Grief Reactions and Depression in Family Practice: Differential Diagnosis and Treatment Jack M. Stack, MD Alma, Michigan

To make a differential diagnosis between depression, normal grieving, and pathological grief reactions is a common problem for family physicians. Patients often present to the family physician with physical symptoms, such as pain, headache, dizziness, fatigue, and disturbances of digestion and sleep, rather than psychological symptoms. Treatment modalities and effectiveness differ depending on specific diagnosis. The family physician is in a unique position to influence preven­ tion, early detection, and morbidity of these disorders.

The family physician is in a unique position to physiological somatic distress, preoccupation with observe the evolution of disease processes and the image of the lost person, feelings of guilt, clinical syndromes and to provide early detection anger, and hostility, and changes in normal con­ and prevention. This is especially true of psycho­ duct.1 Most people who experience and acknowl­ social problems encountered in medical practice. edge a loss grieve to completion with family and The recognition of depression and grief syn­ friends and do not seek psychiatric help.2 dromes is especially important in family practice. Unresolved grief reactions include delayed, in­ It is important to distinguish whether depression is a complete, and pathological grief syndromes. symptom of a psychiatric or medical illness, of nor­ These syndromes may include a persistent memory mal grieving, or of a pathological grief reaction. As of the events surrounding the loss; an anniversary is true of medicine in general, sophisticated differ­ grief experience; persistence of intense affect, ential diagnosis is essential because proper and such as anger or sadness, when discussing the loss; effective therapy is based upon proper diagnosis. a splitting of the cognitive and affective recogni­ The treatment modalities for depression, griev­ tion of the loss, often manifested by verbaliza­ ing, and pathological grief reactions are specific, tions, as if the lost person were still present; an effective, and vary depending upon diagnosis. inability to cry; emotional and irrational hanging on to linking objects; the presence and persistence Grief and Grieving of a variety of physical complaints, such as head­ Grief and grieving are normal aspects of the ache, fatigue, dizziness, and increased suscepti­ human condition. They result from experiencing a bility to real injury,3 illness,4 morbidity, and death; loss and are a consequence of the human capacity and flooding with intense disproportionate emo­ to develop significant attachments. Normal griev­ tion at the time of subsequent loss or crisis. ing is characterized by intellectual and emotional awareness of the loss, acute onset, psychic pain, Depression In a discussion of depression as a counterpoint From the Alma Family Practice, Family Health Research, to the discussion of grief, it is important to review Education and Service Institute, Alma, Michigan. Requests for reprints should be addressed to Jack M. Stack, MD, 503 the medical and social meaning attached to the N. State Street, Alma, Ml 48801. word depression. 0094-3509/82/020271 -05$01.25 5 1982 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 2: 271-275, 1982 271 GRIEF REACTIONS AND DEPRESSION

Table 1. Causes of Secondary Depression

Medical Medications Psychiatric

Major surgery Reserpine Schizophrenia Childbirth Birth control Schizoaffective disorder Hypothyroidism pills Alcoholism Cushing's syndrome Cortisone Borderline syndrome Carcinoma of the lung Alcohol Personality disorders Carcinoma of the pancreas Marijuana Presenile dementia Barbiturates (Alzheimer's disease) Viral disease Mononucleosis Influenza

Depression is a normal human affect; it is a feel­ As a primary illness, depression is character­ ing of sadness. Depression serves as a signaling ized by a positive family history,6 no other under­ device to alert the depressed person and his or her lying illness, and a positive response to tricyclic loved ones that there is a disruption in the usual and tetracyclic antidepressants, monamine oxidase homeostatic state, either physical, psychological, inhibitors, lithium, or electroconvulsive therapy. or social. Depression is an existential state, a normal part of the life experience of normal people, usually Etiology transient and often accompanying anger, conflict, Normal grief and pathological grief syndromes, and disappointment. as well as depressive symptoms or illness, may Depression is also a symptom. If the physician follow crisis events in the life of the individual, his can recognize the presence of depression as a social system, or family, which can include, but symptom beyond a normal transient range of af­ are not limited to, pregnancy, miscarriage, abor­ fect, it may be a symptom of an illness. Depression tion, birth, birth of an ill, injured infant or a prema­ can be a symptom of either a psychiatric or a med­ ture infant, any episode of illness in the person or ical illness. loved one (especially myocardial infarction, Depression as a clinical syndrome includes (1) stroke, or sudden unexpected illness), amputation, dysphoric mood changes of sadness, (2) behav­ diagnosis of cancer, divorce, job loss or change, or ioral changes of psychomotor retardation or agita­ death of child, spouse, friend, or loved one. tion, (3) multiple vague physical symptoms, and If the loss is anticipated, as in the case of pro­ (4) specific physical symptoms from diencephalic longed illness, anticipatory grieving can occur. disturbances, which include appetite and digestive Many, but not all, cases of pathological grief disturbance, diminution of general energy levels occur when the loss is sudden and unexpected, and specific loss of sexual interest, and energy and when the loss is not recognized by the individual sleep disturbances, usually frequent awakening, or others,4,7 or when permission to grieve is denied difficulty returning to sleep, and early morning to the grieving person, either by others or by the awakening. grieving person himself. Depression as an illness is a major affective dis­ Causes of secondary depression can include order, whether a major depressive episode in a re­ nearly all medical, surgical, and psychiatric illness current depressive illness, a single episode of (Table 1). a major depressive disorder, or an episode of de­ A major psychological stress can often cause a pression in the bipolar disorder, manic-depressive primary depression. The stress can be associated illness.5 with a major loss and concomitant prolonged or

272 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 2, 1982 GRIEF REACTIONS AND DEPRESSION incomplete grieving. Major affective disorders, anxiety, stress, adjustment reaction, and alcohol­ especially the bipolar disorder, are more com­ ism making up the remainder. mon among family members than in the general Whenever the patient’s symptoms are vague or population.5,6 the physician suspects a diagnosis of depression or grieving, it is important to pursue this diagnosis early by reviewing the history and inquiring about Incidence past depressive illness, previous manic episodes, Approximately 20 percent of women and 10 family conflict, or loss. The patient will often be percent of men in the adult population have had a able to acknowledge rapidly the psychosocial as­ major depressive episode. About 1 percent of the pects of his present concern. Usually not deeply adult population has had bipolar disorder, which is repressed, these issues are often preconscious and equally common in men and women.5 Incidence easily accessible to the patient if the physician studies report that affective disorders are among inquires. the top ten diagnoses in primary care.8 An accurate diagnosis is important because Widmer and Cadoret9 describe a follow-up proper therapeutic planning is dependent upon it. study of 43 patients previously diagnosed as In fact, the process of obtaining the diagnosis is depressed who had 59 subsequent episodes of de­ often therapeutic in itself, as reported by Brody pression. They emphasized that while psychiatric and Waters.13 criteria for diagnosis of depression emphasize psychological symptoms, the depressed patient presents to the family physician with somatic Treatment symptoms of pain, anorexia, weight loss, fatigue, Treatment of normal grieving should allow headache, symptoms of respiratory illness, gastro­ some degree of distress, allow and encourage intestinal complaints, and other functional com­ questions and talking about the loss, avoid exces­ plaints due to weakness, fatigue, and dizziness. sive sedation, and be alert to the one family mem­ They also noted that the patients were unable to ber who may be taking care of everyone else. In recognize the development of depression in spite cases such as miscarriage, stillbirth, and sudden of their previous experience. death, the physician can alert the patient and fam­ Reifler et al10 reviewed the literature to deter­ ily to the need to grieve, to talk about the loss, to mine incidence and prevalence of depression in cry together, and to hold the bereaved person. primary care practice and found reported inci­ The grieving person should be assured that il­ dence between 0.2 percent to 1.5 percent, and they lusory experiences, dreams, and episodes of un­ reported an incidence of 4.5 percent of 1,321 total explained sadness or crying are signs not of mental adult patient visits. illness but of the normal grieving process. To Raune3 reported a case of repeated trauma as allow these experiences to occur will facilitate the presenting symptom of a pathological grief re­ healing and the pain will subside. The endpoint of action. Comey and Horton11 reported a case of grieving is not to forget the loved lost person but to pathological grief following a spontaneous abor­ be able to remember without pain. tion, and Stack4 presented a number of cases of To treat the unresolved grief reaction is essen­ unresolved grief reactions following spontaneous tially to recognize it, to identify it as the underlying abortion. cause of the patients’ complaints, and if possible, It is important to emphasize that the majority of to encourage normal grief work with family and patients presenting to family physicians with these friends. The treatment by professionals is always clinical conditions do not usually recognize their psychotherapy, usually short-term time-limited symptoms or illnesses as depression or grieving. therapy. Morrison12 reported on a review of records of The treatment of the pathological grief reaction, 176 patients with an isolated diagnosis of fatigue in in which the patient may exhibit severe dissocia­ which a specific physical or psychological diagnosis tive, behavioral, or psychiatric symptoms, consists could be made. He observed that 72 of the 176 (41 of more intense psychotherapy, often requiring percent) diagnoses were psychological. Depres­ hospitalization. In cases of grief work, medica­ sion was diagnosed in 43 percent of the cases, with tions may be of little help and may be contra-

THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 2, 1982 273 GRIEF REACTIONS AND DEPRESSION indicated because of sedation and suppression of woman’s death. Her family physician suggested dreams. If the grief syndrome includes the dience­ that she share with her husband her new aware­ phalic signs of depression, antidepressant medica­ ness of the link between the headache and the tions may be of help. unmet need to grieve and ask him to allow her to To treat depression as a symptom (ie, second­ talk about her friend, to allow her to cry, and to ary depression) is to treat the underlying condi­ hold her. This entire exchange, history, neurologi­ tion, whether medical, surgical, or psychiatric. It cal examination, and elicitation of the nature of the is important to remember that depression, when it loss and its relationship to the headaches, took 20 is a symptom of other psychiatric conditions (bor­ minutes of the family physician’s time. The patient derline syndromes, a character disorder, alcohol­ reported one month later, at the time of an office ism, or schizoaffective disorder), will often not call for one of her children, that she had done as respond to the usual treatment for the illness de­ suggested, her husband had been responsive to pression.14 Frequently these patients complain bit­ her, and she had not had a headache since her terly of the side effects of the medication or visit. experience a worsening of their illness, as when a This case demonstrates the value of im­ psychosis is precipitated in the schizoaffective pa­ mediately asking questions about conflict or loss, tient who is treated with tricyclic antidepressants. the value of the family physician knowing the pa­ The treatment of primary major depression, tient and her family, the easy availability of the whether a single episode or recurrent or bipolar, grief-provoking episode, the role of the care giver includes tricyclic and tetracyclic antidepressants, in facilitation of grieving, and the role of the family monamine oxidase inhibitors, lithium, and/or elec­ in blocking or allowing normal grief work in nor­ troconvulsive therapy. Supportive psychotherapy mal people. is also of help during the episodes of illness.15 Case 2 A 30-year-old mother of two children com­ Case Reports plained of increased susceptibility to illness, fatigue, cough, and nasal discharge since an early Case 1 miscarriage four months previously. Examination A 36-year-old mother of two children com­ revealed a purulent nasal discharge, x-ray evi­ plained of a generalized nonspecific headache of dence of maxillary sinusitis, and a labile, weepy, two months’ duration. Her medical review and and angry affect. When asked to describe how she neurological and funduscopic examinations were felt about her miscarriage, she wept and described normal. She was told that her headache was prob­ the starkly clear recurring memory of the events ably not of physical origin, and she was asked of that day. She acknowledged her ambivalence whether she was having any family or emotional about the pregnancy, her denial of this miscar­ problems or whether she had experienced any re­ riage, and her unfulfilled need to be comforted and cent loss. She immediately began to talk about the to be allowed to assume the role of a grieving per­ sudden death of a woman with whom she worked son. In addition to proper treatment of her sinusi­ in a church guild. Although these women were of tis, she was seen weekly for four weeks for re-grief different educational and social backgrounds, she work with psychotherapy. She did significant grief had been invited to the woman’s home and con­ work with family and friends and in therapy. sidered this woman, who was very kind to her, to Her labile affect subsided, the details of the be her best friend. The patient attended the fun­ memory of the miscarriage began to blur, and she eral, as did many others in the community. She felt could talk about her experience without pain. Her a sadness and a need to cry and to talk about the chronic fatigue and susceptibility to illness re­ woman, but her husband told her not to talk about solved, as did her sinusitis. it, that it would not help bring her friend back. This case demonstrates the role of unresolved On relating these events, the patient experi­ grief in susceptibility to real physical illness, enced considerable sadness and did cry. It was rather than presenting with vague symptoms, and pointed out to her that the duration of her head­ the role of family, friends, and care givers in ache was the same as the interval since the facilitation of normal grief or in re-grief work.

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Other important points in this case were the sud­ necessary for the patient to develop full-blown den nature of the loss, the ambivalence about the psychiatric illness to turn to the family physician loss, and the lack of recognition by the patient or for assistance. Facilitation of normal grieving and others as to whether a loss had occurred. diagnosis of early signs of depression and/or of unresolved grief reactions can be done in the daily Case 3 family practice. A 25-year-old mother of two children com­ Depression may be an early signal to the family plained of excessive fatigue of vague duration, physician that the patient is experiencing a medi­ perhaps between two and four months. She won­ cal or psychiatric illness. Depression as an illness dered if she needed thyroid supplement or an iron can be lethal when it leads to suicide. Undiag­ shot. She was clinically and chemically euthyroid nosed or untreated depression can lead to consid­ and not anemic. When asked, she denied any family erable family disruption. Unresolved grief can problems or any recent loss and requested further result in illness and even death. The poet often workup. Throughout the interview and examina­ suggests that people die of broken hearts. Shake­ tion she had been tense and sighing. She was ad­ speare16 in Macbeth wrote: “ Give sorrow words; vised that further workup could be done but that it the grief that does not speak, whispers to the was the physician’s impression there was some­ o’erfraught heart and bids it break.” thing more psychologically involved than she was What the poet tells us, the pathologist often able to acknowledge. She began to cry and talk confirms. Family physicians are in a position to with considerable difficulty about her loss of inter­ intervene in a timely and effective manner in the est in sex with her husband, her lack of energy, prevention, diagnosis, and treatment of these wanting to be alone, and not being happy. She common human maladies. admitted to a poor appetite, a four-pound weight loss, and increasing sleep. The physician was aware of the basic stability of her marriage but was References also aware of her own family background, with 1. Lindemann E: Symptomatology and management considerable characterological problems in her sis­ of acute grief. Am J Psychiatry 101:141, 1944 2. Clayton P: A study of normal bereavement. Am J ter and parents and episodic depression in her Psychiatry 125:188, 1968 mother. It was suggested to her that she was 3. Raune TJ: Repeated trauma as the presenting symptom of a pathological grief reaction. J Fam Pract 10: experiencing a primary depression and that her 327, 1980 problems with her husband were secondary and 4. Stack JM: Spontaneous abortion and grieving. Am Fam Physician 21:99, 1980 not causal. She was given imipramine to be taken 5. Diagnostic and Statistical Manual of Mental Disor­ at bedtime and was advised not to make any major ders, ed 3. Washington DC, American Psychiatric Associa­ decisions such as separation and to explain to her tion, 1980 6. Geron ME, Cadoret RJ: Genetic aspects of manic husband the nature of the illness. depressive disease in fam ily practice. J Fam Pract 4:453, 1977 This case demonstrates the vague onset of de­ 7. Volkan V: Typical findings in pathological grief. pressive illness as contrasted with the sharply Psychiatr Q 44:231, 1970 marked onset of symptoms in grief reactions. 8. Marsland DW, Wood M, Mayo F: Content of family practice: Part 1: Rank order of diagnoses by frequency. J Although the physical symptoms are similar, the Fam Pract 3:37, 1976 9. Widmer RB, Cadoret RJ: Depression in fam ily prac­ diencephalic signs of disturbance of appetite, tice: Changes in pattern of patient visits and complaints sleep, general energy, and sexual energy are often during subsequent developing depressions. J Fam Pract 9: 1017, 1979 much more distinct and prominent in the depress­ 10. Reifler BV, Okimoto JT, Heidrich FE, Inui TS: Rec­ ive illness. The roles of family history and biologic ognition of depression in a university-based family medi­ therapy are also demonstrated. cine residency program. J Fam Pract 9:623, 1979 11. Corney RT, Horton FT Jr: Pathological grief follow­ ing spontaneous abortion. Am J Psychiatry 131:825, 1974 12. Morrison JD: Fatigue as a presenting complaint in Comment family practice. J Fam Pract 10:795, 1980 13. Brody H, Waters DB: Diagnosis is treatment. J Fam Pract 10:445, 1980 The family physician is often in a position to 14. Egan WH, Smith JA: The unremembered, unim­ prevent the serious sequelae of disruption of nor­ proved depressed patient. Am Fam Physician 15:82, 1977 15. Donlon PT: Primary affective disorders. J Fam Pract mal grieving because he or she is often attending the 9:689, 1979 person or family when the loss occurs. It is not 16. Shakespeare W: Macbeth. Act IV, scene 3

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