depression, trauma and shock.
Dr Zisook’s main concern was that when there’s been a bereavement, even experienced clinicians can mistake depression for grief. This is not a big deal if you’re suffering from grief but if you have depression along with grief then you’ll fare much better if the depression is recognised. Depression can be life threatening but nowadays there are many successful treatments available.
It’s worth noting that when doctors and medical researchers say depression, what they mean is a major depressive disorder.
Depression and grief
If you’re suffering from grief, in most cases your body and mind will work through what they need to do and over time you essentially heal yourself. If you are experiencing a major depressive disorder along with your grief, time probably won’t help and without some support or treatment, symptoms might get worse.
Rather than just wait to see if feeling very bad is going to turn into feeling unbearably bad, the DSM-5 is on hand to provide definitions.
DSM-5 is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association. (Psychiatrists in the UK tend to use the Wold Health Organisation’s International Classification of Diseases).
Dr Zisook points to a footnote on what clinicians should look out for if grief and depression are occurring at the same time. It says the main feelings with grief are “a sense of emptiness and loss”. Where there is grief with a major depressive episode, a persistent depressed mood is joined by “the inability to anticipate happiness or pleasure” which is so “even in the absence of reference to the deceased.”
It goes on to explain that: “In grief, self-esteem is normally preserved” while in a major depressive episode, “thoughts of worthlessness and self-loathing are also common.”
Dysphoria and consolability
Dysphoria is a sci-fi sounding word used to describe an intense sense of unease and dissatisfaction. In grief it comes and goes with the feelings of loss and sadness; in depression it mostly stays put.
Consolability sounds like a made up word but describes whether or not we are consolable. DSM-5 also compares how preoccupations and positive emotions differ when you’re in the grips of depression and when you’re not.
Different types of suicidal thoughts
Perhaps surprisingly, suicidal thoughts are not uncommon with grief but they are different to the suicidal thoughts experienced by someone experiencing depression. A person in acute grief might think of wanting to join the deceased person, while the suicidal thoughts of a depressed person are more likely to be about “feeling underserving of life, unable to withstand the seemingly unending torture of depression and/or mistakenly believing others would be better off without them.”
However Dr Zisook points out that no list of symptoms alone can be used to diagnose anyone. An assessment has to take into account a person’s unique history and environment. This is particularly so where the person has not experienced a major depressive experience before.
Anhedonia is a word that comes up a few times around this subject. It means the inability to feel pleasure from normally pleasurable activities. Grieving people commonly have a time when they don’t want to do the fun things they once did, maybe can’t even remember what fun is exactly. However, some never lose and some soon regain a spark of humour with a friend, an involuntary smile at the sight of a mischievous toddler or puppy, or a warm feeling when their team wins, a favourite song comes on the radio or they catch the scent of a cake shop. In the grips of a major depressive disorder, either you don’t notice or are unmoved by such things.
Reactions to trauma are another collection of things that share some symptoms with grief and also depression, and can occur alongside.
In “Understanding Your Reactions to Trauma”, Dr Claudia Herbert says that, “The experience of trauma often confronts you very suddenly with the possibility of your own and/or other people’s deaths.”
In widowhood this can vary from receiving news of your partner’s sudden death, to being with them when they die, to being hurt in an accident or violent crime where your partner did not survive. Some people will experience these things as trauma, some won’t, some will have a delayed response and none of us get to choose what our reaction will be.
One reaction to trauma is what Dr Herbert describes as feeling, “utterly numb and empty of all feeling and emotions”. This could equally describe the early days of grief and shock or the longer-term effects of depression. Dr Zisook says depression can occur after trauma, so it’s clear that trauma, like grief, could also mask depression.
I ask if there’s a name for the foggy-headed feeling attributed to shock. Apparently there’s not. I wonder if it’s another master of disguise that could be depression posing as shock, or trauma posing as grief because all four can make us feel as if our wheels are turning too slowly.
What about the unhealthy behaviours some of us get up to? I over-work or over-sleep, and I know widowed people who over-eat, over-intoxicate themselves and overly pursue other risky behaviours. I’d been thinking of this as numbing but Dr Zisook has a more interesting word. “All the things you mention are maladaptive” he says. This makes my word, “numbing”, sound like a feeble excuse.
Maladaptive doesn’t sound like a blame word but like malice, malpractice and Malcolm Tucker, it does sound like you’ve strayed into something that will do you no good. This serious but blame-free word might make it easier to seek help when help is needed.
Complicated grief further complicates the picture. I wonder if, when the rebuilding of a life is particularly hard going, could the depressed feelings caused by that be mistaken for complicated grief? Dr Zisook says complicated grief is often mistaken for depression but that trying to treat complicated grief with antidepressants doesn’t often help.
Both complicated grief and a major depressive episode tend to have symptoms sever enough to interfere with day-to-day activities. People usually withdraw from family and friends; some struggle to hold down a job; some lose the ability to look after themselves.
However, Dr Zisook explains a common difference between the two. In complicated grief, the sense of sadness, guilt and/or longing are focused on the person who has died. In depression, negative feelings are focused on the depressed person.
For example, where a person with complicated grief might be stuck in feelings of guilt about the death of someone, a depressed person’s sense of guilt would be more generalised and not specific to any one situation.
And so to normal grief. Only “normal” is not a helpful word, so what does the medical profession call the vanilla stuff of widowhood? Dr Zisook says, “We think of acute grief as the ordinary, almost instinctual reaction to bereavement.”
This word acute, helpfully separates grief over the death of someone very close to you, from the grief of losing a favourite coat, seeing your children start school or moving from a beloved neighbourhood to somewhere new.
However, the way in which we experience acute grief, and for how long, differs from person to person and from loss to loss.
Separation response and stress response
Within acute grief, Dr Zisook identifies a “separation response” and a “response to stress”. Again, these are very helpful terms. They explain, for instance, why some people’s first response is to refuse to believe that their partner has died, while others don’t question it. These people simply have different separation or stress responses.
To talk about both separation and stress is also helpful when confronted with someone who maybe only knows grief from tv shows. My guess is such people accept the separation bit but underestimate the scale of the stress bit.
Today’s scientists don’t have any set timetable in mind for how long our separation responses and stress responses are likely to last. They know it varies from person to person. As Dr Zisook puts it: “The process of adapting to a difficult loss can be lengthy, and emotions may wax and wane unpredictably.” However, “Over time, for most people, acute grief shifts into something we call “integrated grief” where the severe pain and preoccupation with the deceased shift into the background and life moves on. The intensity of grief diminishes as the finality and consequences of the loss are understood and future hopes and plans are revised.” This is not to say that some events might cause some of the feelings of grief to return, such as anniversaries or special family occasions, but in most cases these are just about missing someone we love.
Complicated grief, also known as prolonged grief disorder, affects 2-3% of the population worldwide
The World Health Organisation estimates that 350 million people, around one fifth of the population, live with or have experienced depression
There is no global bereavement figure because sooner or later we all experience the death of a friend or relative, but the Loomba Foundation estimates that in 2015 there were 237 113 760 widows around the world
How to help
If you think one of your widowed friends might be experiencing depression or complicated grief, remember the experts struggle to make accurate diagnoses so just be a friend. Let them know you care about them, listen, don’t judge, and the Mind website has lots of details on how to be supportive
Support for depression
In the UK, some good places to start are
http://www.nhs.uk/, http://www.mind.org.uk and specifically for men under 45, https://www.thecalmzone.net
Mind has an online forum, CALM offers webchat and both have helplines.
Your GP will be able to advise you on support groups in your area. If you’ve been a carer, have served in the armed forces, are a solo parent or are living with another condition where depression is common, such as cancer, you might find that some charities offering support to that group of people also offer support for depression.
Image by iStock.com / rudchenko
First published in Issue 12 Widows and Widowers magazine