Grief as a Risk Factor for Psychosis

Current Psychiatry Reports | 2024, Vol. 26, p. 379–393

Grief as a Risk Factor for Psychosis: A Systematic Review

Pablo del Pozo‑Herce; Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain; Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain

Ana Gonzalo‑de Miguel; Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain

Luis Gonzalez‑Rosas; Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain

Octavio Alejandro‑Rubio; Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain

Carlos Pascual‑Lapuerta; Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain

Alejandro Porras‑Segovia; Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain; Department of Psychiatry, Hospital Rey Juan Carlos, Madrid, Spain

Purpose of Review: The assessment of the risk of triggering psychosis upon exposure to grief is a challenge in clinical practice. Adequate diagnosis and early prevention are essential and may be helpful in the evolution of normal grief. We aimed to identify studies exploring grief as a risk factor for developing psychosis.

Recent Findings: A systematic review of 3 databases (PubMed, EMBASE, and Cochrane Library) was conducted. Results: In the first approach, 618 studies were identified. After the selection process, 15 studies were included in the review. The association between grief and the risk of developing psychosis occurred at younger ages (before 18 years of age) in a first-degree relative and as a consequence of suicide or accidental death.

Summary: We found that risk factors such as comorbidity, mental problems, unemployment, economic difficulties, and close ties with the deceased have a negative impact on health, causing greater vulnerability to psychosis with a risk of developing complicated grief, with statistically significant results regarding the associations between early parental death and the probability of developing psychosis in adulthood.

Systematic review; grief; schizophrenia; psychosis; delusions; hallucinations

“ Grief (also called bereavement or mourning) is the period in which a series of normal and adaptive affective changes occur following the loss of a loved one. Classically, grief follows a series of phases (denial, anger, futile search, grief, acceptance, and resolution) that span a period of 6 to 12 months. Some authors consider grief does not require treatment, as it is a normal process. Because grief is a common feeling among humans, there has been a tendency to underestimate the consequences of it or to ignore the symptoms associated, which are often hidden or minimized” (p. 379). 

“Substantial literature supports the idea that grief is associated with increased general medical morbidity and mortality and an increased risk of cardiovascular and cerebrovascular events. For this reason, among others, the DSM-5 proposed as a novelty in its latest edition the diagnosis of an entity known as Persistent Complex Grief Disorder (CPBD)...In addition, this entity has been associated with deficits in occupational and social functioning and often has comorbidity with major depressive disorder, substance use disorders, and post-traumatic stress disorder. When relating grief, whether normal or pathological, to a pathology such as psychosis, we find that during the last 50 years, symptoms of grief have been described and studied that are ambiguous because they may fall within the psychotic sphere… However, although various life and traumatic events have been studied with the onset or relapse of psychosis, there are still no published reviews that study the role of grief, as a specific entity, in a pathology such as psychosis” (p. 380).

“This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. [They] conducted a systematic literature search in three databases: PubMed, EMBASE, and Cochrane Library. The main outcome that [was] searched for was psychosis, which included psychotic disorders and associated symptoms (hallucinations, delusions, and delusional ideas). Moreover, [they] explored which type of grief is more related to psychosis (complicated vs. uncomplicated; death of a certain family member, such as death of a spouse). Also, [they] analyzed the relationship between the age at which grief occurs and the outcome. Finally, [they] evaluated which kind of psychosis is more related to grief (acute psychotic disorder vs. schizophrenia, etc.)” (p. 380). 

The study “ found that 10 of the 15 included studies provided evidence of an association between grief and the risk of developing psychosis. In most of the studies that found association, grief occurred at younger ages (before 18 years) in a first-degree relative and as a consequence of suicide or accidental death… This review supports the findings of other systematic reviews in related areas showing that grief is a risk factor for developing psychosis” (p. 388).

Furthermore, “several studies show that there is an association between parental death and child separation with the development of psychosis. This may be due to the stress that people experience when witnessing grief and its consequent impact on neurodevelopment which may suggest that there is a greater susceptibility to develop later illnesses in adulthood. In addition, it has been shown that losing both parents in childhood has a higher risk of mental disorders with negative consequences than losing only one parent” (p. 388). 

“Several studies show that early trauma in the child's age can affect its development. This may be due to affective deficiencies and lack of parental support, which may be associated with an increase in psychosomatic symptoms with decreased social bonds and alterations in the way of parenting. These factors have all been linked as risk factors for developing schizophrenia in adulthood” (p. 389). 

“Sadness at the loss of a person in life is a normal adaptive reaction, being necessary to accept it. Grief is a process of elaboration of the loss that goes through different stages such as denial, anger, negotiation, depression, and acceptance. When any of the stages is not adequately resolved and this process is not carried out, it can lead to complicated or even pathological grief. It is defined as "the intensification of grief to the level where the person is overwhelmed, resorts to maladaptive behaviors, or remains endlessly in this state without advancing in the grief process towards its resolution". These life experiences can give rise to psychotic symptomatology as a consequence of the loss of a family member or appear in isolation as hearing or feeling the deceased person, being a trigger for a first latent psychotic episode until the time of grief. In this sense, the bereaved person must be accompanied, and feel supported, loved, and understood. In the early stages of grief, the person is contained and it is necessary to intervene as little as possible, giving him/her time to readapt to his/her life. As time goes by, interventions become more important, as well as counseling to broaden specific knowledge about grief, for example, that grief is a long and normal process. When the person presents complicated or pathological grief, it is necessary to use specific techniques in the resolution of complicated or pathological grief, such as interpersonal therapy and family intervention for trauma elaboration and coping with the loss. With the different techniques, the intensity of grief is reduced, facilitating and promoting memories, the recovery of social relationships, and reincorporation back to normal life. Also, distraction techniques, self-relaxation, and cognitive behavioral therapies are relevant in reducing sensitivity to stress in patients with psychosis exposed to early adversities” (p. 389-390).

“Some limitations of the present systematic review should be highlighted. First, the search for studies was conducted in English and Spanish, which may have led to the exclusion of relevant studies published in other languages. Secondly, qualitative studies that could provide important information on the concept of grief and the lived experiences of people who have experienced grief were excluded. Third, there was methodological heterogeneity among the studies, which made it difficult to compare the results of the studies included in this review. Fourth, each study had its criteria for measuring stressful life experiences as well as study design, and diagnostic criteria so many studies did not take into account the possibility of confounding variables, as well as most studies did not examine the time elapsed between grief and the development of psychosis, nor are there sufficient statistics to analyze sex differences in the risk of developing psychosis, schizophrenia or hallucinations in different periods. Finally, information on the mental health of persons exposed and not exposed to the death of a family member is unknown, so there may be confusion in the association between the development of a mental disorder and grief. As methodological rigor, the protocol previously recorded on a topic that has been specifically studied with new approaches” (p. 390).