Is Grief a Disease?
A Challenge for Medical Research
GEORGE L. ENGEL, M.D.
1 HISIS PAPER has perhaps more the
qualities of a philosophic than a scientific
discourse, but for this I offer no apology. I
shall present no new data and shall speak
of a quite familiar phenomenon, but I
shall invite you to view it from a perspec-
tive perhaps somewhat different from that
to which you are accustomed. In keeping
with this philosophic approach I have writ-
ten this in the form of a Socratic dialogue.
I pose the question, "Is grief a disease?"
No doubt this seems a strange question,
since grief has not usually been considered
in such terms and, on first glance, there
seems little reason to do so. Yet, a thought-
ful consideration of the issues raised by
such a question will, I believe, throw light
on some deficiencies in currently held con-
cepts of disease. And the concept of disease
held by an investigator, whether or not con-
sciously utilized, has an important influ-
ence on the choice of material and the de-
sign of clinical research.1-3
Grief is the characteristic response to the
loss of a valued object, be it a loved person,
a cherished possession, a job, status, home,
country, an ideal, a part of the body, etc.
Uncomplicated grief runs a consistent
From the Departments of Psychiatry and Medi-
cine, University of Rochester Medical Center,
Rochester, N. Y.
Presented at the Annual Meeting, American Psy-
chosomatic Society, Mar. 27, 1960, held at Montreal,
Canada.
Received for publication April 14, 1960.
course, modified mainly by the abruptness
of the loss, the nature of the preparation
for the event, and the significance for the
survivor of the lost object. Generally it in-
cludes an initial phase of shock and disbe-
lief, in which the sufferer attempts to deny
the loss and to insulate himself against the
shock of the reality. This is followed by a
stage of developing awareness of the loss,
marked by the painful effects of sadness,
guilt, shame, helplessness, or hopelessness;
by crying; by a sense of loss and emptiness;
by anorexia, sleep disturbance, sometimes
somatic symptoms of pain or other discom-
fort, loss of interest in one's usual activities
and associates, impairment of work per-
formance, etc. Finally, there is a prolonged
phase of restitution and recovery during
which the work of mourning is carried on,
the trauma of the loss is overcome, and a
state of health and well-being re-estab-
lished.4' 5
In what respects does this correspond to
other situations that we customarily regard
as "disease?" Certainly it involves suffer-
ing and an impairment of the capacity to
function, which may last for days, weeks,
and even months. We can identify a con-
sistent etiologic factor, namely, real, threat-
ened, or even fantasied object loss. It ful-
fills all the criteria of a discrete syndrome,
with relatively predictable symptomatology
and course. The grieving person is often
manifestly distressed and disabled to a de-
gree quite evident to an observer.
PSYCHOSOMATIC MEDICINE
ENGEL
The sceptic quickly raises some pointed
questions: Is not grief simply a natural re-
action to a life experience? How can one
put it into the same category as the patho-
logical states we call disease? To this we
answer that it is "natural" or "normal" in
the same sense that a wound or a burn are
the natural or normal responses to physical
trauma. The designation "pathological"
refers to the changed state and not to the
fact of the response. That one responds to
thermal radiation with a burn is natural or
normal. The burn itself constitutes a
pathological state and the concept is as ap-
propriately applied to the state of grief as
to a wound, burn, or infection.
Or it may be said: Everyone experiences
grief—it's part of life. But that only em-
phasizes the ubiquity in life of the signifi-
cant etiologic factor and the universal
vulnerability of human beings to this par-
ticular stressful experience. The same may
be said of many other disease states to
which man is prone—measles, for example.
Actually, the statement is not entirely cor-
rect. With a short life or under exception-
ally favorable circumstances, one may
escape both measles and grief.
Our sceptic resumes his argument: Grief
is a self-limited process, requiring no medi-
cal attention. But so too are a great num-
ber of disease processes. Actually, many per-
sons suffering primarily from grief do come
to physicians but, because of cultural ex-
pectations and the role ascribed to or held
by the physician, they do not complain to
him of grief. Rather, they report some
other, often somatic, symptom and the
physician may not even learn of the grief.
If he does, he may regard it either as not
related to the complaint or not his concern.
Besides, whether a condition requires medi-
cal attention is not relevant to the judg-
ment as to whether it is to be regarded as a
disease. The history of medicine provides
innumerable examples of conditions that
have come in time to be recognized as dis-
ease states but which had not been so re-
garded earlier. Epilepsy, alcoholism, and
mental disease are examples. We must not
VOL. xxm, NO. 1, 1961
19
forget that in the prescientific era the roles
of physician, magician, and priest were
often embodied in the same person. It is
the obligation of the physician of today to
claim for scientific scrutiny all natural
phenomena involving deviations in the in-
dividual's state of well-being, of which grief
is one.
Grief is a purely subjective, psychological
experience that does not involve any so-
matic changes. But, to my knowledge, no
one has ever studied the bodily changes oc-
curring during grief; hence, to begin with,
there is no basis for such a statement. But
even if it were true, one who holds such a
view is, in essence, relegating to an extra-
medical and extrascientific status any kind
of psychological or behavioral disturbance.
As a matter of fact, many illnesses are large-
ly subjective—at least, until we as observers
discover the parameters and framework
within which we can also make objective
observations. Hyperparathyroidism, in
many of its manifestations, was a purely
subjective experience for many patients un-
til we discovered what to look for and
which instruments to use in the search.
Again, the physician who is familiar with
grief will recognize its occurrence through
his systematic and ordered observations,
even if the patient withholds or denies the
necessary information.
No one ever dies of grief. Again, this is
an irrelevant argument, even if true; but is
it true? The newspapers repeatedly report
persons collapsing and dying soon after
learning of the death of a loved person.
Have these cases been so carefully studied
that we can say that the death represented
pure coincidence, that the shock phase of
the grief contributed in no way to this fatal
outcome? I know of no such studies.
Literature and folklore are replete with the
notion that people fall ill and die "of
grief." (I would prefer to say "during
grief.") And few of the older physicians,
from Hippocrates through the clinical
giants of the late nineteenth century, failed
to allude to grief as a factor in the causa-
tion of disease. While such views hardly
20
constitute scientific evidence, the incidents
are so common and the views so widely
held that the cautious scientist will not be
willing to say, without the benefit of sci-
entific study, that it cannot be so. Actually,
many recent investigations indicate that a
wide variety of illnesses, including some
that are fatal, may begin during a phase of
grief. Schmale has recently surveyed a
medical population and reviewed the mod-
ern as well as some of the older literature
from this perspective.0
Perhaps one should speak of pathological
grief and normal grief and restrict to the
former the category of disease. This is a
welcome concession, but it does not go far
enough. At the outset I intentionally used
the term "uncomplicated grief" rather than
normal grief. It is normal only in a statisti-
cal sense, meaning that it is the common,
usual, and predictable response, as is an
ecchymosis after a blow or measles after an
infection with the measles virus. But it is
not normal in the sense of total health.
Predictable does not mean invariable and,
in any situation, whether it be loss of an
object or an exposure to physical trauma or
a microorganism, we observe and define
conditions under which the response may
be different in degree or kind or where it
may not occur at all. This is a widely ac-
cepted and familiar notion as applied to
traditional disease states, but equally ap-
propriate in respect to grief. We are fa-
miliar with such responses as the absence of
grief, delayed grief, unresolved grief, de-
pression, psychotic or neurotic reactions,
pain or other conversion symptoms, and
even organic disease occurring in place of
or in addition to the usual pattern of grief.
As is true of the complications of a wound
or an infection, we must also expect that
other factors operate to account for these
deviations from the usual course. Yet none
of these considerations refutes the fact that
the experience of uncomplicated grief also
represents a manifest and gross departure
from the dynamic state considered repre-
sentative of health and well-being.
Is not grief really just a healthy, adap-
IS GRIEF A DISEASE?
tive, and reparative process which corrects
or overcomes a stress while the above-men-
tioned responses are the abnormal states
that should be called diseases? The element
of reparation is indeed to be found in grief,
but so too is it found in every other disease;
indeed, it always accounts for some of the
symptoms and signs of a disease. If the
adaptive or reparative processes involved in
disease are successful, recovery occurs and
the patient reachieves a state of health. If
not, continued, progressive, or increased
illness or death is the consequence.
Can it not be said that the person is
really healthy and that he simply had the
misfortune to suffer a loss and is now re-
sponding, naturally, with grief? This argu-
ment implies that all systems and levels of
organization, actually and potentially, must
be impaired by the stress before the condi-
tion can be considered disease. Actually,
not only are health and disease relative con-
cepts, but also at any time parts of the body
and person may be more or less healthy,
while other parts may be more or less im-
paired. Indeed, this is the usual situation.
It is only in fatal disease, when the victim
is near death, that we see total disorganiza-
tion.
Perhaps by now the sceptic is ready to
concede that grief can be considered a dis-
ease state. But what is gained by such a
position? What are the implications for
medical research and practice? They are, in
my opinion, important and far reaching:
1. Grief, in all its forms and with all its
ramifications, becomes a legitimate and
proper subject for study by medical scien-
tists. Research, utilizing the tools of the
physical, biological, and behavioral sci-
ences, must be directed to these sufferers no
less than to those with other disorders. The
occurrence of grief among animals is so
well documented as t(5 free the investigator
from exclusive dependence on human sub-
jects for such research.
2. The occurrence of grief, preceding or
in the course of other illness, somatic and
psychologic, as is so often reported by pa-
tients or their families, can no longer be
PSYCHOSOMATIC MEDICINE
ENGEL
passed off as irrelevant or coincidental until
such data have been subjected to the same
kind of rigorous and systematic exploration
and examination that has been applied to
other phenomena of disease. That grief in
its various forms so often precedes the de-
velopment of other disease states in itself
constitutes no proof of a relationship. But
the medical scientist is remiss if he does not
subject all antecedent circumstances to ex-
amination as to whether they constitute
contributing, necessary, or sufficient condi-
tions for the development of a disease state.
The obvious derangements in the function-
ing of the indidivual suffering from object
loss and consequent grief make such in-
quiry all the more relevant. It is well to be
be reminded in this era of crash-program
applied research that many fundamental
discoveries elucidating the pathogenesis and
mechanisms of disease states came about
through the investigation of just such basic
phenomena, often with grounds for antici-
pating a relationship far less than is the case
with grief. One is reminded of the contro-
versies concerning the role of miasmas in
the pathogenesis of malaria. The investi-
gation of the climatic and geographic con-
ditions under which malaria occurred even-
tually provided the basis for elucidation of
the disease even though the original theo-
ries concerning the miasmas were erroneous.
3. If the actual or threatened loss of an
object so consistently disturbs the total ad-
justment of the organism, then we have
identified an etiologic factor of such gen-
eral importance as to put it in the same
class as other major rtbxa, e.g., physical
agents, microorganisms, eftc. Until—and not
until—much more is known about the bio-
chemical, physiological, and psychological
consequences of such losses, no one is justi-
fied in passing judgment as to how impor-
tant this factor is in the genesis of the
disease states that seem so often to follow
close upon an episode of grief. To dismiss
such inquiry as unnecessary or irrelevant at
this stage of our knowledge is an expression
of prejudice (in its literal sense, a prejudg-
ment, or forming a judgment without due
VOL. XXIII, NO. 1, 1961
21
knowledge or examination). Who now
would be so rash as to dismiss the possi-
bilities that biochemical or physiological
processes occurring during the grief reac-
tion may not constitute conditions condu-
cive to other somatic changes of more seri-
ous consequence?
4. As a corollary of the above, we iden-
tify a ubiquitous psychological stress, mean-
ing that the concept of objects and of ob-
ject loss is only meaningful in terms of the
existence and operation of the mental ap-
paratus. This means that whatever the con-
sequences of object loss and grief may be,
whether manifest ultimately in biochemical,
physiological, psychological, or social
terms, they must first be initiated in the
central nervous system. This imposes upon
the medical scientist the necessity to pay
more attention to the role of the central
nervous system in the maintenance of the
functional integrity of the organism as a
whole as well as of its various parts. In
spite of much lip service to the contrary,
most physicians and clinical investigators
think and work as if the central nervous
system is the seat only of reflexes and of
purely intellectual processes and really
needs not be considered when studying dis-
ease manifest elsewhere in the body. The
reluctance and/or inability to consider psy-
chological components of man and his
illnesses actually has come to include the
nervous system as well. But new knowledge
of central integrating and regulating proc-
esses, as has been brought forth by recent
work on the limbic and reticular activating
systems, promises soon to dissipate this
barrier.7
5. The concept of grief as a disease re-
quires that we keep in view and in perspec-
tive aspects of the external environment
other than what we have been accustomed
to heretofore—namely, the environment
made up of the significant psychic objects.
This becomes one reason why the persons,
job, home, goals, etc., in the life of our
patients cannot be disregarded in our con-
sideration of illness, at least not until it has
been proven that the vicissitudes of object
22
relations, including grief, the disorder con-
sequent to object loss, plays no role in the
pathogenesis of disease.
6. If object loss is a potential stress, then
maintenance of objects or replacement of
objects must be considered as important
variables in sustaining health and adjust-
ment. The physician, the hospital, the clin-
ical investigator, indeed, even the experi-
ment, may come to fulfill the requirements
of a necessary and supporting psychic object
for a patient. Everyone is aware of the
therapeutic influence of the physician on
the patient, but how many unwary clinical
investigators have been observing physiolo-
gic or biochemical changes in their experi-
mental subjects, believing these to be the
influence of some drug or other procedure
when in fact these changes were secondary
to the varying effects of the experimenter's
unwitting role as a psychic object for the
patient. For many varieties of clinical in-
vestigation it is necessary to regard the ex-
perimenter as part of the experiment.8
This does not exhaust the Pandora's box
opened by such a perspective. Once opened,
we cannot easily refute the real, yet un-
known influences that must now come un-
der our scrutiny. Yet the human mind, that
wonderful instrument of discovery, has a
disconcerting capacity to use denial, to turn
away from that which is not easily com-
prehended or which has awesome implica-
tions, as I believe is true of this concept.
The first response when confronted with
news of a grievous loss is, "No, it can't be.
I don't believe it; I won't believe it." I
IS GRIEF A DISEASE?
would call your attention to the fact that
cherished ideas, even if false, are also psy-
chic objects and as such are not easily given
up. And only time and much work will
establish whose cherished ideas are the false
ones.
I close with a quotation ascribed to Al-
bert Szent-Gyorgyi: "Research is to see what
everybody else has seen and think what
nobody else has thought." To this I would
only add that Szent-Gyorgyi wisely refrained
from claiming that this necessarily implied
that the "new" thought is correct—at least,
not until tested. And that is my challenge!
References
1. ENGEL, G. L. "Homeostasis, Behavioral Adjust-
ment and the Concept of Health and Disease."
In GRINKF.R, R. Mid-Century Psychiatry, Thomas,
Springfield, 111., 1953, pp. 33-59.
2. ENGEL, G. L. Selection of clinical material in
psychosomatic medicine: The Need for a New
physiology. Psychosom. Med. 76:368, 1954.
3. ENGEL, G. L. A unified concept of health and
disease, Perspectives in Biology and Medicine.
3 No. 4, 1960.
4. FREUD, S. "Mourning and Melancholia" (1917).
Standard Edition, Complete Works, London, Vol.
XIV, 237, 1957.
5. LINDEMANN, E. Symptomatology and manage-
ment of acute grief. Am. J. Psychiat. 707.14,
- 1944.
(&J SCHMALE, A. H. Relationship of separation and
depression to Disease. Psychosom. Med. 20:259,
1958.
7. JASPER, H. H., Ed. Reticular Formation of the
Brain, Little, Boston, U)58.
8. ENGEL, G. L., REICHSMAN, F., and SEGAL, H. L.
A study of an infant with a gastric fistula. I.
Behavior and the rate of total HC1 secretion,
Psychosom. Med. 7S.374, 1956.
PSYCHOSOMATIC MEDICINE