Bereavement Reactions, Consequences, and Care (1984) / Chapter Skim
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Pages 143-176
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Toward a Biology of Grieving
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From page 144... ...
One of them was Andreas VesaL'us, who In 1543 produced the first "modern" concept of the brain, shown above. Although it now is known that the brain regulates many physiologic fuIlct~'ons that are connnonly disrupted by the stress of bereavement, such as hormones, hears rhythm, andimmune responses, the extent to which these disruptions may affect health has not yet been estab17'shedl.
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However, the significance of these changes is not well understood. They may be primarily adaptive physiologic responses that in some persons become maladaptive and physiologically deleterious.
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146 / Bereavement: Reactions, Consequences, and Care the body's natural defenses may cause disease: the appropriate response to endotoxemia is fever and leukocytosis, but if the response is increased it may result in shock, consumption coagulopathy, tissue necrosis, hemorrhage, and death. The complexing of soluble antigen with antibody is a part of the immune response, but deposition of too many immune complexes can lead to severe vascular disease.
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In an additional example, a single aspect of grief can be isolated and studied in terms of its biological substrate, as in the work of Weiss83 84 on learned helplessness. The helplessness of human grief is surely different from the state induced in rats by inescapable shock.
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. Alm ess actlvlty-mactlvlty Preoccupation with image of deceased Tears Sighing respiration Muscular weakness Chronic background disturbance: lasting weeks to months Social withdrawal Decreased concentration Decreased attention Restlessness, anxiety Decreased or increased food intake Postures and facial expressions of sadness Illusions or hallucinations Depressed mood Decreased or increased body weight Sleep disturbance Muscular weakness Cardiovascular changes Endocrine changes Immunologic changes
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From page 149... ...
This pioneering study raised as many questions as it answered and gave an early indication of the complications that may arise in this kind of research. Current psychoendocrine studies at Yale measure plasma levels of pituitary prolactin and growth hormone, as well as cortisol, in recently bereaved subjects during interviews in which the loss experiences were reviewed.
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Neither of these studies was designed to tell whether the reduced T-cell function posed a clinically significant vulnerability of the subjects to disease. These studies require follow-ups that will include investigations of the mounting of specific immune responses.
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This basic knowledge will be useful in planning clinical studies of patients at risk because of preexisting disease such as asthma, pulmonary emphysema, coronary heart disease, or congestive heart failure. These conditions are most likely to be affected by the physiologic changes of acute distress waves.
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From page 152... ...
Sudden cardiac death, cardiac arrhythmias, myocardial infarction, and congestive heart failure are the most frequently mentioned conditions of that system associated with grief.72 This presents us with the clue that disturbances in autonomic cardiovascular regulation and in circulating catecholamines may be present in bereavement and may be exaggerated in patients with preexisting cardiovascular disease of the arteriosclerotic or hypertensive variety. Studies have shown that patients with congestive heart failures and with essential hypertensions and arrhythmias60 6i are particularly prone to exacerbation of their condition in response to threatened or actual loss of human relationships.
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Alternatively, substance abuse may be related to depression, a possibility discussed in the next section. clues from the Endocrinology and Biochemistry of Depression and Anxiety States Two well-delineated mental disorders, major depression and panic disorder, may share a common neurobiological substrate with the response to loss in the bereaved.
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These involve the autonomic neural system, endocrine events, and immune changes related to endocrine and direct neural influences. i7 Autonomic Neural Effects.
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Toward a Biology of Grieving / 155
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Secretion of other hormones also is altered by stressful situations. Testosterone decreases during stress.43 Sowers and colleagues74 found that physical and psychological stress related to diagnostic procedures and surgery was associated with decreased thyrotropin and thyroxine and with increased prolactin, growth hormone, cortisol, and luteinizing hormone, with no evident effect on follicle stimulating hormone.
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From page 157... ...
Psychiatric interviews, field observations, and measurements of 17-OHCS excretion in army recruits showed that Tow excretors had better defense mechanisms and that high excretors were less successful in dealing with the stress of basic training.66 Animal studies have shown that stress, especially uncontrolIable or inescapable shock, causes many changes in norepinephrine, epinephrine, and dopamine concentrations in peripheral blood and in different parts of the brainstem, hypothalamus, and limbic system.68 Although the link between these neuroendocrine substances and the hypothalamic-pituitary axis has not been completely elucidated, a relationship certainly exists. The "helpless-hopeless syndrome" seen in animal studies of inescapable shock situations appears to have special effects on endocrine activity that may have some potential relevance for studies of human stress, including bereavement.
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i5 Immune Changes Related to Endocrine Events. It is well known that adrenal cortical activity has the effect of reducing circulating lymphocytes and increasing thymic involution, resulting in diminished immune function.55 58 Riley and others have conjectured that an increase in adrenal cortical activity induced by stressful manipulation of experimental animals was causally related to an enhanced susceptibility to the growth of malignant tumors.64 65 Thymic involution and fewer circulating lymphocytes implicate T-cell deficiency as a possible factor in tumor susceptibility; hence Riley and others have shown tumor enhancement.
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. puages, warn acute stress Increasing the immune response and chronic stress decreasing it.~75 Stress such as steep deprivation has caused initial immunosuppression, followed by enhancement of the immune response.s~ In reviewing the positive and negative effects of stress on immune function in animals, Ader3 concluded that "in general.
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A cautionary note about interpreting measurements of immune function must be added, however, along with an argument for clinically relevant research involving human subjects. Assessment of T-cell or B-cell functions in vitro is of uncertain meaning in regard to actual vulnerability to infection.
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One approach, which has yet to be applied systematically, is the direct measure of immune functions in human beings in viva. For example, by skin testing two agents to which nearly everyone is sensitive {"allergic" J
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The simultaneous secretion of substances that suppress immune function may serve as a protection by transiently halting the immune response to a flood of antigens appearing from endogenous {proteolysis) or exogenous {injury)
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It should be noted that they are not mutually exclusive and may even be integrated eventually as data are obtained. Bexcavement as a Stressor As mentioned previously, the current information available on stress and health has been summarized in an Institute of Medicine report.~7 The physiologic responses to a range of external events viewed as stressfu]
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He described several situations of "stress" isuch as acute avoidance, sleep deprivation, and fasting in which the patterns of cortisol, norepinephrine, and epinephrine are different. Kuhn and his colleagues44 also observed different physiologic responses, as measured by omithine decarboxylase activity, in response to maternal separation and other types of stress in rats.
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. Agltatlon Vocalization S earching-inactivity Increased heart rate Increased cortisol Increased catecholamines Slow developing Decreased social Decreased body weight "despair" phase interaction, Sleep disturbance lasting hours decreased play Decreased rapid eye move or days Mouthing, rocking ment Hypo- or hyper- Increased arousals responsiveness Metabolic: Decreased or decreased core increased food temperature intake decreased oxygen Postures and facial consumption expressions of Cardiovascular: sadness decreased cardiac rate decreased resistance increased ectopic beats Endocrine: decreased growth hormone Immune: decreased T-cell activity
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From page 166... ...
There is an obvious similarity between these responses and the cognitive and perceptual disturbances seen in the chronic grief response, all TABLE 3 Responses to Disrupted Regulation of Homeostas~s Human StudiesJ Symptoms following sensory deprivation: Fluctuating concentration and attention Restlessness, anxiety Difficulty in ordering thoughts Decreased food intake Illusions and hallucinations Decreased body weight Sleep disturbance Muscular weakness Symptoms following jet travel across time zones: Decreased vigilance, decreased attention span Decreased appetite Sleep disturbance Malaise, fatigue Symptoms following work shift change: Decreased vigilance Cognitive impairment Insomnia Weakness, fatiguability Depression, hostility
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From page 167... ...
Study of the regulatory aspects of social relationships may eventually lead to some underst~nding of the mechanisms by which the presence or absence of social support systems modifies physiologic responses to stress and vulnerability to disease. Rhythms in the Endocrine and Immune Systems.
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Abnormalities in growth hormone, insulin, and thyroid-stimulating hormone are often observed in depression.67 Depressed
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Studies are needed on basic neurophysiologic parameters, including cardiovascular, thermal, and central nervous system regulation. In particular, more information is needed on the long-term effects of bereavement: how do physiologic responses change during prolonged grief, both "spontaneously" and in response to specific stimuli and to other significant life events?
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Effect of premature weaning on lymphocyte stimulation in the rat. {Abstract.J Psychosomatic Medicine 45:75, 1983.
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Survival and recovery of physiologic functions after early maternal separation in infant rats. Psychosomatic Medicine 15:475-480, 1975.
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Suppressed immune response in infant monkeys associated with maternal separation. Behavioral and Neural Biology 36:40-48, 1982.
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Depression in infant monkeys: physiological correlates. Psychosomatic Medicine 36:363-367, 1974.
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Survival and development of maternally deprived rats: role of body temperature. Psychosomatic Medicine 38:242-249, 1976.
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Psychosomatic Medicine 26:576-609, 1964.
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