Prolonged grief disorder

According to Sigmund Freud (1917), the work of mourning is described as a normal, adaptive stage that enables the libido to gradually detach itself from the beloved object and reinvest itself in new objects, leading to the resolution of grief. Melancholia, on the other hand, was seen by the author as a pathological and destructive reaction to loss, resulting in a destabilization of the libido and an inability to clearly identify the loss suffered. Thus, in this approach, the grief experienced in bereavement is here considered a normal response, whereas melancholia, due to its pathological nature and depressive symptoms, was seen as an abnormal response to a similar event.

Elisabeth Kübler-Ross's (1969) five-stage model was originally developed to describe the stages that patients with terminal illnesses go through up to the acceptance of their own death, and was later extended to the patient's loved ones who may be going through a similar experience. Five phases are proposed: denial, anger, bargaining, depression and acceptance. These stages are not described as linear, as the individual may navigate between them, relive them or experience them simultaneously. Despite the impact and widespread adoption of this model, it has been criticized for its flimsy theoretical underpinnings and overly linear vision, implying that there is an ideal way to grieve.

Klass, Silverman and Nickman's (1996) Continuous Bonding approach departs from some past considerations that see the function of grief and mourning as breaking ties with the deceased so that relationships can be reinvested in the present. Klass et al.'s approach considers that mourning does not necessarily imply letting go or moving on, so that a healthy resolution of grief can be envisaged. On the contrary, it involves maintaining a "continuous bond" with the deceased. This perspective emphasizes how relationships with the deceased can continue to evolve and have meaning after their death.

John Bowlby's (1980) theory of attachment describes 4 stages in the grieving process. First, the mourner goes through a state of numbness, disbelief or shock. This then evolves into a phase marked by desire or search for the deceased, often accompanied by anger and protest. In the third stage, the search for the deceased ceases, and the mourning process gives way to despair and disorganization, giving way to feelings of depression and desolation. The fourth and final phase is that of reorganization, which takes shape when the loss is accepted and the bereaved person gradually returns to his or her former interests. The inability to achieve this reorganization may be indicative of a persistent fixation on the lost attachment figure, preventing the bereaved person from moving on.

The pioneering contribution of Erich Lindemann (1944) is a description of the symptoms and emotional responses observed in the bereaved. Based on his clinical observations, Lindemann developed a five-phase theory of grief. Several typical reactions to loss are identified: somatic disturbance (loss of appetite, exhaustion and lack of motivation, etc.), preoccupation with the memory of the deceased, overwhelming guilt, hostile or angry feelings, and difficulty in carrying out daily routines. According to the author, for these reactions, which are sometimes too severe, to diminish, mourning work is necessary, involving detachment from the deceased, adaptation to an environment devoid of the deceased, and the formation of new relationships.

The theory of symptom networks applied to psychopathology after the death of a loved one (2021) conceptualizes mental disorders as arising from "self-reinforcing" interactions between the symptoms of a pathology9. This theory, although still in development, offers an alternative approach to understanding bereavement and, more specifically, prolonged mourning10. It suggests that the thoughts, emotions and behaviours that occur during bereavement are interconnected in a network of reactions that can be self-reinforcing, leading to persistent grief in some people. This theory emphasizes that the biological and social disturbances induced by prolonged grief can, in turn, influence and interact with the grieving process.

The resilience perspective of George A. Bonanno (2002) emphasizes the central role of resilience in the grieving process and reactions to trauma. In a book entitled "The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss", Bonnano challenges the idea of stages of grief and, as a result, questions many of the principles underlying traditional conceptions of bereavement, which often lack a scientific basis. His pioneering contributions to the field reveal a heterogeneity of responses to loss that can be grouped into a relatively small number of trajectories (chronic, delayed or absent grief, depression, etc.), one of the most common of which is resilience.

Margaret Stroebe and Henk Schut's dual-process model of grief adjustment (1999) offers a dynamic view of the grieving process, integrating elements from attachment and stress theories. It aims to overcome the shortcomings of traditional approaches, criticized for their lack of empirical evidence and cultural and historical validity. Since its inception, numerous updates and revisions have been made to refine its clinical application and increase its relevance in response to recent advances in the field of bereavement. Originally designed to explain the grieving process in widows and widowers, Stroebe and Henk's original model describes bereavement as a dynamic process confronting the individual with two categories of stressors: those related to loss, such as crying and ruminating, and those related to restoration, such as increased responsibilities and the adoption of new roles following the loss of a spouse. The constant oscillation between loss confrontation and restoration strategies enables the grieving person to alternate between active expression of emotions and the search for meaning, and avoidance, which can include engaging in new activities or bypassing painful memories. Thus, in this approach, a balance between confrontation and avoidance is deemed necessary for healthy adaptation to grief.