WebMD Medical News
Louise Chang, MD
Feb. 21, 2007 -- What is "normal" when it comes to grieving the loss
of a loved one? A new study offers some surprising answers, finding acceptance
and longing to be far more common than disbelief and depression.
The study included only survivors of people who died of natural causes. Most
had lost middle-aged or elderly spouses to illness.
In this population, yearning and other grief symptoms typically began to
subside after six months.
"We found that it was normal to yearn for a lost loved one up until this
time," researcher Holly G. Prigerson, PhD, tells WebMD. "But people
whose symptoms persist beyond this are at risk for having ongoing complications
associated with loss."
The notion that the grief process occurs in orderly stages is widely
accepted, but studied little. According to the "stage theory," the
process includes stages of disbelief, followed by yearning for the lost loved
one, anger, depression, and acceptance.
The new study, published in the Feb. 21 issue of The Journal of the
American Medical Association, is among the first to examine whether the
stage theory actually reflects normal grief patterns.
Prigerson and colleagues from Harvard Medical School and Yale University
School of Medicine examined data from the Yale Bereavement Study.
The 233 study participants were followed for two years following the death
of a close family member or other loved one. Eighty-four percent of the study
subjects had lost a spouse, and most were in their 60s or older, Prigerson
Counter to the stage theory, acceptance, not disbelief, was a major early
dominant grief indicator.
"Evidently, a high degree of acceptance, even in the initial month
[after death], is the norm in the case of natural deaths," the researchers
And yearning was the most commonly cited negative psychological response
reported throughout the study. Feelings of longing or pining for the lost loved
one tended to peak four months after the loved ones' death and began to subside
at six months.
"Yearning was seen much more often than depression," Prigerson says.
"This has important clinical implications because most of the models we use
[to assess grief] focus on depression. This suggests that we are focusing on
the wrong target."
Sudden death was associated with a higher degree of disbelief among
survivors. While this finding is not surprising, Prigerson says it too has
major implications for clinical practice.
Terminal illness was the cause of the vast majority of deaths in the study.
Researchers found that having knowledge of a diagnosis for six months or longer
was associated with higher levels of acceptance among survivors.
"We know that very few doctors discuss life expectancy with their
terminal patients and their loved ones," Prigerson says. "That is a
hard conversation to have, but it is an important one."
Prigerson acknowledges that the grief model may not apply to other
populations, such as survivors grieving deaths from unnatural causes like car
crashes and suicide, or parents grieving the loss of a child.
But the researchers point out that more than nine out of 10 deaths in the
U.S. are the result of natural causes, and the vast majority of these deaths
occur among middle-aged and elderly people like the ones reflected in the
Grief counselor David Fireman says even among this population it is
difficult to characterize what it normal when it comes to reactions to the
death of a loved one.
Fireman is director of the Center for Grief Recovery in Chicago.
"Grief is very personal and many variables are involved," he says.
"Grief is a process, not a condition, and from my perspective there is no
correct timetable for the waves of grief that people feel."
SOURCES: Maciejewski, P.K. Journal of the American Medical
Association, Feb. 21, 2007; vol 297: pp 716-723. Holly G. Prigerson, PhD,
director, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber
Cancer Institute, Boston. David Fireman, LCSW, director, Center for Grief
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