Grief is commonly viewed as a natural response to loss, rather than a disease state. However, the author argues that grief fulfills the criteria of a disease - it involves suffering, impairment of functioning, has a consistent etiological factor (loss of an object), and follows a predictable course. Viewing grief as a disease would open up important implications for medical research and practice, such as studying grief using scientific tools and examining its potential role in other illness. This perspective recognizes significant life stressors and central nervous system processes as important to health.

1. Is Grief a Disease?
A Challenge for Medical Research
GEORGE L. ENGEL, M.D.
1 HIS PAPER has perhaps more the
IS course, modified mainly by the abruptness
qualities of a philosophic than a scientific of the loss, the nature of the preparation
discourse, but for this I offer no apology. I for the event, and the significance for the
shall present no new data and shall speak survivor of the lost object. Generally it in-
of a quite familiar phenomenon, but I cludes an initial phase of shock and disbe-
shall invite you to view it from a perspec- lief, in which the sufferer attempts to deny
tive perhaps somewhat different from that the loss and to insulate himself against the
to which you are accustomed. In keeping shock of the reality. This is followed by a
with this philosophic approach I have writ- stage of developing awareness of the loss,
ten this in the form of a Socratic dialogue. marked by the painful effects of sadness,
I pose the question, "Is grief a disease?" guilt, shame, helplessness, or hopelessness;
No doubt this seems a strange question, by crying; by a sense of loss and emptiness;
since grief has not usually been considered by anorexia, sleep disturbance, sometimes
in such terms and, on first glance, there somatic symptoms of pain or other discom-
seems little reason to do so. Yet, a thought- fort, loss of interest in one's usual activities
ful consideration of the issues raised by and associates, impairment of work per-
such a question will, I believe, throw light formance, etc. Finally, there is a prolonged
on some deficiencies in currently held con- phase of restitution and recovery during
cepts of disease. And the concept of disease which the work of mourning is carried on,
held by an investigator, whether or not con- the trauma of the loss is overcome, and a
sciously utilized, has an important influ- state of health and well-being re-estab-
ence on the choice of material and the de- lished.4' 5
sign of clinical research.1-3 In what respects does this correspond to
Grief is the characteristic response to the other situations that we customarily regard
loss of a valued object, be it a loved person, as "disease?" Certainly it involves suffer-
a cherished possession, a job, status, home, ing and an impairment of the capacity to
country, an ideal, a part of the body, etc. function, which may last for days, weeks,
Uncomplicated grief runs a consistent and even months. We can identify a con-
sistent etiologic factor, namely, real, threat-
From the Departments of Psychiatry and Medi- ened, or even fantasied object loss. It ful-
cine, University of Rochester Medical Center, fills all the criteria of a discrete syndrome,
Rochester, N. Y. with relatively predictable symptomatology
Presented at the Annual Meeting, American Psy-
chosomatic Society, Mar. 27, 1960, held at Montreal,
and course. The grieving person is often
Canada. manifestly distressed and disabled to a de-
Received for publication April 14, 1960. gree quite evident to an observer.
PSYCHOSOMATIC MEDICINE

2. ENGEL 19
The sceptic quickly raises some pointed forget that in the prescientific era the roles
questions: Is not grief simply a natural re- of physician, magician, and priest were
action to a life experience? How can one often embodied in the same person. It is
put it into the same category as the patho- the obligation of the physician of today to
logical states we call disease? To this we claim for scientific scrutiny all natural
answer that it is "natural" or "normal" in phenomena involving deviations in the in-
the same sense that a wound or a burn are dividual's state of well-being, of which grief
the natural or normal responses to physical is one.
trauma. The designation "pathological" Grief is a purely subjective, psychological
refers to the changed state and not to the experience that does not involve any so-
fact of the response. That one responds to matic changes. But, to my knowledge, no
thermal radiation with a burn is natural or one has ever studied the bodily changes oc-
normal. The burn itself constitutes a curring during grief; hence, to begin with,
pathological state and the concept is as ap- there is no basis for such a statement. But
propriately applied to the state of grief as even if it were true, one who holds such a
to a wound, burn, or infection. view is, in essence, relegating to an extra-
Or it may be said: Everyone experiences medical and extrascientific status any kind
grief—it's part of life. But that only em- of psychological or behavioral disturbance.
phasizes the ubiquity in life of the signifi- As a matter of fact, many illnesses are large-
cant etiologic factor and the universal ly subjective—at least, until we as observers
vulnerability of human beings to this par- discover the parameters and framework
ticular stressful experience. The same may within which we can also make objective
be said of many other disease states to observations. Hyperparathyroidism, in
which man is prone—measles, for example. many of its manifestations, was a purely
Actually, the statement is not entirely cor- subjective experience for many patients un-
rect. With a short life or under exception- til we discovered what to look for and
ally favorable circumstances, one may which instruments to use in the search.
escape both measles and grief. Again, the physician who is familiar with
Our sceptic resumes his argument: Grief grief will recognize its occurrence through
is a self-limited process, requiring no medi- his systematic and ordered observations,
cal attention. But so too are a great num- even if the patient withholds or denies the
ber of disease processes. Actually, many per- necessary information.
sons suffering primarily from grief do come No one ever dies of grief. Again, this is
to physicians but, because of cultural ex- an irrelevant argument, even if true; but is
pectations and the role ascribed to or held it true? The newspapers repeatedly report
by the physician, they do not complain to persons collapsing and dying soon after
him of grief. Rather, they report some learning of the death of a loved person.
other, often somatic, symptom and the Have these cases been so carefully studied
physician may not even learn of the grief. that we can say that the death represented
If he does, he may regard it either as not pure coincidence, that the shock phase of
related to the complaint or not his concern. the grief contributed in no way to this fatal
Besides, whether a condition requires medi- outcome? I know of no such studies.
cal attention is not relevant to the judg- Literature and folklore are replete with the
ment as to whether it is to be regarded as a notion that people fall ill and die "of
disease. The history of medicine provides grief." (I would prefer to say "during
innumerable examples of conditions that grief.") And few of the older physicians,
have come in time to be recognized as dis- from Hippocrates through the clinical
ease states but which had not been so re- giants of the late nineteenth century, failed
garded earlier. Epilepsy, alcoholism, and to allude to grief as a factor in the causa-
mental disease are examples. We must not tion of disease. While such views hardly
VOL. xxm, NO. 1, 1961

3. 20 IS GRIEF A DISEASE?
constitute scientific evidence, the incidents tive, and reparative process which corrects
are so common and the views so widely or overcomes a stress while the above-men-
held that the cautious scientist will not be tioned responses are the abnormal states
willing to say, without the benefit of sci- that should be called diseases? The element
entific study, that it cannot be so. Actually, of reparation is indeed to be found in grief,
many recent investigations indicate that a but so too is it found in every other disease;
wide variety of illnesses, including some indeed, it always accounts for some of the
that are fatal, may begin during a phase of symptoms and signs of a disease. If the
grief. Schmale has recently surveyed a adaptive or reparative processes involved in
medical population and reviewed the mod- disease are successful, recovery occurs and
ern as well as some of the older literature the patient reachieves a state of health. If
from this perspective.0 not, continued, progressive, or increased
Perhaps one should speak of pathological illness or death is the consequence.
grief and normal grief and restrict to the Can it not be said that the person is
former the category of disease. This is a really healthy and that he simply had the
welcome concession, but it does not go far misfortune to suffer a loss and is now re-
enough. At the outset I intentionally used sponding, naturally, with grief? This argu-
the term "uncomplicated grief" rather than ment implies that all systems and levels of
normal grief. It is normal only in a statisti- organization, actually and potentially, must
cal sense, meaning that it is the common, be impaired by the stress before the condi-
usual, and predictable response, as is an tion can be considered disease. Actually,
ecchymosis after a blow or measles after an not only are health and disease relative con-
infection with the measles virus. But it is cepts, but also at any time parts of the body
not normal in the sense of total health. and person may be more or less healthy,
Predictable does not mean invariable and, while other parts may be more or less im-
in any situation, whether it be loss of an paired. Indeed, this is the usual situation.
object or an exposure to physical trauma or It is only in fatal disease, when the victim
a microorganism, we observe and define is near death, that we see total disorganiza-
conditions under which the response may tion.
be different in degree or kind or where it Perhaps by now the sceptic is ready to
may not occur at all. This is a widely ac- concede that grief can be considered a dis-
cepted and familiar notion as applied to ease state. But what is gained by such a
traditional disease states, but equally ap- position? What are the implications for
propriate in respect to grief. We are fa- medical research and practice? They are, in
miliar with such responses as the absence of my opinion, important and far reaching:
grief, delayed grief, unresolved grief, de- 1. Grief, in all its forms and with all its
pression, psychotic or neurotic reactions, ramifications, becomes a legitimate and
pain or other conversion symptoms, and proper subject for study by medical scien-
even organic disease occurring in place of tists. Research, utilizing the tools of the
or in addition to the usual pattern of grief. physical, biological, and behavioral sci-
As is true of the complications of a wound ences, must be directed to these sufferers no
or an infection, we must also expect that less than to those with other disorders. The
other factors operate to account for these occurrence of grief among animals is so
deviations from the usual course. Yet none well documented as t(5 free the investigator
of these considerations refutes the fact that from exclusive dependence on human sub-
the experience of uncomplicated grief also jects for such research.
represents a manifest and gross departure 2. The occurrence of grief, preceding or
from the dynamic state considered repre- in the course of other illness, somatic and
sentative of health and well-being. psychologic, as is so often reported by pa-
Is not grief really just a healthy, adap- tients or their families, can no longer be
PSYCHOSOMATIC MEDICINE

4. ENGEL 21
passed off as irrelevant or coincidental until knowledge or examination). Who now
such data have been subjected to the same would be so rash as to dismiss the possi-
kind of rigorous and systematic exploration bilities that biochemical or physiological
and examination that has been applied to processes occurring during the grief reac-
other phenomena of disease. That grief in tion may not constitute conditions condu-
its various forms so often precedes the de- cive to other somatic changes of more seri-
velopment of other disease states in itself ous consequence?
constitutes no proof of a relationship. But 4. As a corollary of the above, we iden-
the medical scientist is remiss if he does not tify a ubiquitous psychological stress, mean-
subject all antecedent circumstances to ex- ing that the concept of objects and of ob-
amination as to whether they constitute ject loss is only meaningful in terms of the
contributing, necessary, or sufficient condi- existence and operation of the mental ap-
tions for the development of a disease state. paratus. This means that whatever the con-
The obvious derangements in the function- sequences of object loss and grief may be,
ing of the indidivual suffering from object whether manifest ultimately in biochemical,
loss and consequent grief make such in- physiological, psychological, or social
quiry all the more relevant. It is well to be terms, they must first be initiated in the
be reminded in this era of crash-program central nervous system. This imposes upon
applied research that many fundamental the medical scientist the necessity to pay
discoveries elucidating the pathogenesis and more attention to the role of the central
mechanisms of disease states came about nervous system in the maintenance of the
through the investigation of just such basic functional integrity of the organism as a
phenomena, often with grounds for antici- whole as well as of its various parts. In
pating a relationship far less than is the case spite of much lip service to the contrary,
with grief. One is reminded of the contro- most physicians and clinical investigators
versies concerning the role of miasmas in think and work as if the central nervous
the pathogenesis of malaria. The investi- system is the seat only of reflexes and of
gation of the climatic and geographic con- purely intellectual processes and really
ditions under which malaria occurred even- needs not be considered when studying dis-
tually provided the basis for elucidation of ease manifest elsewhere in the body. The
the disease even though the original theo- reluctance and/or inability to consider psy-
ries concerning the miasmas were erroneous. chological components of man and his
3. If the actual or threatened loss of an illnesses actually has come to include the
object so consistently disturbs the total ad- nervous system as well. But new knowledge
justment of the organism, then we have of central integrating and regulating proc-
identified an etiologic factor of such gen- esses, as has been brought forth by recent
eral importance as to put it in the same work on the limbic and reticular activating
class as other major rtbxa, e.g., physical systems, promises soon to dissipate this
agents, microorganisms, eftc. Until—and not barrier.7
until—much more is known about the bio-
5. The concept of grief as a disease re-
chemical, physiological, and psychological quires that we keep in view and in perspec-
consequences of such losses, no one is justi- tive aspects of the external environment
fied in passing judgment as to how impor- other than what we have been accustomed
tant this factor is in the genesis of the to heretofore—namely, the environment
disease states that seem so often to follow made up of the significant psychic objects.
close upon an episode of grief. To dismiss This becomes one reason why the persons,
such inquiry as unnecessary or irrelevant at job, home, goals, etc., in the life of our
this stage of our knowledge is an expression patients cannot be disregarded in our con-
of prejudice (in its literal sense, a prejudg- sideration of illness, at least not until it has
ment, or forming a judgment without due been proven that the vicissitudes of object
VOL. XXIII, NO. 1, 1961

5. 22 IS GRIEF A DISEASE?
relations, including grief, the disorder con- would call your attention to the fact that
sequent to object loss, plays no role in the cherished ideas, even if false, are also psy-
pathogenesis of disease. chic objects and as such are not easily given
6. If object loss is a potential stress, then up. And only time and much work will
maintenance of objects or replacement of establish whose cherished ideas are the false
objects must be considered as important ones.
variables in sustaining health and adjust- I close with a quotation ascribed to Al-
ment. The physician, the hospital, the clin- bert Szent-Gyorgyi: "Research is to see what
ical investigator, indeed, even the experi- everybody else has seen and think what
ment, may come to fulfill the requirements nobody else has thought." To this I would
of a necessary and supporting psychic object only add that Szent-Gyorgyi wisely refrained
for a patient. Everyone is aware of the from claiming that this necessarily implied
therapeutic influence of the physician on that the "new" thought is correct—at least,
the patient, but how many unwary clinical not until tested. And that is my challenge!
investigators have been observing physiolo-
gic or biochemical changes in their experi- References
mental subjects, believing these to be the 1. ENGEL, G. L. "Homeostasis, Behavioral Adjust-
influence of some drug or other procedure ment and the Concept of Health and Disease."
when in fact these changes were secondary In GRINKF.R, R. Mid-Century Psychiatry, Thomas,
Springfield, 111., 1953, pp. 33-59.
to the varying effects of the experimenter's 2. ENGEL, G. L. Selection of clinical material in
unwitting role as a psychic object for the psychosomatic medicine: The Need for a New
patient. For many varieties of clinical in- physiology. Psychosom. Med. 76:368, 1954.
vestigation it is necessary to regard the ex- 3. ENGEL, G. L. A unified concept of health and
perimenter as part of the experiment.8 disease, Perspectives in Biology and Medicine.
3 No. 4, 1960.
This does not exhaust the Pandora's box 4. FREUD, S. "Mourning and Melancholia" (1917).
opened by such a perspective. Once opened, Standard Edition, Complete Works, London, Vol.
we cannot easily refute the real, yet un- XIV, 237, 1957.
known influences that must now come un- 5. LINDEMANN, E. Symptomatology and manage-
der our scrutiny. Yet the human mind, that ment of acute grief. Am. J. Psychiat. 707.14,
- 1944.
wonderful instrument of discovery, has a (&J SCHMALE, A. H. Relationship of separation and
disconcerting capacity to use denial, to turn depression to Disease. Psychosom. Med. 20:259,
away from that which is not easily com- 1958.
prehended or which has awesome implica- 7. JASPER, H. H., Ed. Reticular Formation of the
tions, as I believe is true of this concept. Brain, Little, Boston, U)58.
8. ENGEL, G. L., REICHSMAN, F., and SEGAL, H. L.
The first response when confronted with A study of an infant with a gastric fistula. I.
news of a grievous loss is, "No, it can't be. Behavior and the rate of total HC1 secretion,
I don't believe it; I won't believe it." I Psychosom. Med. 7S.374, 1956.
PSYCHOSOMATIC MEDICINE