For too long, Americans grieved alone. For too long, the deaths of others held too many intimations of our own mortality, and, somehow, once the immediate amenities were passed, the funeral held, the hushed "whatever-we-can-dos" said, the mourner was just supposed to get over it. Preferably out of sight.
With a little psychosocial boost from Dr. Elisabeth Kubler Ross and, indeed, from the entire hospice movement, all that began to change a decade or so ago. Now it is pretty well accepted among health professionals and pastoral counselors, at least, that it is the rare bereaved individual who does not need some help, sometimes for a year or more, in dealing with grief.
"Grief process" or even, as some have called it, "psychic metabolism" are stark terms for what is involved in coming to terms with the loss of someone very close. This is especially true because all of us see ourselves reflected in the daily responses of our partners, our children, our parents. When they are gone, that reflection of self is gone as well.
Nevertheless, grief is a process involving both the mind and the body -- a psychoneurobiological process -- often marked by specific stages. These stages vary from person to person, but often involve denial, anger, degrees of depression and eventual acceptance. But some people do not go through these stages. For them, the grief does not get "worked out," and the loss does not become assimilated into the emotional balance of the bereaved. For some, time does not heal.
Psychobiologists at the National Institute of Mental Health have been studying some people in whom the grieving process has "become stuck," says Dr. Alec Roy, a British psychobiologist now working with scientists at the National Institute of Alcohol Abuse and Alcoholism and NIMH.
The scientists have determined that in certain individuals, the stress of a bereavement tends to throw one of the body's basic systems of stress regulation out of kilter. This is the so-called hypothalamic-pituitary-adrenal (HPA) axis, which is activated in the face of a threat of danger, or, as it turns out, in response to an adverse life event, such as the death of a loved one.
A team of scientists headed by Dr. Phillip Gold of the NIMH biological psychiatry branch has developed a delicate blood test -- the corticotropin-releasing hormone (CRH) infusion test -- which can determine if the HPA axis is not functioning correctly and how much it deviates from normal.
This test has already demonstrated that the HPA axis is often malfunctioning in people diagnosed with medical depression. And most recently, Dr. Gold's team has shown a dysfunction of the HPA axis in young women with anorexia -- but not in those with bulimia. It has also been identified in persons with panic disorder.
Now Roy has preliminary evidence that a similar dysfunction can exist in bereavement. In some people the dysfunction is only temporary and the system returns to normal by itself. In others, however, it does not.
"If scientists can confirm preliminary findings that certain people are especially vulnerable to 'getting stuck' in bereavement-linked depressions," Roy said, "we will be that much closer to being able to treat or even prevent some of these disorders."
This distinction between healthy mourning and problematic "melancholia" was noted as early as 1917 by Sigmund Freud.
But like most doctors of his time, he adhered to the "time heals" point of view, suggesting that interference with the mourning process was not helpful and possibly harmful.
Gradually, the psychiatric community began to note that in some people, bereavement was a precipitating factor in clinical, or medical, depression.
Then, as biological psychiatrists began to learn more about how external events could influence the brain to activate a series of endocrine feedback systems, clear evidence of genuine mind-body interactions began to emerge. Now some behavioral and mood changes can almost be tracked biologically as they move from nerve cell to hormone to gland to a different hormone and back to the brain for direction of mood or behavior. Furthermore, there are links between poor functioning of these central nervous and endocrine system feedback loops and suppression of the body's immune system.
Evidence that the immune system has been compromised has been found in people under all sorts of stress -- from accountants at tax time to bereaved spouses.
The purpose of the current NIAAA/NIMH studies is to hone in on the changes, especially those that do not more or less automatically return to normal.
In a preliminary study of 19 recently bereaved individuals who felt that they were not "getting over" their loss the way they and others felt they should, the scientists were able to show two things:
All 19 bereaved individuals displayed the same dysfunction of the HPA axis that is found in more than half of people diagnosed with medical depressions.
All 19 had either a previous history of depressive illness or family members with such illness.
Typical of several members of the group was this composite patient: "She is," said Roy, "about 40 years old. She is apparently in good mental health, on no medication. However, when she was 26 and had her first child, she became depressed. After about three months of tearfulness, sleeplessness and other signs of a lingering depression, she went to her family physician, who diagnosed a medical depression and prescribed antidepressant drugs.
"Since then she'd been fine, except about six years earlier she'd had trouble with her boss at work and again experienced a mild depressive episode. She lost interest in things, including sex, had difficulty sleeping, was not doing well at work, was irritable with her children. Again, her family doctor found she was depressed and a brief course of psychoactive medication was prescribed. Since then, she'd had no problems. Her marriage was happy. Her children were developing nicely.
"Then, when she was 40, her 63-year-old father, with whom she was very close, dropped dead with a coronary. She was devastated. She went to the funeral and felt utterly miserable for several weeks after his death. However, six months later, she realized that her brothers and sisters were doing well, but she still tended to cry a lot, was sleeping poorly and again irritable with her children and her husband, and she seemed still stuck in a sort of miserable depressed rut."
"We actually found," said Roy, "that people who had had psychotropic antidepressant medications in the past, usually because of an anxiety state or previous depression, had even more profound reactions on this particular test, suggesting again that people with a predisposition to depression might be the ones who respond that way to bereavement."
"A couple of other members of the group struck me very forcibly as well," Roy said. These were women who had lost members of their family by suicide. "This is especially significant," he said, "because many times the suicide victim and the survivor share genes for depression. About eight times out of 10, the victim was suffering from depression at the time of the suicide. In a surviving relative, the suicide might well be the life event which triggered a major depression."
Several members of his group of 19 bereaved persons had been referred for psychiatric treatment, and had returned for retesting, Roy noted. After treatment, the tests found the HPA axis to be normal.
Now Roy wants to "expand the window into the brain" in recently bereaved individuals who feel themselves unable to work out their grief. There are, he noted, two other systems responsive to stress which may show abnormalities in depression, he hypothesizes, and especially in those depressions triggered by stressful life events.
Participants in the testing program are individuals who suffered a loss within the past year, but who feel they are unable to cope with the grief. Phone: 496-0983.