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PII S0272-7358(00)00062-3
Stacey Kaltman
The Catholic University of America
ABSTRACT. The bereavement literature has yet to show consensus on a clear definition of
normal and abnormal or complicated grief reactions. According to DSM-IV, bereavement is a
stressor event that warrants a clinical diagnosis only in extreme cases when other DSM categories
of psychopathology (e.g., Major Depression) are evident. In contrast, bereavement theorists have
proposed a number of different types of abnormal grief reactions, including those in which grief is
masked or delayed. In this article, we review empirical evidence on the longitudinal course,
phenomenological features, and possible diagnostic relevance of grief reactions. This evidence
was generally consistent with the DSM-IV's view of bereavement and provided little support for
more complicated taxonomies. Most bereaved individuals showed moderate disruptions in
functioning during the first year after a loss, while more chronic symptoms were evidenced by a
relatively small minority. Further, those individuals showing chronic grief reactions can be
relatively easily accommodated by existing diagnostic categories. Finally, we found no evidence to
support the proposed delayed grief category. We close by suggesting directions for subsequent
research. D 2001 Elsevier Science Ltd. All rights reserved.
KEY WORDS. Grief, Bereavement, Loss, Stressor.
INTRODUCTION
GRIEF IS A painful, but unfortunately common experience. Most people at different
points in their lives are confronted with the death of a close friend or relative. There
are, however, marked individual differences in how intensely and how long people
grieve. Some grieve openly and deeply for years, and only slowly return to a
semblance of their normal level of functioning. Others suffer intensely, but for a
relatively more proscribed period of time. Still others appear to get over their losses
705
706 G. A. Bonanno and S. Kaltman
almost immediately, and to move on to new challenges and new relationships with
such ease as to raise doubts among their friends and relatives as to whether they may
be hiding something or running away from their pain.
The extent that grief varies across individuals suggests important questions about
what constitutes normal or common grief, and when, if at all, too much or too little
grief might be considered abnormal, or even pathological. Unfortunately, the
bereavement literature has yet to agree on a clear, empirically defensible definition
of grief, or its normal and abnormal course and manifestations (Bonanno, 1998;
Hansson, Carpenter, & Fairchild, 1993). The present review was motivated by this
deficiency. First, we review competing formulations of normal and complicated
grieving found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV, American Psychiatric Association, 1994) and in the bereavement literature.
According to the DSM-IV, bereavement is a stressor that produces relatively normal
and expectable distress. DSM-IV does not offer a complicated grief diagnosis, and
allows for bereavement-related diagnoses only in extreme cases when existing
diagnostic categories (e.g., Major Depression) may be relevant. In contrast, bereave-
ment theorists have argued for the clinical necessity of a complicated grief diagnosis,
and have proposed a number of different types of complicated grief. In an effort to
reconcile these competing positions, we review the available empirical evidence on
grieving. Specifically, we examine three kinds of evidence: longitudinal studies of
grief outcome, descriptive studies of the phenomenological features of grieving, and
diagnostic studies that focus on the distinction between normal and pathological or
complicated variants. Our analysis is generally supportive of the DSM-IV's conception
of grief as a normal reaction to an enduring stressor, and reveals little in the way of
empirical evidence to support the complex taxonomies of grief outcome developed
in the bereavement literature. We summarize the available evidence into a working
definition of grief course patterns, and close by suggesting several avenues for future
bereavement research.
grief becomes exceptional or severe are conceptualized using other known categories
of psychopathology. For example, Major Depressive Disorder can be diagnosed after
an interpersonal loss if the depressive symptoms endure longer than 2 months or are
marked by significantly disrupted functioning, suicidal ideation, psychotic symptoms,
psychomotor retardation, or extreme feelings of worthlessness. Alternatively, DSM-IV
indicates that Posttraumatic Stress Disorder may be diagnosed following the sudden,
unexpected death of a family member or close friend in the presence of the
characteristic constellation of intrusion, avoidance, and hyperarousal symptoms.
Thus, beyond the normal bereavement response, DSM-IV provides for the diagnosis
of more severe pathology in exceptional cases, but only in the form of existing
diagnostic categories.
years after the loss, most bereaved individuals returned to normal (baseline) levels of
functioning by the end of the first year. In addition, most bereaved individuals
experienced positive thoughts and emotions associated with the lost relationship,
even in the early months of grieving. Only a relatively smaller subset (approximately
15%) of the bereaved individuals in these studies tended to continue to show serious
disruptions in functioning at the 1 ± 2 year point, thereby suggesting some form of
chronic grief. In further concordance with DSM-IV, these individuals appeared to
experience symptoms similar to individuals suffering from depression and anxiety
disorders, and to some extent trauma reactions, and thus were adequately captured
by existing diagnostic categories. Importantly, our review also revealed a significant
minority of bereaved individuals who showed mininal grief (i.e., little or no overt signs
of disrupted functioning) in the early months after a loss. Due to variations in
measurement and other uncontrolled factors, the size of this group has varied,
ranging from 15% to 50% of the bereaved participants across studies.
DSM-IV does not discuss the absence of grief symptoms, as could be expected given
its view of bereavement as a stressor event and its primary emphasis on psychopathol-
ogy. In contrast, the bereavement literature has tended to view individuals showing
little or no grief with suspicion, and as having some form of inhibited or masked grief
or as prone to develop delayed grief symptoms. Wortman and Silver (1989) were
among the first to note the absence of empirical support for the existence of delayed
or inhibited grief. A decade later, however, we still find no concrete evidence to
support these categories and, rather, we suggest that the absence of intense grief in
the early months after a loss should be considered an indicator of adjustment, and
not a potentially abnormal or pathological response.
patterns of grief course. Unfortunately, there have been relatively few studies of
grieving beyond the first year. The longitudinal studies that are available,
however, provide important evidence: (a) that grief over the loss of a loved
one tends to disrupt psychological and physiological functioning in most but not
all bereaved individuals, (b) that a small, but significant minority of bereaved
individuals will continue to evidence disrupted functioning for many years after a
loss, and (c) that there does not appear to be any concrete justification for the
assumption that minimal grief in the early months of bereavement will eventually
lead to delayed grief.
The earliest studies of bereavement suggested relatively optimistic conclusions
about the normal duration of grief. Lindemann (1944) conducted what is generally
viewed as the first formal bereavement study and concluded that ``with a period of
from four to six weeks, it was ordinarily possible to settle an uncomplicated and
undistorted grief reaction'' (p.144). Parkes (1964) later endorsed a similar position,
concluding that his preliminary studies of health difficulties after loss provided
evidence ``consonant with the traditional picture of grief as a severe but self-limiting
affective disorder'' (p. 276).
Although these investigators presaged later observations of the time-limited aspects
of normal grieving, subsequent studies provided convincing evidence that for some
bereaved individuals the death of a spouse or close relative may lead to more
protracted disruptions in psychological and physical health. Parkes and Brown
(1972) used structured interviews to examine long-term health decrements among
a sample of middle-aged conjugally bereaved individuals and a matched married
comparison sample. The bereaved sample had higher levels of depressive symptoms
14 months after their loss, but was no longer distinguished from the comparison
sample after 2 years of mourning. However, by the second year after their loss, the
bereaved participants still reported significantly greater numbers of sick days, hospital
admissions, disturbances in sleep and appetite, and greater consumption of alcohol,
tobacco, and tranquilizers, compared to their nonbereaved counterparts.
Lehman, Wortman, and Williams (1987) used a cross-sectional design to assess
bereaved individuals between 4 and 7 years after the sudden and unexpected death of
either a spouse or a child. Although the results were strongest for the bereaved
spouses, this study provided important evidence for the enduring nature of severe
grief reactions. Compared to a matched married sample, the bereaved spouses
showed significantly more depression on several different indices, reported higher
levels of all types of psychiatric symptoms (e.g., anxiety, somatization, hostility), had
increased worry, less optimism, felt that their lives were significantly more negative,
and evidenced significantly greater mortality. A similar but less consistent pattern of
deficits was observed for the bereaved parents.
Although these studies provided convincing evidence that grief symptoms may
persist for years after a loss, they did not address the question of individual variation
in grief severity or duration. In an early effort to examine individuals differences in
grief symptoms and difficulties, Zisook, Devaul, and Click (1982) developed the
Expanded Texas Inventory of Grief (ETIG) to measure the ``frequency and time
course of present grief-related behaviors and feelings'' (p. 1590). Using a cross-
sectional design, they administered the ETIG to 211 people who had lost a loved one
between 1 month to 22 years previously. Zisook et al. observed that grief-related
behaviors and feelings peaked for most participants between 1 ± 2 years following the
death and then gradually declined. Nonetheless, there were still a small number of
712 G. A. Bonanno and S. Kaltman
the bereaved participants who endorsed items related to present feelings of grief as
late as 10 years after their loss.
Subsequently, Lundin (1984) used the ETIG in a cross-sectional, retrospective
study of bereaved participants who had lost either a spouse or a child 8 years earlier.
To assess outcome, Lundin selected items from the ETIG that satisfied Parkes and
Weiss'(1983) proposed criteria that recovery from bereavement involved a decreased
preoccupation with grief, the return of the ability to function well in everyday life,
and a sense of well being. Using these criteria, 65% of the sample had evidenced
recovery at the 8-year mark after their loss. These results, however, point to a
significant minority of subjects who were still preoccupied with the death and unable
to achieve a complete adjustment in this same lengthy time period.
What about delayed grief? Many of the grief course taxonomies reviewed earlier
included the delayed appearance of grief symptoms, typically accompanied by the
assumption that grief at early points in bereavement had been avoided (Bowlby, 1980;
Rando, 1992; Raphael, 1983; Sanders, 1993; Worden, 1982). Like many aspects of
bereavement theory, the assumption of delayed grief appears to have persevered
despite the relative absence of empirical support (Bonanno & Kaltman, 1999;
Wortman & Silver, 1989). There is some evidence that therapists can reliably identify
delayed grief from clinical vignettes (Marwit, 1996). However, diagnostic reliability in
this study was not surprising because a portion of the case vignettes were explicitly
designed to illustrate the delayed grief pattern. Further, none of the case vignettes
represented normal or uncomplicated bereavement. Thus, it is impossible to
determine the true reliability of the diagnoses. Finally, even if the reliability of the
delayed grief category was accepted, there is still a glaring absence of validity data for
the category.
Only two studies have directly attempted to examine the presumed existence
of delayed grief, and neither study was able to provide concrete support for the
construct. Middleton, Burnett, Raphael, and Martinek (1996) examined the grief
course of bereaved spouses (N = 44), bereaved adult children (N = 40) and
bereaved parents (N = 36). All three groups were interviewed about their grief
experiences within one month of the loss and again at 10 weeks, 7 months and
13 months of bereavement. Cluster analyses were used to classify participants into
the most representative categories of grief course. The results were similar across
the different types of bereavement. The most common pattern (43% to 70%)
was a moderate level of grief symptoms that declined over time. Relatively smaller
number of bereaved participants showed either low levels of grief across all four
assessments (17% to 25%), or relatively elevated grief across all four assessments
(14% to 31%). Importantly, despite the authors' conviction that delayed grief is a
genuine clinical phenomenon, Middleton et al. (1996) concluded that ``no
evidence was found for the pattern of response which might be expected for
delayed grief'' (p. 169).
In our own longitudinal research, we examined the relationship between grief
reactions and emotional avoidance among 42 conjugally bereaved individuals at 6,
14, 25, and 60 months of bereavement (Bonanno & Field, 2001; Bonanno, Keltner,
Holen, & Horowitz, 1995; Bonanno, Znoj, Siddique, & Horowitz, 1999). To oper-
ationally define delayed grief, we first defined severe and mild grief reactions using
the 6-month median score on a structured clinical interview for grief-related
disruptions in daily functioning (e.g., sleep disruption, weight loss, dysphoric affect).
The validity of the mild and severe grief categories was established by their
Varieties of Grief Experience 713
point in the study. Thus, there was not a reliable association between emotional
avoidance and either elevated grief or delayed elevations in grief.
Still another avenue we explored was the possibility of delayed increases in somatic
symptoms. Somewhat unexpectedly, bereaved individuals who showed affective ±
autonomic dissociation in the early months of bereavement reported concurrent
elevations in somatic complaints. However, at follow-up assessments, these partici-
pants no longer had high levels somatic complaints (Bonanno et al., 1995, 1999).
There was a small number of participants at each assessment who did show marked
increases in somatic complaints, relative to the previous assessment, but there was no
systematic relationship between changes in somatic complaints and affective ±auto-
nomic dissociation. Further, the level of change was always within a standard
deviation of the sample mean, suggesting normal measurement variance. Finally,
affective ± autonomic dissociation was found to be unrelated to other indices of
health, such as the frequency of visits to medical professionals.
It might be argued that even one participant showing both avoidant behavior
and delayed elevations in grief at 60 months lends the category at least a
modicum of clinical utility. However, even in this limited application, a relation-
ship between emotional avoidance and delayed elevations in grief was observed
for only 1 participant in 14 (or 7%), hardly a solid basis for clinical intervention.
Indeed, there are several more plausible, and more parsimonious, explanations
for delayed increases in just a few participants, explanations that may also be
applied to clinical reports of isolated cases of delayed grief. One such explana-
tion is that other stressors over-and-above the original loss produced the observed
increase in symptoms.
An even more parsimonious explanation is that elevations in symptom levels for a
few participants is simply the result of normal, random measurement error (Nunn-
ally, 1978). Bereavement theorists have assumed that when delayed grief emerges, it
is usually ``as fresh and intense as if the loss had just occurred'' (Humphrey &
Zimpfer, 1996, p. 152). Thus, delayed grief should be evident on multiple grief
indices. A measurement error explanation of delayed grief suggests, however, that
participants who show delayed symptom elevations will tend to do only on isolated
measures, and will score within the normal range on other, related symptom
measures (i.e., the elevated symptoms should occur in a random manner across
measurements). The data supported this point. When assessed at 60 months, the
three participants showing delayed elevations from the original Bonanno et al.
(1995) study each showed an elevation on only one measure (Bonanno & Field,
2001). Further, when measurement error was minimized by weighting each of several
grief-related symptom measures by their alpha reliability and then summing the
weighted measures into a composite grief score, there were effectively no cases of
delayed grief (Bonanno & Field, 2001).
When this evidence is considered together with the fact that delayed grief has yet
to be demonstrated convincingly in any empirical study (Bonanno & Kaltman, 1999;
Wortman & Silver, 1989), it would appear that a diagnostic category for delayed grief
is unwarranted. Nonetheless, we echo Bonanno and Field's (2001) conclusion that it
may be premature to completely dismiss the possible existence of delayed grief on
the basis of only two empirical studies, especially when it is considered that the
construct is still strongly endorsed in the bereavement literature. However, given the
increasingly important role empirical evidence plays in modern clinical science, we
also echo Bonanno and Field's (2001) conclusion that the burden of proof now lies
Varieties of Grief Experience 715
most heavily on the shoulders of those who believe the construct to be valid and
clinically useful.
Cognitive Disorganization
A number of investigators have noted the disorganizing impact of interpersonal
losses. These difficulties appear to be largely due to the way interpersonal losses
challenge the survivor's personal sense of identity and to the difficulty most bereaved
survivors experience comprehending a loved one's death. These types of cognitive
alterations have been found in most bereaved people during the initial months after
the loss and, although many bereaved people report continued struggles to make
sense of a loss even years after its occurrence, gradually decline during the first year.
In addition, there appear to be two subsets of bereaved individuals: one group who
show no signs of altered cognitive functioning, and one group who evidence more
pronounced alterations in cognitive functioning similar to trauma reactions.
only 1% to 4% endorsed any of these items. Finally, although it has been assumed
that many bereaved individuals feel that something is wrong with them, or that they
are ``approaching insanity'' (Lindemann, 1944, p. 142), when Shuchter and Zisook
(1993) asked participants directly if they felt that something was wrong with their
minds, only 5% endorsed this item. Again, however, this was greater than the 1%
endorsement of this item by the married counterparts.
Similar findings were reported by Horowitz and colleagues (Horowitz et al.,
1997). Among a sample of middle-aged, conjugally bereaved adults, the majority
(72%) experienced ``unbidden'' memories and images of the deceased at 6 months
post-loss. However, fewer participants experienced extreme difficulties concentrat-
ing (34%) or perceptual aberrations in which it seemed that the deceased was still
alive (24%) or had appeared in a public place (17%). Even smaller subsets of
participants evidenced cognitive alterations commonly associated with trauma
reactions (DSM-IV; APA, 1994), such as hypervigilance (13%), or a foreshortened
sense of the future (12%).
Sense of disrupted future. In the early months after a loss, the majority of bereaved
individuals report uncertainty about the future (Horowitz et al., 1997; Shuchter &
Zisook, 1993). However, by the end of the first year of bereavement, most bereaved
individuals no longer report this experience (Horowitz et al., 1997). Small subsets of
bereaved individuals (less than 15%) also tend to experience a sense of hopelessness
or perception of foreshortened future (Horowitz et al., 1997; Shuchter & Zisook,
1993). Lehman et al. (1987) found that 4 to 7 years after a sudden loss, conjugally
bereaved individuals may still endorse feeling less ``optimistic about the future'' than
matched controls.
The long-term search for meaning. Another cognitive alteration commonly associated
with bereavement is the concerted and enduring search for some way to understand
or find meaning in the loss. Schwartzberg and Janoff-Bulman (1994) questioned
undergraduates who had experienced the death of a parent within the past 3 years
and a group of matched controls on several meaning-oriented dimensions. Com-
pared with their matched counterparts, the bereaved participants in general
Varieties of Grief Experience 717
described the world as less meaningful and believed more strongly that personal
events were determined by chance. Further, the more grief the bereaved individuals
reported, the less likely they were to perceive the world as meaningful or to perceive
themselves as worthy, and the more likely they were to believe that personal events
were determined by chance or by powerful others.
Lehman et al. (1987) demonstrated convincingly that the search for meaning after
a loss is a typically long term if not impossible proposition. As late as 4 to 7 years after
a sudden loss of a spouse or child, the vast majority of bereaved individuals continued
to talk about the loss, to review memories, thoughts, or mental pictures of the
deceased, or to ask themselves the question ``Why me?'' or ``Why my spouse/child?''
Perhaps due to the potentially traumatic nature of unexpected or violent losses, close
to half the participants in this study also reported that they continued to relive, or
review events leading up to, their loved one's death. Finally, 68% of the bereaved
spouses and 59% of the bereaved parents reported that they had not found any
meaning or made any sense at all of the loss.
Dysphoria
Another dimension of bereavement, closely related to disordered cognitive function-
ing, is prolonged or intensified emotional malaise or dysphoria. Most but not all
bereaved individuals experience dysphoric states in the early months after a loss that
gradually subside during the initial year of bereavement, while more extreme or
enduring forms of dysphoria tend to characterize only the smaller minority of
severely grieved individuals.
a wide range of dysphoric themes. Distress was the most common theme, evidenced
in 39% of the narratives, followed by sadness (36%), contempt (34%), and anger
(14%). In addition, the themes of anxiety, shame, guilt, disgust, envy, fear, and
jealousy were evidenced in lesser frequencies.
Pining or yearning. From an emotional perspective, although grief may evoke a range
of different emotional responses, it is nonetheless distinguished from emotion by its
enduring nature and by its recruitment of long-term coping efforts (Bonanno, in
press; Izard, 1977; Lazarus, 1991). Several investigators have, however, identified
more complex and enduring aspects of dysphoria during bereavement. For example,
Parkes (1970) concluded that ``the central and pathognomonic feature of grief'' is an
intense ``pining'' or yearning for the deceased, such that ``without it grief cannot
truly be said to have occurred and when present it is a sure sign of a person grieving''
(p. 451). Parkes and Weiss (1983) later identified a ``high yearning'' group of
conjugally bereaved individuals who appeared to yearn for their deceased spouses
``constantly,'' ``frequently'', or ``whenever inactive.'' A team of interviewers also
found the high yearning group to have a poorer grief outcome during the second to
fourth years of bereavement. Although these findings would suggest that intense
yearning for the deceased is found only in complicated or severe grief, Parkes and
Weiss (1983) stressed that ``high yearning'' was by far the most frequent categoriza-
tion of their participants, describing about two thirds of the sample during the initial
months after the loss. Other studies have also demonstrated the normative, and time-
limited aspect of yearning. Of the 350 widows and widowers questioned by Shuchter
and Zisook (1993), 77% reported yearning for their deceased spouses in the first 2
months after the loss, while 58% still yearned for their spouses into the second year of
bereavement. Using a structured clinical interview format, Horowitz et al. (1997)
found that 58% of their conjugally bereaved sample experienced strong yearning for
their lost spouses nearly every day at the 6-month point in bereavement, while this
percentage dropped to 35% by 14 months post-loss.
while social loneliness was not significantly different between the married and
bereaved participants.
Health Deficits
There is considerable evidence that the stress of interpersonal loss incurs a
significant health cost. This has been observed most commonly in the form of
increased doctor visits and complaints about general health. As with the other
aspects of grieving, health deficits are commonly observed among recently bereaved
individuals, but appear to be particularly enduring among a small subset of severely
grieved individuals.
Health behaviors and complaints. A number of studies have provided clear evidence
associating interpersonal loss with increased somatic difficulties, including shortness
of breath, palpitations, digestive difficulties, loss of appetite, restlessness, and
insomnia (Clayton, 1974; Horowitz et al., 1997; Lindemann, 1944; Parkes, 1970).
Several studies offered preliminary evidence for increased mortality and morbidity
rates during bereavement (Marris, 1958; Young, Benjamin, & Wallis, 1963). However,
several studies had also failed to find bereavement-related health deficits (Clayton,
1982; Heyman & Gianturco, 1973). To investigate these inconsistencies, Thompson,
Breckenridge, Gallagher, and Peterson (1984) compared the health of an elderly
bereaved sample 2 months into bereavement with an elderly comparison sample and
statistically controlled for a number of potentially confounding socioeconomic and
demographic variables. With potential confounding variance controlled, the
bereaved participants still reported more new or worsened illnesses, more severe
illnesses, more new or increased use of medications, poorer perceived health, and
poorer health relative to others of the same age.
Parkes (1964) examined doctor visits prior to and after the death of a spouse. In
the first 6 months of bereavement, doctor visits increased by 60%. Although the
number of doctor visits fell during the second and third 6-month periods, partici-
pants on the whole still visited their doctors more often than they had prior to the
loss. Bereaved individuals have also been found to report significantly greater health
complaints, into the second year of bereavement, relative to matched comparison
groups (Maddison & Viola, 1968; Parkes & Brown, 1972). In Lehman et al.'s (1987)
more lengthy 4 to 7 year study, however, neither parentally bereaved nor conjugally
bereaved individuals differed from matched controls in perceived health scores.
To explore individual differences in somatic complaints over time, Bonanno et al.
(1999) categorized conjugally bereaved individuals as has having high or low levels of
somatic symptoms based on the sample median at the 6-month point in bereavement.
Using this definition, approximately one third (35%) of the participants had low
levels of somatic complaints at each assessment through 25 months, while another
third (32%) showed initial elevations in somatic symptoms but dropped to low levels
between the first and second year of bereavement. A smaller group of bereaved
participants (19%) had varied levels of somatic complaints across assessments, while
only a small subgroup, comprising 13% of the sample, reported chronically elevated
somatic complaints.
Neuroendocrine activity and immune functioning. Several studies have examined the
possible role of neuroendocrine activity, such as changes in cortisol or serum
720 G. A. Bonanno and S. Kaltman
growth hormone levels, during bereavement. However, as yet these studies have
failed to provide clear evidence that neuroendocrine activity is altered signifi-
cantly during bereavement, or that it influences the course of grieving (Kim &
Jacobs, 1993).
In contrast, there is a growing body of evidence to suggest a link between grief and
a relatively short-lived compromise in immune functioning. Bartrop, Luckhurst,
Lazarus, Kiloh, and Penny (1977) examined cellular immunity in a conjugally
bereaved sample at 2 and 6 weeks post-loss and in a matched control sample. The
bereaved group showed reduced T-cell responsivity at both assessments, but did not
differ from the comparison sample in B-cell responsivity, or in T-cell or B-cell counts.
Schleifer, Keller, Camerino, Thornton, and Stein (1983) obtained repeated assess-
ments of immune functioning among 15 men before and after the death of their
wives from metastatic breast cancer. In the first month following the loss, over half of
the bereaved men showed reduced lymphocyte responsivity. However, there were no
differences pre and postloss in absolute T-cell or B-cell counts. Further, lymphocyte
responsivity was not different from preloss levels when assessed beyond the first 2
months of bereavement, suggesting that immune suppression due to loss is specific
and relatively short-lived.
Subsequent studies have refined this conclusion, indicating that the link between
bereavement and brief immune suppression may be mediated by depression (Irwin,
Daniels, Smith, Bloom, & Weiner 1987; Irwin & Weiner, 1987; Linn, Linn, & Jensen,
1984). For instance, Zisook et al. (1994) examined several different immune
functioning variables in a sample of middle-aged conjugally bereaved women and
in a sample of matched controls. There were no significant differences between the
bereaved women at 2 months post-loss and their married counterparts on any of the
immune variables. However, when the bereaved sample was separated into depressed
and nondepressed widows using the DSM-III-R, depressed widows had a lower
concentration of T-cells, lower NK activity, and a trend toward lower lymphocyte
stimulation responses compared to the nondepressed widows.
As compelling as the link between grief-related depression and a short-term
suppression of immune functioning may be, it has not yet been demonstrated that
the depressive aspects of grief exert a longer term influence on immune function-
ing, or that the short-term suppression effects produce any lasting health conse-
quences (Irwin & Pike, 1993). Additional research will be necessary to address this
question further.
Since the extensive literature on the bereavement ± mortality effect has been
reviewed in detail elsewhere (Mergenhagen, Lee, & Gove, 1985; Stroebe & Stroebe,
1993; Stroebe, Stroebe, Gergen, & Gergen, 1981; Stroebe & Stroebe, 1987), we will
not consider individual studies further in this article. Rather, we reiterate the
conclusions of Stroebe and Stroebe (1993). Following an extensive review of a large
number of cross-sectional and longitudinal bereavement studies conducted in several
different countries, they concluded that despite inconsistencies across studies, there
was plentiful evidence that the ``bereaved are indeed at higher risk of dying than are
nonbereaved persons'' (p.188), and that the risk of increased mortality extends to all
types of bereavement, particularly in the early months after the loss and particularly
among younger bereaved individuals.
Negative impact on others. One factor that may contribute to the distinction
between normal social withdrawal and more chronic social difficulties is the way
grief may impact on others. In other words, the constant expression of pain on the
part of severely grieved individuals may drive away potential avenues of social
support (Bonanno & Keltner, 1997; Coyne, 1976; Harber & Pennebaker, 1992;
Kelly & McKillop, 1996). This possibility received preliminary support in a recent
study in which untrained observers were asked to rate their subjective reactions to
722 G. A. Bonanno and S. Kaltman
Role disruptions. Bereaved individuals also appear to struggle in their social roles as
parents or in their careers (Parkes & Weiss, 1983). Several cross-sectional studies have
provided data consistent with this conclusion. Compared to a matched sample of
married men, widowers recruited during their first year of bereavement reported
greater difficulties in their work roles both outside the home and in the home,
greater difficulties managing spare time, and greater difficulties with their family
roles (Tudiver, Hilditch, & Permaul, 1991). In another cross-sectional study, Lehman
et al. (1987) also found that 4 ± 7 years after the sudden death of a spouse, conjugally
bereaved individuals were still less likely to look forward to doing things with others,
less confident that they could handle or cope with a serious problem or major change
in their life, and rated the general state of their lives more negatively, compared to a
matched married group. The conjugally bereaved parents in the Lehman et al.
(1987) study showed similar but nonsignificant trends toward the same results.
A more precise estimation of the impact of bereavement on work performance and
its decrease over time was provided by Shuchter and Zisook (1993) in their
prospective study of a large, representative sample of recently conjugally bereaved
adults. They found that over a third (36%) of their sample reported dissatisfaction in
their work performance at 7 months, and that 28% still endorsed this problem at 13
months post-loss. Although these percentages show that dissatisfaction with work may
not be as widespread as other grief-related difficulties, is was still more common
among bereaved individuals relative to the 10% of the married comparison sample
who reported such difficulties.
Difficulties with new relationships. The death of a spouse is commonly associated with
temporary difficulties initiating and maintaining new intimate relationships. Hor-
owitz et al. (1997) found that 59% of the conjugally bereaved individuals they
interviewed at the 6-month point in bereavement had difficulties developing new
intimate relationships. However, by 14 months, only about a third of the sample
(32%) reported such difficulties. Schneider, Sledge, Shuchter, and Zisook (1996)
reported similar findings. Because these investigators considered a relatively large
conjugal bereavement sample (N = 350), they were also able to identify relevant
gender differences (W. Stroebe & Stroebe, 1993). Two months after the deaths of
their spouses, 55% of the widowers and 46% of the widows had difficulties developing
new relationships. By 25 months, however, the portion of widowers who experienced
difficulties with new relationships had dropped to 37%, while the proportion for
widows had risen significantly to 58%. Widows were also relatively slower to engage in
new romantic involvements. By the 2-month point in bereavement, only 3% of the
widows were invovled in new romantic relationships and this portion rose only
modestly to 19% at 25 months. On the other hand, 12% of the widowers were in
new romantic relationships at 2 months, and by 25 months this portion had risen
Varieties of Grief Experience 723
sharply to 61%. Widowers were also more likely than widows to remarry. Younger
widows were more likely to develop new romantic involvements than older widows,
while for widowers new romantic involvements were associated with income and
education level. Finally, but again similar to other facets of grief, there appears to be a
more severely grieved subgroup for whom developing new relationships is a particu-
larly exacting task. Regardless of gender, bereaved individuals who were depressed
found it more difficult to begin new relationships.
Positive thoughts, beliefs, and appraisals. Several recent studies have shown that
significant interpersonal losses often induce relatively positive changes in identity,
sometimes even in the first few months after the loss. Shuchter & Zisook (1993)
found that at the 2-month point in bereavement, 42% of the conjugally bereaved
respondents they questioned had already reported that they were better people for
having gone through the experience of grief. Further, over a third of their 2-month
sample (36%) reported that they had begun to enjoy the freedom of being on their
own. And these percentages only increased over time. By the second year of
bereavement, over half the bereaved sample had endorsed each item.
Evidence from recent narrative studies has provided even more striking contrast to
the traditional assumption that positive experiences are rare during bereavement. In
their study of bereaved gay men's narratives, Stein et al. (1997) coded a number of
appraisal variables and found that overall the men in their sample described
significantly more positive than negative appraisals in the first month of bereavement.
More specifically, the bereaved men reported almost twice as many positive ``belief
appraisals'' (e.g., belief in self-growth from past events) than negative belief apprai-
sals (e.g., fear of the future), and three times as many positive goal outcomes (e.g., ``I
gave him a massage, and he felt better'') than negative goal outcomes (e.g.,
``Although I gave him the medicine, he got worse.''). The proportion of positive
appraisals in the bereaved men's narratives was also associated with a greater
emphasis on both current and future-oriented goals and plans. Finally, the greater
the proportion of positive appraisals in the bereaved men's narratives during the first
month of bereavement, the more likely they were to show improved a health outcome
12 months after the loss.
In a related study, Capps & Bonanno (2000) coded bereavement narratives for the
extent that they included positive and negative thought content (thoughts, beliefs,
appraisals, opinions, and other forms of personal information that could not be
verified without access to the narrators' internal state) (Stiles, Shuster, & Harrigan,
1992). Thought content was slightly more often positive (29%) than negative (25%).
Further, positive thought content at the 6-month point in bereavement was predictive
724 G. A. Bonanno and S. Kaltman
of less interviewer-rated grief two years later. In addition, transcripts that showed a
greater prevalence of positive thoughts were rated by naive judges as indicative of
better adjustment and reduced suffering.
Positive emotions and laughter. It has become increasingly evident that positive
emotions serve an important adaptive function in the negotiation of negative life
events (Bonanno, in press; Fredrickson & Levenson, 1998; Lazarus, Kanner, &
Folkman, 1980). Recent bereavement studies have shown that, like positive thoughts
and appraisals, positive emotional experiences play an important role in the grieving
process (Bonanno & Kaltman, 1999). Shuchter and Zisook (1993) found that 28% of
their conjugally bereaved sample reported experiencing relief as early as 2 months
after the loss, while the majority of the sample (82%) reported that they were
``comforted'' by a sense that their spouse was in heaven. Stein et al. (1997) found
that, while bereaved gay men described overall more negative emotion states than
positive emotion states, positive emotion states were far from infrequent and
occurred in 39% of all the emotion states coded. In the Capps & Bonanno (2000)
study of conjugal bereavement narratives, mention of emotion in general was
relatively infrequent, occurring in only 11% of all narrative units. However, when
emotions were mentioned, almost half (49%) were positive emotions and an
additional 21% included both positive and negative emotion. Finally, in Bonanno
et al.'s (1999) investigation of core emotion themes during conjugal bereavement,
positive themes were the most common themes mentioned, including pride in the
deceased (82%), love/affection, (81%), and happiness (55%).
Conjugally bereaved participants have reported experiencing positive emotions
while describing their loss to an interviewer (Bonanno et al., 1995). Bonanno and
Keltner (1997) examined the facial expressions of emotion that occurred in these
same interviews and found that most of the bereaved participants also showed facial
expressions associated with enjoyment (smiling: 63%) and amusement (laughter:
58%). Further, smiling and laughter during the 6-month interviews were predictive of
reduced grief into the third year of the loss, and this predictive relationship remained
significant even when initial levels of grief and self-reported emotion were statistically
controlled. In a subsequent study, Keltner and Bonanno (1997) further explored the
adaptive role of laughter during bereavement. Bereaved individuals who showed
genuine or Duchenne laughter, which involves the orbicularis occuli muscles around
the eyes, at some point during their discussion of the loss reported less anger and
more enjoyment during the interview, evidenced the dissociation of distress (affec-
tive ±autonomic response dissociation), reported better social relations, and evoked
more positive responses from strangers who viewed them on videotape.
Using a criteria that at least three of these symptoms be observed at a level of severity
that interferes with daily functioning, Horowitz et al. identified ``Complicated Grief
Disorder'' in 41% of the 14-month sample. Only 21% of these participants evidenced
a comorbid diagnosis of Major Depression. However, much like the Kim and Jacobs
(1991) data, the high prevalence of Complicated Grief diagnosis in this study appears
to have resulted from the inclusion of common grief features among the ``symptoms''
of Complicated Grief.
Anxiety Disorder (GAD) was by far the most common diagnosis. Compared to the
community prevalence rate of 9%, GAD was identified in 23% of the 6-month
bereaved sample and 39% of the 12-month bereaved sample. Panic Disorder was
the next most common. Compared to the less than 1% prevalence in the community
sample, Panic Disorder was identified in 6% of the 6-month bereaved sample and
13% of the 12-month bereaved sample.
In addition, the Jacobs et al. (1990) data evidenced considerable overlap between
chronic anxiety and depression. The majority of depressed participants in the 6-
month sample (63%) were also diagnosed with an anxiety disorder, and all of the
bereaved individuals in the 12-month sample who had Major Depression were also
diagnosed with an anxiety disorder. Thus, although depression typically declines
during bereavement, it appears that the more anxious, chronically grieved individuals
also continue to experience enduring depression. Additional longitudinal data will
be needed to examine this conclusion further.
show more chronic depressive symptoms than bereaved individuals whose spouses
had died of natural causes. Together, these studies suggest that loss due to violent
death may be one of the factors that most strongly contribute to the eventual
development of chronic grieving.
Our review also revealed a significant distinction that has not been well represented
in either the DSM-IV or the contemporary bereavement literature. The available
research suggests that considerable numbers of bereaved individuals experience little
or no overt disruptions in daily functioning as a result of their bereavement. In other
words, these individuals do not show the common grief symptoms, but neither do
they show any indication of abnormal or pathological mourning or any concrete signs
of delayed difficulties. One implication of this distinction is that there needs to be
greater research on prebereavement factors, and their role in informing the initial
reaction to loss. There has been remarkably little research on prebereavement
variables, perhaps due in part to the fact that such measurements are notoriously
difficult to obtain. Certainly, some of the contextual factors that might inform initial
grief can be measured retrospectively (e.g., type of loss, change in financial status,
etc.). However, a number of other variables that might potentially serve as predictors
of grief response (e.g., coping styles, attachment behavior, the quality of the marital
relationship) tend to be confounded with initial grief reactions and, thus, are best
measured a priori.
One of the few bereavement studies to incorporate prebereavement measure-
ments, conducted by Folkman and her colleagues (Folkman, Chesney, Collette,
Boccellari, & Cooke, 1996), is illustrative of this point. Folkman et al. (1996) first
recruited a sample of gay men who were caring for their partners, many of whom
were expected to die of AIDS in the near future. They measured a number of
variables, including life stressors, depression, and coping strategies, and followed the
caregivers through their partner's death and into bereavement. Using this design,
Folkman et al. were able to control for initial increases in depression after the
partner's death, and to show that depression at 7 months post-loss was predicted by
prebereavement stressors (daily hassles) and by the prebereavement use of distancing
and self-blame to cope with the burden of care giving. More research of this type will
greatly enhance our understanding of the initial stages of bereavement, and may
provide invaluable information to inform strategies for early clinical intervention.
Although much of the recent bereavement research has focused on determining
the factors that predict grief severity over the long term (for a review of this research,
see Bonanno & Kaltman, 1999), there has been relatively little research on the role of
the initial grief response. Indeed, if initial grief reactions are considered at all,
generally they are viewed in terms of variance that needs to be controlled while
predicting later grief. The research we reviewed in this article suggests, however, that
intense or pronounced initial grief reactions may be an important indicator of
whether individuals go on to develop chronic grief reactions. The available evidence
on this point was far from conclusive, however, therefore indicating another
important area for future research.
A further implication of our review is suggested by the absence of clear support for
the concept of delayed grief. In addition to assumptions about treatment, uncritical
acceptance of the existence of delayed grief has also unnecessarily limited the scope
of bereavement research. For example, delayed grief is widely assumed to arise from
the minimization or avoidance of grief-related distress in the early months after a loss.
This assumption has tended to preclude investigation of the potentially adaptive
value of grief-related avoidance, or of positive experiences such as laughter. It is only
recently that these phenomena have been examined empirically and, in contrast to
traditional assumptions about the importance of ``working through'' grief, the
evidence thus far indicates that adjustment during bereavement is fostered by
730 G. A. Bonanno and S. Kaltman
AcknowledgmentsÐThe authors thank Diane Arnkoff for her many useful insights
during the development of this manuscript.
REFERENCES
Abraham, K. (1924). A short study of the development of the libido; viewed in the light of mental disorders.
In: K. Abraham (Ed.), Selected papers on psychoanalysis ( pp. 418 ± 501). London: Hogarth Press.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Anderson, C. (1949). Aspects of pathological grief and mourning. Internal Journal of Psychoanalysis, 30,
48 ± 55.
Asendorpf, J. B., & Scherer, K. R. (1983). The discrepant repressor: differentiation between low anxiety,
high anxiety, and repression of anxiety by autonomic ± facial ± verbal patterns of behavior. Journal of
Personality and Social Psychology, 45, 1334 ± 1346.
Bartrop, R. W., Luckhurst, E., Lazarus, L., Kiloh, L. G., & Penny, R. (1977). Depressed lymphocyte function
after bereavement. Lancet, 1, 834 ± 836.
Belitsky, R., & Jacobs, S. (1986). Bereavement, attachment theory, and mental disorders. Psychiatric Annals,
16, 276 ± 280.
Bernstein-Carlson, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation
scale. Journal of Nervous and Mental Disease, 174, 727 ± 735.
Bonanno, G. A. (1998). The concept of ``working through'' loss: a critical evaluation of the cultural,
historical, and empirical evidence. In: A. Maercker, M. Schuetzwohl, & Z. Solomon (Eds.), Posttraumatic
stress disorder: vulnerability and resilience in the life-span ( pp. 221 ± 247). GoÈttingen, Germany: Hogrefe
and Huber.
Bonanno, G. A. (in press). Grief and emotion: comparing the grief work and social ± functional perspec-
tives. In: M. Stroebe, W. Stroebe, R. O. Hansson, & H. Schut (Eds.), New handbook of bereavement:
consciousness, coping, and care. Washington, DC: American Psychological Association.
Bonanno, G. A., & Field, N. P. (2001). Predicting bereavement outcome across five years: I. The question of
delayed grief. American Behavioral Scientist, 44, 798 ± 816.
Bonanno, G. A., & Kaltman, S. (1999). Toward an integrative perspective on bereavement. Psychological
Bulletin, 125, 760 ± 776.
Bonanno, G. A., & Keltner, D. (1997). Facial expressions of emotion and the course of bereavement.
Journal of Abnormal Psychology, 106, 126 ± 137.
Bonanno, G. A., Keltner, D., Holen, A., & Horowitz, M. J. (1995). When avoiding unpleasant emotion
Varieties of Grief Experience 731
might not be such a bad thing: verbal ± autonomic response dissociation and midlife conjugal
bereavement. Journal of Personality and Social Psychology, 46, 975 ± 989.
Bonanno, G. A., Mihalecz, M. C., & LeJeune, J. T. (1999). The core themes of conjugal loss. Motivation
and Emotion, 23, 175 ± 201.
Bonanno, G. A., Znoj, H. J., Siddique, H., & Horowitz, M. J. (1999). Verbal ± autonomic response dissocia-
tion and adaptation to midlife conjugal loss: a follow-up at 25 months. Cognitive Therapy and Research,
23, 605 ± 624.
Bowlby, J. (1980). Loss: sadness and depression (attachment and loss), vol. 3. New York: Basic Books.
Capps, L. & Bonanno, G. A. (2000). Narrating bereavement: thematic and grammatical predictors of
adjustment to loss. Discourse Processes, 30, 1 ± 26.
Cerney, M. W., & Buskirk, J. R. (1991). Anger: the hidden part of grief. Bulletin of the Menninger Clinic, 55,
228 ± 237.
Clayton, P. J. (1974). Mortality and morbidity in the first year of bereavement. Archives of General Psychiatry,
30, 747 ± 750.
Clayton, P. J. (1982). Bereavement. In: E. S. Paykel (Ed.), Handbook of affective disorders ( pp. 403 ± 415).
London: Livingstone.
Clayton, P. J., Desmarais, L., & Winokur, G. (1968). A study of normal bereavement. American Journal of
Psychiatry, 125, 168 ± 178.
Clayton, P. J., Halikas, J. A., & Maurice, W. L. (1972). The depression of widowhood. British Journal of
Psychiatry, 120, 71 ± 76.
Coyne, J. C. (1976). Depression and the response of others. Journal of Abnormal Psychology, 85, 186 ± 193.
Deutsch, H. (1937). Absence of grief. Psychoanalytic Quarterly, 6, 12 ± 22.
Faschingbauer, T. R. (1981). The Texas revised inventory of grief manual. Houston, TX: Honeycomb.
Faschingbauer, T. R., Devaul, R. D., & Zisook, S. (1977). Development of the Texas inventory of grief.
American Journal of Psychiatry, 134, 696 ± 698.
Field, N. P., Bonanno, G. A., Williams, P., & Horowitz, M. J. (2000). Appraisals of blame in adjustment to
conjugal bereavement. Cognitive Therapy and Research, 24, 549 ± 568.
Folkman, S., Chesney, M., Collette, L., Boccellari, A., & Cooke, M. (1996). Postbereavement depressive
mood and its prebereavement predictors in HIV+ and HIV gay men. Journal of Personality and Social
Psychology, 70, 336 ± 348.
Fredrickson, B. L., & Levenson, R. W. (1998). Positive emotions speed recovery from the cardiovascular
sequelae of negative emotions. Cognition and emotion, 12, 191 ± 220.
Glick, I. O., Weiss, R. S., & Parkes, C. M. (1974). The first year of bereavement. New York: Wiley-Interscience.
Gorer, G. (1965). Death, grief, and mourning in contemporary Britain. London: Tavistock Publications.
Green, B. L. (1997). Traumatic loss: conceptual issues and new research findings. Keynote address. 5th
International Conference on Grief and Bereavement, Washington, DC.
Hansson, R. O., Carpenter, B. N., & Fairchild, S. K. (1993). Measurement issues in bereavement. In: M. S.
Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement: theory, research and intervention
( pp. 62 ± 76). Cambridge, England: Cambridge Univ. Press.
Harber, K. D., & Pennebaker, J. W. (1992). Overcoming traumatic memories. In: S. A. Christianson (Ed.),
The handbook of emotion and memory ( pp. 359 ± 388). Hillsdale, NJ: Erlbaum.
Harvey, J. H., & Miller, E. D. (1998). Toward a psychology of loss. Psychological Science, 9, 429 ± 434.
Heyman, D. K., & Gianturco, D. T. (1973). Long term adaptation by the elderly in bereavement. Journal of
Gerontology, 28, 359 ± 362.
Horowitz, M. J. (1986). Stress response syndromes. Northvale, NJ: Aronson.
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath, C., & Stinson, C. H. (1997). Diagnostic
criteria for complicated grief disorder. American Journal of Psychiatry, 154, 904 ± 910.
Horowitz, M. J., Wilner, N., & Alvarez, M. A. (1979). Impact of event scale: a measure of subjective distress.
Psychosomatic Medicine, 41, 209 ± 218.
Humphrey, G. M., & Zimpfer, D. G. (1996). Counseling for grief and bereavement. Thousand Oaks, CA:
Sage Publications.
Irwin, M. R., Daniels, M., Smith, T. L., Bloom, E., & Weiner, H. (1987). Impaired natural killer cell activity
during bereavement. Brain, Behavior, and Immunity, 1, 98 ± 104.
Irwin, M. R., & Pike, J. (1993). Bereavement, depressive symptoms, and immune function. In: M. S.
Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement: theory, research, and intervention
( pp. 160 ± 171). Cambridge, England: Cambridge Univ. Press.
Irwin, M. R., & Weiner, H. (1987). Depressive symptoms and immune function during bereavement. In: S.
Zisook (Ed.), Biopsychosocial aspects of grief ( pp. 159 ± 174). Washington, DC: American Psychiatric Press.
732 G. A. Bonanno and S. Kaltman
Parkes, C. M. (1972). Bereavement: studies of grief in adult life. New York: International Universities Press.
Parkes, C. M., & Brown, R. J. (1972). Health after bereavement: a controlled study of young Boston widows
and widowers. Psychosomatic Medicine, 34, 449 ± 461.
Parkes, C. M., & Weiss, R. S. (1983). Recovery from bereavement. New York: Basic Books.
Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds III, C. F., Anderson, B., Zubenko, G. S., Houck, P. R.,
George, C. J., & Kupfer, D. J. (1995). Complicated grief and bereavement-related depression as distinct
disorders: preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry,
152, 22 ± 30.
Rando, T. (1992). The increasing prevalence of complicated mourning: the onslaught is just beginning.
Omega, 26, 43 ± 59.
Rando, T. (1993). Treatment of complicated mourning. Champaign, IL: Research Press.
Raphael, B. (1983). The anatomy of bereavement. New York: Basic Books.
Rounsaville, B. J., & Chevron, E. (1982). Interpersonal psychotherapy: clinical applications. In: A. J. Rush
(Ed.), Short-term psychotherapies for depression: behavioral, interpersonal, cognitive, and psychodynamic
approaches ( pp. 107 ± 142). New York: Guilford.
Rynearson, E. K. (1996). Psychotherapy of bereavement after homicide: be offensive. In Session: Psychother-
apy in Practice, 2, 47 ± 58.
Rynearson, E. K., & McCreery, J. M. (1993). Bereavement after homicide: a synergism of trauma and loss.
American Journal of Psychiatry, 150, 258 ± 261.
Sable, P. (1989). Attachment, anxiety, and loss of a husband. American Journal of Orthopsychiatry, 59,
550 ± 556.
Sanders, C. M. (1979). The use of the MMPI in assessing bereavement outcome. In: C. S. Newmark (Ed.),
MMPI: clinical and research trends ( pp. 223 ± 247). New York: Praeger.
Sanders, C. M. (1993). Risk factors in bereavement outcome. In: M. S. Stroebe, W. Stroebe, & R. O.
Hansson (Eds.), Handbook of bereavement: theory, research, and intervention ( pp. 255 ± 270). Cambridge,
England: Cambridge Univ. Press.
Schleifer, S. J., Keller, S. E., Camerino, M., Thornton, J. C., & Stein, M. (1983). Suppression of lymphocyte
stimulation following bereavement. Journal of the American Medical Association, 250, 374 ± 377.
Schneider, D. S., Sledge, P. A., Shuchter, S. R., & Zisook, S. (1996). Dating and remarriage over the first two
years of widowhood. Annals of Clinical Psychiatry, 8, 51 ± 57.
Schwartzberg, S. S., & Janoff-Bulman, R. (1994). Grief and the search for meaning: exploring the assump-
tive worlds of bereaved college students. Journal of Social and Clinical Psychology, 10, 270 ± 288.
Shuchter, S. R., & Zisook, S. (1993). The course of normal grief. In: M. S. Stroebe, W. Stroebe, & R. O.
Hansson (Eds.), Handbook of bereavement: theory, research, and intervention ( pp. 23 ± 43). Cambridge,
England: Cambridge Univ. Press.
Stein, N. L., Folkman, S., Trabasso, T., & Christopher-Richards, A. (1997). Appraisal and goal processes as
predictors of well being in bereaved care-givers. Journal of Personality and Social Psychology, 72, 863 ± 871.
Stiles, W. B., Shuster, P. L., & Harrigan, J. A. (1992). Disclosure and anxiety: a test of the fever model.
Journal of Personality and Social Psychology, 63, 980 ± 988.
Stroebe, M. S., & Stroebe, W. (1993). The mortality of bereavement: a review. In: M. S. Stroebe, W. Stroebe,
& R. O. Hansson (Eds.), Handbook of bereavement ( pp. 175 ± 195). New York: Cambridge Univ. Press.
Stroebe, M. S., Stroebe, W., Gergen, K. J., & Gergen, M. (1981). The broken heart: reality or myth? Omega,
12, 87 ± 105.
Stroebe, W., & Stroebe, M. S. (1987). Bereavement and health. Cambridge, England: Cambridge Univ. Press.
Stroebe, W., & Stroebe, M. S. (1993). Determinants of adjustment to bereavement in younger widows
and widowers. In: M. S. Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement
( pp. 208 ± 226). New York: Cambridge Univ. Press.
Stroebe, W., Stroebe, M. S., Abakoumkin, G., & Schut, H. (1996). The role of loneliness and social
support in adjustment to loss: a test of attachment versus stress theory. Journal of Personality and Social
Psychology, 70, 1241 ± 1249.
Thompson, L. W., Breckenridge, J. N., Gallagher, D., & Peterson, J. A. (1984). Effects of bereavement
on self-perceptions of physical health in elderly widows and widowers. Journal of Gerontology, 39,
309 ± 314.
Tudiver, F., Hilditch, J., & Permaul, J. A. (1991). A comparison of psychosocial characteristics of new
widowers and married men. Family Medicine, 23, 501 ± 505.
Weinberger, D. A., & Davidson, M. N. (1994). Styles of inhibiting emotional expression: distinguishing
repressive coping from impression management. Journal of Personality, 62, 587 ± 613.
Weinberger, D. A., Schwartz, G. E., & Davidson, J. R. (1979). Low-anxious and repressive coping styles:
734 G. A. Bonanno and S. Kaltman
psychometric patterns of behavioral and physiological responses to stress. Journal of Abnormal Psychol-
ogy, 88, 369 ± 380.
Weiss, (1975). Marital separations. New York: Basic Books.
Worden, J. W. (1982). Grief counseling and grief therapy: a handbook for the mental health practitioner. New
York: Springer.
Worden, J. W. (1996). Tasks and mediators of mounting: a guide for the mental health practitioner. In
Session: Psychotherapy in Practice, 2, 73 ± 80.
Wortman, C. B., & Silver, R. C. (1989). The myth of coping with loss. Journal of Consulting and Clinical, 57,
349 ± 357.
Young, M., Benjamin, B., & Wallis, C. (1963). Mortality of widowers. Lancet, 2, 454.
Zisook, S., Chentsova-Dutton, Y., & Shuchter, S. R. (1998). PTSD following bereavement. Annals of Clinical
Psychiatry, 10, 157 ± 163.
Zisook, S., Devaul, R. A., & Click, M. A. (1982). Measuring symptoms of grief and bereavement. American
Journal of Psychiatry, 139, 1590 ± 1593.
Zisook, S., Paulus, M., Shuchter, S. R., & Judd, L. L. (1997). The many faces of depression following spousal
bereavement. Journal of Affective Disorders, 45, 85 ± 95.
Zisook, S., Schneider, D., & Shuchter, S. R. (1990). Anxiety and bereavement. Psychiatric Medicine, 8,
83 ± 96.
Zisook, S., & Shuchter, S. R. (1986). The first four years of widowhood. Psychiatric Annals, 16, 288.
Zisook, S., & Shuchter, S. R. (1991). Depression through the first year after the death of a spouse. American
Journal of Psychiatry, 148, 1346 ± 1352.
Zisook, S., & Shuchter, S. R. (1996). Psychotherapy for depression in spousal bereavement. In Session:
Psychotherapy in Practice, 2, 31 ± 46.
Zisook, S., Shuchter, S. R., Irwin, M., Darko, D. F., Sledge, P., & Resovshy, K. (1994). Bereavement,
depression, and immune function. Psychiatric Research, 52, 1 ± 10.