BEREAVEMENT (DSM, p. 740, V62.82) (grief, mourning) is a normal response to a significant loss (of spouse, parent, child—but also of health, limb, career, savings, status, etc.) (1). Expect to see it with major losses—be alert for future problems if the patient does not grieve (although 30% of widows mourn briefly and very little) (2,3). If a loss is obviously approaching, mourning may begin before the loss actually occurs (anticipatory grief). Symptoms associated with divorce may also be coded as PARTNER RELATIONAL PROBLEM (DSM, p. 737, V61.10).

Recognize grief by restlessness, distractibility, disorganization, preoccupation, “numbness,” feelings of sadness, apathy, crying, anxious pining, a need to talk about the dead, and intense mental pain during the days, weeks, and months after a loss. Somatic distress is common and includes generalized weakness, a tightness in the throat, choking, shortness of breath, palpitations, headaches, and gastrointestinal (GI) complaints. Do not be surprised if the patient displays marked but short-lived irritability, hostility, or anger toward you, others, or the dead (you did not “do enough,” they do not “care enough,” he died, etc.). This often alternates with listlessness, social withdrawal, depression, and feelings of guilt (about that which was left undone or could have been done differently). Patients become preoccupied with their loss. They constantly think about the dead and review past experiences, visit the grave, and may even briefly deny the death.

About 25% to 35% of patients have symptoms that suggest a major depression: anorexia, feelings of worthlessness, impaired memory, suicidal thoughts, and hopelessness. Nearly 10% have delusional thoughts or hallucinations or both. Be careful not to “overread” temporary bizarre behavior in the bereaved. Some patients develop psychophysiologic disorders, hypochondriasis, major anxiety symptoms, or phobias. A few begin to drink too much; some deteriorate physically; and major psychiatric illnesses (e.g., acute schizophrenia) may be precipitated in those predisposed (e.g., with a family history). Moreover, bereavement has been associated with increased adrenocorticotropic hormone (ACTH) and cortisol, decreased immune function and natural killer cell activity, and an increased rate of heart disease and malignancy (4). Recent magnetic resonance imaging (MRI) studies (5) implicate the cerebellum, posterior cingulate gyrus, and medialsuperior frontal gyrus in grief. Death from suicide and illness is increased during the first year after the loss.