Grief differs considerably from depression. In depression, there is a drop in self-esteem and self-worth. In grief, there is either internal distress over the loss of another, or external distress over the loss of an ideal. When grief is at its worst, such distress is usually experienced as overwhelming separation anxiety.
Grief is generally experienced in stages. The first stage, which may last from hours to days, is a phase of ‘numbness’ where the individual is in a state of disbelief or even denial. The second stage, which may last from weeks to several months, is when separation anxiety is at its most severe as waves of grief, sadness and tears are experienced. During this stage, sleep and appetite disturbances are common, as are social withdrawal, a sense of guilt or a wish to blame others. The lost individual may be ‘seen’ or experienced in some way. The third stage, which may commence after weeks or months, is associated with a cessation of social withdrawal, a settling of distressful symptoms and the return of happy or positive memories of the dead individual. Only one-third of grieving people actually go on to develop distinct depression, but usually not until weeks or months after their loss.
This biphasic response of grief (first phase) and depression (second phase) may be a ‘built in’ response designed to promote survival. An analogy from the animal kingdom will make the argument clearer. Imagine a mother and infant monkey in the jungle. The mother disappears and, after an interval, the baby begins to emit high-pitched screams and run around in a seemingly erratic way. If it is not reunited with its mother, the infant is likely to assume a fixed, slumped over, immobile position. Why?
The first phase is designed to re-establish contact with the mother. Assuming that she has just wandered away, she is more likely to see a darting infant, hear its screams, and come running back. If, however, the mother has been taken by a predator, it would be unwise for the infant to continue such behaviours—even if it were not taken by the same predator, it would soon become exhausted. The second phase of behaviour therefore protects the infant against both detection and dehydration or heat loss. In other words, first-phase anxiety is designed to promote re-attachment, while second-phase ‘depression’ promotes survival.
Thus, grief (separation anxiety) is a state distinct from depression (loss), although it may lead to a depressive state.
The following example illustrates a situation in which it is difficult to determine where grief ends and depression begins, as the two states seem to overlap to such a degree.
A 23-year-old woman states that she became severely distressed when she found that her boyfriend had been unfaithful to her and had left her for the ‘other woman’. In the first week she was unable to sleep for more than two or three hours a night, had completely lost her appetite and admitted to a significant weight loss of 6 kg. She was crying repeatedly. She then described being hypervigilant, jumping at any loud noise and on more than one occasion she thought she saw her boyfriend and his red sports car—only to find that it was a complete stranger. She felt insecure, jumpy and anxious. Interestingly, at that time she noted a fantasy of being pregnant. She cannot remember any loss of self-esteem, and was more distressed by the loss of her boyfriend and her sense that they had formed a couple.
In the second week, she observed less anxiety and insecurity and reported that her sleep, although still patchy, was improving, as was her appetite. However, she was then aware, either validly or not, that she had lost her boyfriend irrevocably, and felt hopeless, helpless and depressed. Her self-esteem dropped, she became critical of herself and started blaming herself for having ‘lost another bloke’.
In the third week, she stopped going to work or discussing the issue with her girlfriends. Instead, she spent the days lying in bed and pigging out on boxes of chocolates.
This example describes the biphasic process noted earlier, with grief rather than depression being the driving condition in the first week. Her fantasies of pregnancy can be presumed to reflect her wish to be reunited with her boyfriend or, if she couldn’t have him, to have at least part of him. It could also signify her desire for a surrogate relationship with another person she could care for—a baby. She moves into depression in the second week. In the third week, she chooses a self consolatory strategy as a way of dealing with her pain (eating chocolate in response to food cravings). She is ‘caring’ for herself in a surrogate way, with an unconscious motivation of ‘I’ll care for myself as I wish to be cared for, as no one else is caring for me’.
Perhaps the most severe examples of a grief–depression sequence are observed in mothers who have had a young baby die, for example, from Sudden Infant Death Syndrome (SIDS). Here the response pattern is so distinct that we can only wonder at how instinctive the behaviour is and the role of evolution. In the first week after the death of the baby the mother might wake during the night and run through the house searching for her baby, even emitting high-pitched screams. After days or weeks, the high arousal pattern is replaced by one in which the mother spends most of her time slumped, rarely responding to others and appearing almost robotic. The depressed state begins to overwhelm her.
The two phases of any biphasic response (that is, high arousal and depression) following a significant loss generally overlap, rather than forming time-discrete stages. This makes it difficult to determine whether an individual’s current state is one of grief, depression or a combination of both.
As noted earlier, only one-third of people experiencing grief will go on to develop a distinct depressive phase. Most will experience a range of alternating and evolving grief stages before some resolution occurs.
Grief can be suppressed, unresolved or prolonged. In such cases the grief can be labelled ‘pathological’. The commonest causes of unresolved grief are blocked anger or suppressed emotions, and the excessive use of benzodiazepines such as Valium, or other drugs that suppress grief and its processing.
While some antidepressant drugs can reduce the intensity of grief, a range of proven counselling techniques is generally preferred to medication.
(extracted from) Dealing with Depression: A Commonsense Approach to Mood Disorders y Gordon Parker, published by Allen & Unwin.