Grief Reaction

Common grief reactions: Reactions to loss are called grief reactions and vary from person to person and within the same person over time.  Grief reactions lead to complex somatic and psychological symptoms.

Feelings: The person who experiences a loss may have a range of feelings, including shock, numbness, sadness, denial, anger, guilt, helplessness, depression, and yearning. A person may cry for no reason.

Thoughts: Grief can cause feelings of disbelief, confusion, difficulty concentrating, preoccupation, and hallucinations.

Physical sensations: Grief can cause physical sensations like tightness and heaviness in the chest or throat, nausea or stomach upset, dizziness, headaches, numbness, muscle weakness, tension, or fatigue. It will make the person vulnerable to illness.

Behaviors: Difficulty sleeping, loss of interest in daily activities, and becoming more aggressive or irritable. 

Somatic symptoms: Chest tightness and choking, shortness of breath, abdominal distress, decreased muscle power, and lethargy.

Psychological symptoms: Guilt, anger, hostility, restlessness, inability to concentrate, lack of capacity to initiate and maintain an organized pattern of activities.

Takosubo cardiomyopathy: Chest pain and shortness of breath after severe stress (emotional or physical), ECG changes that mimic heart attack with no coronary artery occlusion, movement abnormalities of left ventricle and ballooning of left ventricle.

Screening questionnaires such as the Brief Grief Questionnaire (BGQ) and the Inventory of complicated grief (ICG) can reliably identify complicated grief. [10][11] There are some screening tools designed to predict complicated grief in the spouses of cancer patients. These two scales, Family Adaptability and Cohesion Evaluation Scale (FACES III), and Brief Symptom Inventory (BSI) assess family functioning, psychological functioning, and grief reaction. 

The grief evaluation measure (GEM) can also assist in identifying the development of complicated grief symptoms in a mourning adult. It assesses both qualitative and quantitative risk factors including mourner's loss and medical history, financial resources both before and after the loss, and circumstances surrounding the death. It provides in-depth information on bereaved the individuals' subjective grief symptoms and associated experience.[12]

In the majority of the patients with Takosubo cardiomyopathy, a coronary angiogram may be inconspicuous. Cardiac imaging plays an important role and shows left ventricular dysfunction.

Normal Grief: Most bereaved persons adapt over six months to 2 years.

Complicated grief is best-managed by complicated grief therapy.[3] Complicated grief therapy removes the impediment and promotes the adaptation to the loss. This therapy is more effective than citalopram and interpersonal therapy. [13][14] Patients experiencing complicated grief may require psychological treatment in the form of cognitive-behavioral therapy (CBT) and pharmacological bereavement-related depression.[15]

Takosubo cardiomyopathy (TCM): Patients with TCM will require inpatient cardiology service. Treatment options are empiric and supportive; however, beta-blockers can be helpful when hemodynamics permit. Serial imaging studies may be necessary. These patients should follow-up with a cardiologist within one week of diagnosis to resolve cardiomyopathy with echocardiograms.

Complicated grief should be differentiated from major depressive disorder(MDD) and post-traumatic stress disorder(PTSD). Complicated grief's classic symptom presentation of yearning and sorrow, along with the preoccupied thoughts of the deceased and the inability to accept the reality of death, help in differentiating this from MDD and PTSD.[3]

Physical Complications

• Impairment of immune response system
• Increased adrenocortical activity
• Increased serum prolactin and increased serum growth hormone. 
• Increased mortality from heart disease (especially in elderly widowers)

Psychosomatic disorders 

Psychiatric (nonspecific) 

• Depression (with or without suicidal risk)
• Anxiety 
• Panic disorders
• Other psychiatric disorders

Psychiatric (specific)

• Post-traumatic stress disorders
• Chronic grief
• Delayed or inhibited grief

Deterrence and Patient Education

It is important to consider the following before disclosing bad news: [16]

• It is essential to have social support and place where to meet (setting). 
• Try to establish a relationship of mutual trust and respect. 
• Provide information at a speed and language that is easily understood.
• Try to discover what facts are already known by the patient and family.
• Encourage questions and monitor what is understood. It takes time to hear and understand the negative news. 
• Give verbal and nonverbal assurance regarding the normality of their reactions.
• It is important to give some time to the patient and family to react emotionally. 
• Stay with the patient and the family until they are ready to leave and offer further opportunities for clarification, information, or support.[17]

Preparedness for End-of-Life Care

It is important to prepare spouses of terminally ill patients mentally. Preparedness for death and coping with bereavement play a crucial role in complicated grief.[18]

Management of the grieving patient is optimal with an interprofessional team that includes a mental health nurse, palliative care team, psychiatrist, primary care provider, social worker, and other support teams. Even temporary grieving can affect patients both physically and mentally, and it is best to have a mental health nurse involved in the care early on. For most patients, time will help heal the grieving process, but some patients may benefit from counseling or temporary use of pharmacotherapy.