Grief, Bereavement, and Loss (PDQ®): Supportive care - Patient Information [NCI]

Overview

Grief and mourning are part of the normal process of dealing with a loss. Bereavement is the period of grief and mourning after a death of a loved one. Most people will adjust to the loss over time. Others will have longer periods of bereavement and may benefit from treatment.

This summary explains how grief, mourning, and bereavement are different and describes the different types of grief, treatments for grief, and important issues for grieving children.

Grief, Mourning, and Bereavement

Grief is the emotional response to the loss of a loved one.

Common grief reactions include:

• Feeling emotionally numb.
• Being unable to believe the loss occurred.
• Having anxiety from the distress of being separated from the loved one.
• Mourning along with feeling depressed.
• A feeling of acceptance.

Mourning is the way we show grief in public.

The way people mourn is affected by beliefs, religious practices, and culture. Grief and mourning are closely related.

Bereavement is the period of sadness after a death of a loved one.

Grief and mourning occur during the period of bereavement. People who are grieving are described as bereaved.

Types of Grief

There are three types of grief: anticipatory, normal or common, and complicated.

Anticipatory grief occurs before death.

Anticipatory grief is grief that occurs leading up to a death. It may be felt by the person dying or person's family. When a patient experiences distress, pain, and medical complications, it can add to anticipatory grief. Anticipatory grief is different from grief that occurs after the death.

Anticipatory grief does not affect everyone.

Research has shown that about one in four patients with incurable cancer feels anticipatory grief. Anticipatory grief is less likely to occur when the patient and family accept death. Talking with someone who is trained in grief and bereavement may help patients and their family come to terms with impending death.

In a study of parents who have lost a child to cancer, parents who felt prepared for their child's end of life were better able to function in social roles and activities in the first 2 years after their loss.

Normal or common grief begins soon after a loss and symptoms go away over time.

Normal grief occurs in most people who have experienced a loss. During normal grief, the bereaved person accepts the loss and continues with daily activities even though it is hard to do. Common emotional reactions include:

• Emotional numbness, shock, disbelief, or denial. These often occur right after the death, especially if the death was not expected.
• Anxiety over being separated from the loved one. The bereaved may wish to bring the person back and become lost in thoughts of the deceased. Images of death may occur often in the person's thoughts.
• Distress that leads to crying; sighing; having dreams, illusions, and hallucinations of the deceased; and looking for places or things that were shared with the deceased.
• Anger.
• Periods of sadness, loss of sleep, loss of appetite, fatigue, guilt, and loss of interest in life.

Grief bursts or pangs are short periods (20-30 minutes) of very intense distress. These bursts are caused by reminders of the deceased person, such as during holidays, the anniversary of the loved one's death, or when giving away items that belonged to the person. At other times they seem to happen for no reason.

In normal grief, symptoms will occur less often and will feel less severe as time passes. Recovery time will vary with each person. For most bereaved people, symptoms lessen between 6 months and 2 years after the loss. Although many bereaved people have similar responses as they cope with their losses, there is no typical grief response.

Normal grief is different from major depression.

When a person grieves they can have symptoms that overlap with major depression, such as sleep problems, feelings of guilt, repeated thoughts, and lack of interest. Normal grief is different from major depression in the following ways:

• Painful feelings come and go instead of being constant.
• There are feelings of emptiness rather than sadness or not feeling pleasure.
• People have good self-esteem and do not feel worthless or badly about themselves.
• If there are thoughts of suicide, they are focused on the deceased person, such as a wish to join them in death, instead of thoughts about oneself.

A bereaved person can be diagnosed with major depression if they have symptoms that occur outside of the normal grief process.

Complicated grief lasts longer than normal grief.

Complicated grief is when symptoms don't improve and last for a long period of time, cause extreme distress, affect multiple areas of their lives, and decrease the ability to take part in daily activities.

Factors that Affect Grief

There are factors that affect the response to grief.

A person's grief is affected by their:

• Personality, age, and gender.
• Cultural and religious background.
• Coping skills and mental health history.
• Amount of support they have.
• Social and financial position.
• Relationship with the person who died.
• The deceased's cancer experience and the way the disease progressed.

The personality, age, and gender of the bereaved may affect whether they are more likely to experience depression with their grief.

Studies have found that people with certain personality traits are more likely to have long-lasting depression after a loss. These include people who are dependent on a loved one (such as a spouse), and people who deal with distress by thinking about it all the time.

In general, younger bereaved people have more problems after a loss than older bereaved people do. They have more severe health problems, grief symptoms, and other mental and physical symptoms. Younger bereaved people, however, may recover more quickly than older bereaved people do, because they tend to have more resources and social support.

Men have more problems than women do after a spouse's death. Men tend to have worse depression and more health problems than women do after the loss. Some researchers think this may be because men tend to have less social support after a loss.

Culture and religion play a part in grief and bereavement.

Grief occurs in all cultures. However, some cultures have different beliefs about death that affect the attitudes and practices of the bereaved. They use what will best meet their needs to deal with death.

Some studies show that religion helps people cope better with grief, while other studies show it does not help or causes more distress. Regular church attendance and social support from a religious setting are linked to positive grief outcomes, such as coping and understanding the loss.

Coping skills and mental health history affect the response to an expected or unexpected loss.

It may seem that any sudden, unexpected loss might lead to more difficult grief. However, studies have found that bereaved people with high self-esteem and/or a feeling that they have control over life are likely to have a normal grief reaction even after an unexpected loss. Bereaved people with low self-esteem and/or a sense that life cannot be controlled are more likely to have complicated grief after an unexpected loss. This includes more depression and physical problems.

Social support for the bereaved.

Lack of social support increases the chance of having problems coping with a loss. Social support includes the person's family, friends, neighbors, and community members who can give psychological, physical, and financial help. After the death of a close family member, many people have related losses. The death of a spouse, for example, may cause a loss of income and changes in lifestyle and day-to-day living. These are all related to social support.

Treatment of Grief

Normal grief may not need to be treated.

Most bereaved people work through grief and recover within the first 6 months to 2 years. Researchers are studying whether bereaved people who have normal grief would be helped by treatment. They are also studying whether treatment might prevent complicated grief in people who are likely to have it.

For people who have serious grief reactions or symptoms of distress, treatment may be helpful.

Cognitive behavioral therapy may help people with complicated grief.

Cognitive behavioral therapy (CBT) helps a person learn skills that change negative thoughts and behaviors about grief.

A clinical trial compared CBT to counseling for complicated grief. Results showed that patients treated with CBT had more improvement in symptoms and general mental distress than those in the counseling group.

Depression related to grief may be treated with drugs.

There is no standard drug therapy for depression that occurs with grief. The decision to treat grief-related depression with drugs is up to the patient and the health care professional.

Clinical trials of antidepressants for depression related to grief have found that the drugs can help relieve depression. However, they give less relief and take longer to work than they do when used for depression that is not related to grief. Some clinical trials have found that psychotherapy while on antidepressants can improve depression and reduce the intensity of grief.

Children and Grief

Children have a different grief experience than adults.

Children do not react to loss in the same ways as adults. These are some of the ways children's grief is different:

• Children show grief once in a while and for a short time span. A child who grieves may be sad one minute and playful the next. Often families think the child doesn't understand the loss or has gotten over it quickly. Usually, neither is true. Children's minds protect them from what is too much for them to handle.
• The bereavement process may continue as the child gets older. Children will revisit the loss repeatedly, especially at important times, such as going to camp, graduating from school, getting married, or having children.
• Grieving children may not show their feelings as openly as adults. Grieving children may jump right into activities instead of withdrawing or showing grief.
• Children cannot think through their thoughts and feelings like adults. Children may have trouble putting their feelings about grief into words. Strong feelings of anger and fears of death or being left alone may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and worries. These games give children a safe way to express their feelings.
• While grieving adults may withdraw and not talk to other people about the loss, children often talk to the people around them (even strangers) to see how they react and to get clues for how they should respond to the loss.
• Children may ask confusing questions such as, "I know grandpa died, but when will he come home?" This is a way of testing reality and making sure the story of the death has not changed.

Several factors can affect how a child will cope with grief.

Although grief is different for each child, several factors can affect the grief process of a child:

• The child's age and stage of development.
• The child's personality.
• The child's previous experiences with death.
• The child's relationship with the deceased.
• The child's surroundings.
• The cause of death.
• The way the child acts and communicates within the family.
• How stable the family life is after the loss.
• How the child continues to be cared for.
• Whether the child is given the chance to share and express feelings and memories.
• How the parents cope with stress.
• Whether the child has ongoing relationships with other adults.

A child's understanding of death and the events near death depend on their age and developmental stage.

Infants

Infants do not recognize death, but feelings of loss and separation are part of their awareness of death. Children who have been separated from their mother may be sluggish and quiet, may not respond to a smile or a coo, may have physical symptoms (such as weight loss), and may sleep less.

Age 2-3 years

Children at this age often confuse death with sleep and may feel anxiety as early as age 3. They may stop talking and appear to feel overall distress.

Age 3-6 years

At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though he or she might have been buried. The child may ask questions about the deceased (for example, how does the deceased eat, go to the bathroom, breathe, or play?). Young children know that death is physical, but think it is not final.

A child may think death involves "magical thinking." For example, the child may think that his or her thoughts can cause another person to become sick or die.

Grieving children under 5 may have trouble eating, sleeping, and controlling their bladder and bowel.

Age 6-9 years

Children at this age are often very curious about death and may ask what happens to the body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel, or bogeyman. They may see death as final and scary but as something that happens mostly to old people (and not to themselves).

Grieving children can become afraid of school, have learning problems, show antisocial or aggressive behavior, or become overly worried about their own health and complain of imaginary symptoms. Children this age may either withdraw from others or become too attached and clingy.

Boys may become more aggressive and destructive (for example, acting out in school), instead of showing their sadness openly.

When one parent dies, children may feel abandoned by both the deceased parent and the living parent, whose grief may make him or her unable to emotionally support the child.

Age 9 and older

Children aged 9 and older know that death cannot be avoided and do not see it as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.

Grief and Developmental Stages

Age	Understanding of Death	Expressions of Grief
0-2 years	Is not yet able to understand death.	Quietness, crankiness, decreased activity, poor sleep, and weight loss.
	Separation from mother causes changes.
2-6 years	Death is like sleeping.	Asks many questions (How does she go to the bathroom? How does he eat?).
		Problems with eating, sleeping, and bladder and bowel control.
		Fear of being left alone.
		Tantrums.
	Dead person continues to live and function in some ways.	"Magical thinking" (Did I think or do something that caused the death? Like when I said I hate you and I wish you would die?).
	Death is not final.
	Dead person can come back to life.
6-9 years	Death is thought of as a person or spirit (skeleton, ghost, or bogeyman).	Curious about death.
		Asks specific questions.
		May have fears about school.
	Death is final and scary.	May have aggressive behavior (especially boys).
		Worries about imaginary illnesses.
	Death happens to others, but it won't happen to me.	May feel abandoned.
9 and older	Everyone will die.	Strong emotions, guilt, anger, shame.
		Increased anxiety over own death.
		Mood swings.
	Death is final.	Fear of rejection; not wanting to be different from peers.
	Even I will die.	Changes in eating habits.
		Sleeping problems.
		Regressive behavior (loss of interest in outside activities).
		Impulsive behavior.
		Feels guilty about being alive (especially related to death of a sibling or peer).

There are three common worries children coping with a loss have about death.

Did I make the death happen?

Children often think that they have "magical powers." If a mother is irritated and says, "You'll be the death of me" and later dies, her child may wonder if he or she caused the mother's death. Also, when children argue, one may say (or think), "I wish you were dead." If that child dies, the surviving child may think that those thoughts caused the death.

Is it going to happen to me?

The death of another child may be very hard for a child. If the child thinks that the death may have been prevented (by either a parent or a doctor) the child may fear that he or she could also die.

Who is going to take care of me?

Since children depend on parents and other adults to take care of them, a grieving child may wonder who will care for him or her after the death of an important person.

Talking honestly about the death and including the child in rituals may help the child cope with the loss.

Explain the death and answer questions.

Talking about death helps children learn to cope with loss. When talking about death with children, describe it simply. Each child should be told the truth with as much detail as he or she is able to understand. Answer questions in a way the child can understand.

Children often worry that they will also die, or that their surviving parent will go away. They need to be told that they will be safe and taken care of.

Use the correct language.

When talking with the child about death, include the correct words, such as "cancer," "died," and "death." Other phrases such as, "he passed away," "he is sleeping," or "we lost him," can confuse children.

Include the child in planning and attending memorial services.

When a death occurs, children may feel better if they are included in planning and attending memorial services. These events help children remember the loved one. Children should be encouraged to take part when they feel comfortable doing so and not be forced. Before a child attends a funeral, wake, or memorial service, give the child a full explanation of what to expect. A familiar adult or family member may help with this if the surviving parent's grief makes him or her unable to.

There are books and other resources with information on helping a grieving child.

The following books and videos may be helpful with grieving children:

1. Worden JW: Children and Grief: When a Parent Dies. New York, NY: The Guilford Press, 1996.
2. Doka KJ, ed.: Children Mourning, Mourning Children. Washington, DC: Hospice Foundation of America, 1995.
3. Wass H, Corr CA: Childhood and Death. Washington, DC: Hemisphere Publishing Corporation, 1984.
4. Corr CA, McNeil JN: Adolescence and Death. New York, NY: Springer Publishing Company, 1986.
5. Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed., Pacific Grove: Brooks/Cole Publishing Company, 1997.
6. Grollman EA: Talking About Death: A Dialogue Between Parent and Child. 3rd ed., Boston, MA: Beacon Press, 1990.
7. Schaefer D, Lyons C: How Do We Tell the Children? Helping Children Understand and Cope When Someone Dies. New York, NY: Newmarket Press, 1988.
8. Wolfelt A: Helping Children Cope with Grief. Muncie: Accelerated Development, 1983.
9. Walker A: To Hell with Dying. San Diego, CA: Harcourt Brace Jovanovich, 1988.
10. Williams M: Velveteen Rabbit. Garden City: Doubleday, 1922.
11. Viorst J: The Tenth Good Thing About Barney. New York, NY: Atheneum, 1971.
12. Tiffault BW: A Quilt for Elizabeth. Omaha, NE: Centering Corporation, 1992.
13. Levine JR: Forever in My Heart: a Story to Help Children Participate in Life as a Parent Dies. Burnsville, NC: Mountain Rainbow Publications, 1992.
14. Knoderer K: Memory Book: a Special Way to Remember Someone You Love. Warminster, PA: Mar-Co Products, 1995.
15. de Paola T: Nana Upstairs and Nana Downstairs. New York, NY: GP Putnam's Sons, 1973.

To Learn More About Grief, Bereavement, and Loss

For more information from the National Cancer Institute about grief, see the following:

• Coping With Your Feelings During Advanced Cancer
• Taking Care of Yourself

About This PDQ Summary

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This PDQ cancer information summary has current information about how individuals cope with grief, bereavement, and mourning. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

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PDQ® Supportive and Palliative Care Editorial Board. PDQ Grief, Bereavement, and Loss. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389267]

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Last Revised: 2024-07-09

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