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When Does Grief Become Pathological?

In abnormal grief, the lost person can't be given up, but is absorbed into the survivor's psyche as an "object" covered with negative feelings and experienced as part of the self.
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Jonathan's* father had always taken care of everything, from their business to social activities. Jonathan, even though he was 50, was comfortable taking a back seat while his father drove, both literally and metaphorically. He'd been trained to believe that his secondary status was normal. His father was a big, blustery, commanding man operated and owned a chain of electronics stores throughout the country. When he died suddenly of a brain aneurysm at 75, Jonathan was stunned. Four years earlier he'd lost his mother to lung cancer. Now he had to endure his father's death.

The vast fortune, including his father's five homes, 11 electronics stores, seven cars and other miscellaneous luxury goods went to Jonathan, the only child. Jonathan was overwhelmed. He felt like staying in bed and pulling the covers over his head, but since he came from an old, prominent family where appearance meant everything he went through the motions of dealing with the relatives and the funeral. Inside he felt like a tiny, scared child acting the part of a gracious adult. He was the executor of his father's will, but the estate attorney kindly told him to take his time, they could resolve matters when Jonathan was ready.

Jonathan worried that he'd never be ready. Once chubby, he lost weight rapidly. He longed for the tri-weekly dinners he'd share with his father at fancy restaurants around town where everyone knew them. Instead now he only allowed himself to nibble on cheese and crackers or sometimes apples and pears in his bedroom. Sleep escaped him until very late at night. When he did manage to doze off, it was a fitful sleep in which he'd wake too frequently and too early. His concentration was impaired. Just before his father died, Jonathan had entered a belated M.B.A. program but he couldn't bring himself to read the required texts. He blamed his lack of discipline on his former shoddy education, which had consisted of an undergraduate Ivy League college, but where he'd been friends with the drinking crowd instead of the scholars. It was his uncontrollable anxiety that forced him to seek psychiatric care four months after his father's death.

"I haven't been able to cry," he reported to the doctor as they sat across from each other in comfortable leather chairs.

"Even at the funeral?" she asked, in a low voice.

Jonathan liked the way her questions were smooth transitions from his own thoughts. Her short, wavy blonde hair reminded him of his mother's hairstyle. Jonathan found the psychiatrist insightful and soothing.

"At the funeral I felt numb and spaced out. Now I'm so nervous. I keep thinking what an idiot I am for not taking my father to the internist. I was blind and stupid."

The doctor assured him that he couldn't have anticipated his father's brain aneurysm and reminded him that he'd said that his father generally refused to see doctors. She gave Jonathan a prescription for anti-depressants. He'd had psychotherapy briefly in college for poor grades and excessive drinking. He agreed to have a short course of psychotherapy to deal with his bereavement once per week.

Jonathan discussed how entwined he'd been with his father for his whole life. Ever since he was a young boy he'd proudly drive around with his father to visit their stores. How he admired his father commanding his employees and reigning over everyone like a general over his troops. Jonathan's role was to approbate and encourage his father. He hadn't been taught to do any real work or take over the business. His mother's position was similar, although sometimes, instead of being obsequious, his mother would rebel by criticizing or ignoring his father who responded with fits of rage. Jonathan never risked his father's anger; he always gave him approval. His father discouraged Jonathan's relationships, few as they were, by telling him that his girlfriends were "not good enough for him." He said the same thing about men friends until Jonathan wound up being alone.

His prescription had to be increased over the course of two months before Jonathan slept and ate better. Ativan even at 3 mg did little to relieve his anxiety, which manifested as shakiness, constant negative thoughts about himself and concern that he'd done the wrong thing with his father. He felt inadequate and thought that he'd be unable to deal with his father's estate. Jonathan dropped out of his M.B.A. program because he couldn't read or study. The psychiatrist tried 2.5 mg of Abilify to control his anxiety but this made him feel like a "zombie" so she discontinued it. Depakote decreased his anxiety finally. The doctor believed that Jonathan's grief developed into pathological mourning.

Freud addressed these issues in "Mourning and Melancholia," writing that normal grief results from the withdrawal of feelings from the lost person. In abnormal grief, the lost person can't be given up, but is absorbed into the survivor's psyche as an "object" covered with negative feelings and experienced as part of the self. The self then has this negative part, which leads to low self-esteem and worthlessness and ultimately to depression. Major depressive disorder, which lasts longer than normal grief (greater than 2 months), may include suicidal ideation and worsens over time.

Jonathan, who had been symbiotic with his father, couldn't give him up even after he died. He incorporated his father into his psyche, but all of his negative feelings (which were repressed when his father was alive) came out and attacked Jonathan, causing major depressive disorder and anxiety. His therapist medicated him in time and wisely allowed attachment to her to develop; the attachment provided Jonathan with temporary support and then she encouraged him to move towards autonomy, something his father never did. Dr. Elisabeth Kubler-Ross wrote about the five stages in dealing with dying. They are: 1) shock and denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance. Jonathan went directly from shock and denial through anger (at himself, not his father) to depression. Doing psychotherapy allowed him to work through the stages more thoroughly to reach acceptance of his father's death.

*Not this person's real name.

Carol W. Berman, M.D. is a writer, psychiatrist and artist who lives and works in New York City. When she's not listening to patients, she's writing or painting. As an undergraduate she attended the University of California at Berkeley; she went to medical school at NYU Medical Center. Presently she is an Assistant Clinical Professor at NYU. She has practiced psychiatry for 25 years and is a member of the APA, ASJA and NWU. Her two books, "100 Questions and Answers About Panic Disorder" and "Personality Disorders," have helped thousands of patients deal with mental disorders. Read her blog on Red Room.