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The mourning process and its
importance in mental illness: a
psychoanalytic understanding of
psychiatric diagnosis and
classification
Rachel Gibbons
SUMMARY
This article brings together the psychiatric and
psychoanalytic views of mental illness to deepen
the understanding of mental disorder. The intention
is to bring to the fore the importance of loss and
mourning in clinical practice. Looking for the loss
event that underpins the disorder helps determine
therapeutic treatment options and increases the
chance of authentic therapeutic engagement and
recovery. The article summarises theory about the
mourning process and discusses the relationship
of loss and pathological mourning to mental illness.
Fictitious case vignettes developed from years in
psychiatric practice are used to illustrate how
this relates to clinical practice and formulation.
LEARNING OBJECTIVES
After reading this article you will be able to:
•understand the different stages of the mourning
process
•recognise the important role of mourning in dif-
ferent mental illnesses
•psychologically formulate psychiatric
presentations.
KEYWORDS
Mourning; psychodynamic psychiatry; loss; DSM/
ICD; biopsychosocial formulation.
‘What it is to be human. It seems to me that the
common agent that binds us all together is loss, and
so the point in life must be measured in relation to
that loss. Our individual losses can be small or
large. They can be accumulations of losses barely
registered on a singular level, or full-scale cataclysms.
Loss is absorbed into our bodies from the moment we
are cast from the womb until we end our days, sub-
sumed by it to become the essence of loss itself.’
(Cave, 2022)
This article brings together the psychiatric and psy-
choanalytic views of mental illness to provide a
model by which to understand the nature of psychi-
atrically diagnosed disorders. Why has this person
developed this particular disorder, been diagnosed
and classified in this particular way, at this point
in their life? The psychiatric diagnostic system can
be understood and enriched through the psycho-
dynamic lens. Psychiatrists tend to view the mind
from the outside and diagnose different disorders
depending on the symptom constellations observed,
using classification systems (e.g. ICD and DSM).
Psychoanalysts look from the inside of the mind at
the unifying human psychodynamics where mental
illness is understood to arise from difficulties in the
response to the human experience of loss and grief
(as described by Nick Cave above).
In summary, this article will argue that psychiatric
illness can be understood to result from ‘patho-
logical mourning’due to arrests, or retreats, in the
passage through the mourning process. The charac-
teristic symptoms of different psychiatric illnesses
used to classify disorders can be conceptualised as
resulting from the overuse of different constellations
of psychic defences (Table 1) used at specific and dif-
ferent stages in the mourning process. Differently
classified illnesses have different symptoms depend-
ing on the particular point in mourning where the
arrest occurs. Key terms used in the article are
defined in Box 1.
The obstruction, in pathological mourning, can
result from combinations of different aetiological
factors (A), which include:
•genetics (A1)
•organic brain injury/disease (A2)
•lack of developmental containment (A3)
•a loss of such magnitude that a retreat from reality
is essential for psychic and/or physical survival
(A4)
•collusion of the social system around the bereaved
to perpetuate the disturbance (A5).
ARTICLE
Rachel Gibbons, FRCPsych, is a
consultant psychiatrist, psychoana-
lyst and group analyst. She works
independently. She is Chair of the
Working Group on the Effect of
Suicide and Homicide on Clinicians,
the Co-Chair of the Patient Safety
Group and the Vice-Chair of the
Faculty of Medical Psychotherapy at
the Royal College of Psychiatrists.
London, UK.
Correspondence Dr Rachel
Gibbons. Email: drrachelgibbons@
icloud.com
First received 4 Nov 2022
Final revision 13 Jan 2023
Accepted 20 Jan 2023
Copyright and usage
© The Author(s), 2023. Published by
Cambridge University Press on behalf
of the Royal College of Psychiatrists.
This is an Open Access article, dis-
tributed under the terms of the
Creative Commons Attribution
licence (http://creativecommons.org/
licenses/by/4.0/), which permits
unrestricted re-use, distribution and
reproduction, provided the original
article is properly cited.
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The normal mourning process
‘[The normal mourning process] carried out bit by bit,
at great expense of time and cathectic energy [ …]
Each single one of the memories and expectations in
which the libido is bound to the object is brought up
and hyper-cathected, and detachment of the libido is
accomplished in respect of it.’
(Freud, 1917)
Psychoanalysts have explored in detail the
normal mourning process, describing it as excruci-
atingly painful and laborious ‘work’which, when
successful, is rewarded by ego growth through the
installation of reality-based imagoes of lost
‘objects’(representations of lost meaningful attach-
ment figures) in the internal world. This results in
an enrichment of psychic life and a deepened cap-
acity for joy and love. This process is life’s great
challenge and is fundamental to individuation
and separation (Freud 1917; Fairbairn 1941;
Balint 1952;Fromm1956;Bowlby1988;Kernberg
2011):
‘Implicit in mature love is an honest acceptance of
one’s essential need of the other in order to
achieve full enjoyment and security in life’
(Kernberg 2011).
Many psychoanalysts believe that the template for
lifelong mourning is developed in the early years of
life (Balint 1952; Fairbairn 1943; Fromm 1956;
Klein 1957; Kernberg 2011). It is during this time
that the infant faces their first great losses as they
start the process of separation and individuation
(Klein 1957). The mourning process occurs for the
first time in the first year but thereafter a multitude
of times, after every loss that occurs throughout a life-
time at varying degrees of intensity on a daily,
weekly, monthly and yearly basis (Klein 1957).
Every time a loss occurs the process is repeated
and reworked and the internal world and the
psychic capacities of the individual grow and
deepen. With this development there is an increase
in the capacity to form truly loving intimate relations.
These analysts believed that how this process is
negotiated in early life determines the individual’s
future capacity to deal with losses, and therefore
their later predisposition to psychiatric illness.
TABLE 1 Psychic defences
Level of
defence Name of defence Definition
Level of cognitive
and symbolic
function required
Mature Altruism Satisfying unconscious internal needs by prioritising others High
Anticipation Putting energy into predicting and solving problems that may cause
painful feelings before they arise
Humour Unconscious painful material can be made conscious and bearable by
laughing at the comical absurdity
Sublimation Socially unacceptable urges are transformed into a constructive and
acceptable form
Suppression Voluntarily, with conscious intent, diverting the mind away from
anxiety or pain
Neurotic Isolation of affects Separation of painful feeling from the person, idea or event that
causes them
Medium
Intellectualisation Reason and logic are used to avoid anxiety and painful affect
Reaction formation Taking the opposite attitude to the unconscious one that is really
desired
Displacement Transferring feelings onto a substitute, alternative, object
Undoing Trying to make an undesirable unconscious impulse ‘unhappen’by
enacting the reverse/opposite
Dissociation Disconnection/detachment from painful reality to protect the mind
Regression Returning to an earlier stage of development to avoid painful
experience in the present
Immature/
primitive/
psychotic
Idealisation The attribution of exaggerated positive qualities to the self or others
to avoid the pain of seeing reality
Low
Devaluation The attribution of exaggerated negative qualities to the self or others
to avoid the pain of seeing reality
Omnipotence Distorting reality and assuming superior power to avoid vulnerability
Denial Unconscious refusal to accept a threatening reality
Rationalisation Using apparent logic and justification to validate incorrect
explanations for thoughts, actions or feelings: ‘Used by the
psychotic part of the personality to cover up its murderousness’
(Lucas 2009: p. 142)
Projection Expulsion from the mind of unwanted affects or attributes, then
perceived as coming from the external and not internal world
Splitting Binary and polarized views allow the avoidance of conflict and
uncertainty. Separation of good and bad experiences.
Acting out Act to avoid painful feelings
Gibbons
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Stages of mourning
‘The nature of sorrow is so complex, its effects in dif-
ferent characters so various, that it is rare, if not impos-
sible, for any writer to show an insight into all of them.’
(Shand 1914: p. 361)
Different physicians, including Parkes (1988)and
Kubler-Ross (1969), and psychoanalysts, such as
Freud (1917), Fairbairn (1941), Klein (1957),
Bowlby (1988) and Steiner (1990), have observed dif-
ferent stages of the mourning process. Although
making it clear that individuals negotiate loss in
unique ways, overall they have described a process
of breakdown and reconstruction, disorganisation
and reorganisation. Colin Murray Parkes calls it a
‘psychosocial transition’where the ‘assumptive
BOX 1 Definitions of terms
Mourning: The psychological processes that are set in motion
by a loss.
Grief: The sequence of subjective states that follow loss and
accompany mourning.
Ego: One of three parts of Freuds ‘structural model’of the
psyche that mediates between the ‘id’and the ‘superego’. The
ego engages with reality and it is where self-identity is
located. The id is entirely unconscious and holds the basic
instinctual urges, such as aggression and sexuality. The
superego functions as a conscience, repressing what it con-
siders to be morally unacceptable.
Imago: The unconscious mental image of another person.
This image becomes more accurate through effective
mourning.
Object: In object relations theory, early infantile experi-
ence is describe as relationally based. The attachment
energy, or libido, is focused on people and things, which
are defined as ‘objects’. There is an internalisation of
representations of these ‘objects’that populate the mind
and increase in complexity and depth throu gh mourning and
separation.
Lost object: What has been lost. The focus of the grief. The
loss of the object triggers the mourning process. This can be
symbolic as well as concrete. For example it can be an actual
person/relationship, a view of oneself (considered a narcis-
sistic loss) or a loss that changes one’s perception of the
world.
Good object and bad object: Early primitive objects
internalised that both represent aspects of the same primary
care giver. The ‘good object’is experienced by the infant
when their needs are being met and they experience satis-
faction, and the ‘bad object’is experienced when they are not
and they experience frustration. Through mourning it is rec-
ognise that both represent aspects of the same external
other.
Mentalise: The ability to reflect on, and to understand one’s
own state of mind. To have insight into what one is feeling
and why. To be able to conceptualise other people’s mental
states and to recognise that they may be different to one’s
own.
Symbolic capacity: A symbol is an indirect form of
representation that allows an individual to think about people,
objects and events that are not concretely available. These
symbols are available for utilisation intrapsychically to
represent ideas, conflicts or wishes. To generate these
representations in psychic space is an abstract task and
requires cognitive capacity. It moves the concrete to the
abstract. Symbolic capacity is needed to be able to think and
play with ideas in the mind:
‘The symbol proper, available for sublimation and furthering the
development of the ego, is felt to represent the object; its own char-
acteristics are recognized, respected, and used. It arises when
depressive feelings predominate over the paranoid-schizoid ones,
when separation from the object, ambivalence, guilt, and loss can be
experienced and tolerated. The symbol is used not to deny but to
overcome loss’(Segal 1957).
Symbolic processing: The process of thinking using symbols
where certain ideas, pictures or other mental statement acts
as intermediaries of thought (Segal 1957).
Omnipotence: A defensive position where one has unlimited/
great power and vulnerability is avoided.
Sadomasochistic engagement: This describes a method of
relating and managing intimacy that keeps the object at a
controlled distance. There is usually a movement from a sad-
istic state of mind where there is a feeling of power and
control to a masochistic state of mind where there is a feeling
of vulnerability and exposure. This is experienced as exciting.
A degree of this relating is commonplace, but it can become
disturbed or entrapping under certain circumstances (Glasser
1979).
Phantasy: The ‘ph’spelling is often used to differentiate this
unconscious process from fantasy, which is conscious and
deliberate.
Libido/psychic energy: The life force driving and sustaining
mental activity. In much psychoanalytic theory the ‘id’is con-
sidered to be the source of this energy. It can be considered as
mediating desire, curiosity and passion.
Transitional space: The conceptual space that develops
between the infant and caregiver through separation and
individuation. This space allows for a move away from con-
crete thought and functioning to symbolisation, complex
thought, mental creativity and play:
‘I have introduced the terms “transitional object”and “transitional
phenomena”for designation of the intermediate area of experience,
between the thumb and the teddy bear, between the oral erotism and
true object-relationship, between primary creative activity and pro-
jection of what has already been introjected, between primary
unawareness of indebtedness and the acknowledgement of indebt-
edness’(Winnicott 1953)
The mourning process and mental illness
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world’(all that we assumed was securely in place) is
thrown into disarray and has to be rebuilt (Mallon
2008).
The mourning process can broadly be divided into
five stages that clinicians have described in different
ways (Fig 1). To assist further discussion, they will
be identified here as:
(1) denial;
(2) hatred, anger, persecutory guilt, and blame;
(3) transition and bargaining;
(4) sadness and neurotic guilt;
(5) acceptance.
Stage 1: Denial
‘[M]an’s usual response is “No, it cannot be me.”Since
in our unconscious mind we are all immortal, it is
almost inconceivable for us to acknowledge that we
too have to face death.’
(Kubler-Ross, 1969: p. 55)
Stage 1 starts in the period directly after the loss.
The ego is overwhelmed with anxiety and the cap-
acity to mentalise and therefore symbolise is lost
(Bateman 2013). Primitive psychotic defences,
including denial, splitting and projection, that can
be mobilised rapidly and require little psychic cap-
acity, are utilised to buffer and titrate the awareness
of reality. This results in a dissociation from the
experience of loss and the initial characteristic
picture of numbness and unreality. The loss itself
and the hatred of reality generated by it are totally
denied.
Stage 2: Hatred, anger, persecutory guilt and
blame
Hate [ …] in a healthy man is only potential or inciden-
tal [ …] it should be more like acute anger; in contrast
to love, hate should easily and speedily dissipate.’
(Balint 1952:p.358)
Once the immediate shock is buffered and some
symbolic capacity recovered, there is some re-estab-
lishment of engagement with reality. The primitive
immature defences start to lessen their hold on the
psyche and those that utilise some symbolic func-
tioning, and are therefore less radical, are activated.
The emotional temperature changes from numbness
and disconnection to hatred, anger and protest
(Balint 1952; Kubler-Ross 1969; Parkes 1988). In
the early part of stage 2, murderous phantasies
and impulses unconsciously directed towards the
lost object are common:
‘Since none of us likes to admit anger at a deceased
person, these emotions are often disguised or
repressed and prolong the period of grief or show up
in other ways’(Kubler-Ross 1969: p. 18).
The hatred and later, the more nuanced anger, are
not initially directed at who or what is lost, which is
initially preserved through the use of defences char-
acteristic of stage 2. These include: projection, dis-
placement, anger turned inward and identification.
As a result, a perceived less valuable external ‘bad
object’is labelled as the source of the problem. As
time progresses, and as long as the ‘bad object’
survives the attacks, the rage at the real subject of
the loss can be acknowledged and mourning can
progress:
‘If you had stood in front of me when I was so full of
hatred after my daughter’s death, I could have killed
you and not thought twice about it’(Grieving mother).
This is a highly emotionally charged and challen-
ging stage. The reality of the loss and the powerless-
ness of the individual are still resisted. The psychic
pull of omnipotence and sadomasochistic engage-
ment with the ‘bad object’is exciting and hard to
relinquish (Steiner 1990). It is during stage 2 that
the ability to grieve and the nature of the relation-
ship to the lost object are of utmost importance. As
described above, if there has been successful mourn-
ing in childhood true loving feelings generally
prevail (Abraham 1911; Balint 1952; Steiner
1990), because the individual has developed confi-
dence they can survive the pain of loss: through
effective mourning they have internalised ‘good
objects’that they can utilise to support them in
their grief. The ‘bad object’is not successfully
destroyed and the difference between it and the
real external object can start to be seen (Bion 1962).
Psychiatrists and psychiatric services can play an
important role as the ‘bad object’through stage 2:
it is important that those involved do not identify
too strongly with this projection for the well-being
of those grieving and to prevent a collusion that
arrests mourning (A5).
Stage 2 is potentially a very dangerous stage of
mourning. Arguably, many of the destructive acts of
humanity, including wars, murder and violence,
have resulted from a lack of containment and arrests
during stage 2 of the mourning process. The war
on Afghanistan, starting just 15 days after the
September 11 attacks in the USA, is likely to have
been sanctioned, in part, by the fear, anger and uncon-
scious desire for retribution resulting from the grief
following this profound loss event (Witte 2010).
Stage 3: Transition and bargaining
‘I do not normally pray but I have been since my diag-
nosis –I think “If I pray to you now Lord, I will do any-
thing you ask [ …] will you tell the cancer to go away?”.’
Patient
‘You were giving him, my father, another chance, even
with your nose still crooked from his countless back-
hands.’
(Ocean Vuong, 2014: p. 28)
Gibbons
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During the transitional stage there is a gradual
growing awareness of the reality of the loss,
although it continues to have an unreal quality
and there is some hope, through the defence of
‘magical thinking’, of reversal (Fairbairn 1941;
Steiner 1990). It is a time of ‘hope and hopeless-
ness’. With the recovering of symbolic functioning
there is the development of a ‘transitional’space
(Winnicott 1971), where the loss can be played
with in phantasy. This transitional phase continues
until there is finally a taking in, or submission to,
the full reality of loss.
Stage 4: Sadness and neurotic guilt
‘His numbness or stoicism, his anger and rage will
soon be replaced with a sense of great loss.’
(Kubler-Ross, 1969: p. 97)
During this stage the loss is actively mourned,
and painful sadness predominates. This grief takes
a considerable amount of psychic energy, libido
(Freud 1917), which is directed into the internal
world and therefore cannot be externally discerned.
Instead, the individual suffering tends to appear
listless, withdrawn and lacking in motivation.
Gradually, through the ‘work’of stage 4, a genuine
compassionate resilient mental representation of
the ‘lost object’is internalised. This is the time of
realistic neurotic guilt, and gradual reparative feel-
ings and behaviours.
Stage 5: Acceptance
‘I hold it true, whate’er befall; / I feel it when I sorrow
most; / ’Tis better to have loved and lost / than never
to have loved at all.’
(Alfred Lord Tennyson (1809–1892),
In Memoriam
A. H. H.
)
In this final stage the pain eases and there is
the possibility of learning to live with the loss.
Gradually the memories bring pain, joy and grati-
tude for having loved and for life itself. These
stages are negotiated repeatedly, often with some
degree of cyclicity.
Pathological mourning and psychiatric
illness
‘[…] disease proceeded from an attitude of hate [ …]
paralysing the patient’s capacity to love.’
(Abraham, 1911: p. 19)
Freud (1917), Bowlby (1988), Abraham (1911)
and Steiner (1990) all describe psychiatric illness
resulting from defensive processes ‘interfering with’
or ‘fixating’the progress of mourning in stages 1
and 2 (Fig 2). The illness provides a ‘refuge’,a
defence against reality. This is described by Steiner
as a ‘psychic retreat’. Although some time spent in
this refuge can be healthy, providing some protec-
tion and defence against reality, when entrenched
the retreat leads to developmental arrest and psychi-
atric illness. The longer reality is avoided, the
greater the losses to be mourned. As well as the ori-
ginal loss there is now the loss of the time spent in
withdrawal:
‘The patient who has hidden himself in the retreat
often dreads emerging from it because it exposes
him to anxieties and suffering –which is often pre-
cisely what had led him to deploy the defences in the
first place’(Steiner 1990).
2.
Hatred,
anger,
persecutory
guilt
and blame
3.
Transition
and
bargaining
1.
Denial
Loss event
4.
Sadness and
neurotic guilt
5.
Acceptance
t
Loss acknowledged
FIG 1 The stages of mourning.
The mourning process and mental illness
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For some, remaining in the retreat may be a matter
of psychic and physical survival. It is frequently
reported that a patient has the greatest risk of
death by suicide when starting to recover from a psy-
chiatric illness (Chung et al 2017; Healthcare
Quality Improvement Partnership 2022).
This article puts emphasis on the view held by
Freud (1917), Abraham (1911), Bowlby (1988)
and Steiner (1990) that the symptoms that define
every DSM/ICD diagnosis of mental illness are
determined by the point in the mourning process
where the arrest occurs. This in turn is determined
by the individual’s vulnerabilities and the constella-
tions of defences they constitutionally call on. If only
psychotic defences can be used, as in dementia and
some forms of schizophrenia, the arrest will occur
very early in the mourning process, in denial, and
a psychotic illness will be the result. If, during child-
hood, anger was not an acceptable emotion and was
not contained, it is likely that the arrest will be in
stage 2 of the mourning process, where anger is
mobilised, and the presentation of illness will be
that of depression:
‘When I was a child, our parents would become abso-
lutely furious if my brother or sister or I cried. [If] one
of us did cry they both became almost insane in their
anger toward us’(Strout 2022: p. 48).
Some symptoms similar to those of mental illness,
such as hallucinations, guilt, anger, withdrawal and
behavioural disturbance, are normal in mourning.
It is when these become stuck and intractable that
a classifiable disorder develops.
Examples of psychiatric illness
Primary psychotic illness
The symptoms used to diagnose psychotic illness
according to ICD and DSM broadly include:
•delusions
•hallucinations
•perceptual disturbances
•severe disruption of ordinary behaviour
•abnormality of thought experience that can be
identified in speech structure
•cognitive effects, including negative symptoms,
where the level of functioning is below the level
achieved prior to the onset.
These symptoms may be understood to result
from the overuse of primitive, immature, psychotic
defences such as denial, projection, splitting and
rationalisation. These defences do not require
higher-level cognitive and symbolic functioning
(Lucus 2009; Gabbard 2014). Around 30–40% of
illnesses that present to mental health services with
psychotic symptoms recover and full symbolic func-
tioning is regained (Li 2022). It is worth noting that
a transient psychotic state can occur when the brain
is strained or tired and with some drugs, such as can-
nabis and alcohol. If an individual is deprived of
sleep over a significant period, they are prone to
develop fleeting psychotic experience. However, in
some the psychotic state is persistent and the
illness is progressive. Recent developments in
research in schizophrenia shows that in a number
of patients there is a reduction in cerebral grey
matter before any positive symptoms of the illness
become apparent (Nenadic 2015). This cognitive
impact explains the intractable course for some:
the illness in itself is a huge loss of identity, future
and capacities, and then in turn it robs the individual
of the means of working through this loss.
Case vignette 1: Schizophrenia (ICD-11 6A20, DSM-5
F20.9)
a
Mr R was a university student who had achieved well
in all his exams. He had family history of mental
illness. One maternal uncle had a diagnosis of schizo-
phrenia and the other a bipolar disorder. His first
year at university seemed to be going as expected;
however, soon his parents found it difficult to
contact him. When he came home at the first
Christmas break, he did not seem himself. He was
withdrawn and stayed in his room smoking cannabis
and playing computer games. Soon after his return to
university his parents began hearing concerning
reports. He had started to behave oddly. He had
lost a lot of weight and was not caring for himself.
He told his housemates that he believed that a
secret organisation was following him and had
been tracing his work on the internet because, he
said, they found out that he understood the networks
of all governments.
1.
Denial
Anxiety
BAD
Psychosis Depression
2.
Hatred,
anger,
persecutory guilt
and blame
3.
Transition
and bargaining
FIG 2 The place of arrest in the mourning process for
various diagnosable illnesses. BAD, bipolar affective
disorder.
a. The case vignettes describe ficti-
tious patients based on numerous
individuals treated during my years in
psychiatric practice.
Gibbons
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Mr R was admitted to hospital voluntarily. He will-
ingly agreed to a brain scan so he could show his
family that a chip had been implanted in his brain
by this secret organisation. This scan showed
enlarged brain ventricles and a loss of brain volume.
He was subsequently diagnosed with schizophrenia.
He left hospital 6 months later. He was stable on anti-
psychotic medication, but he did not recover his sym-
bolic capacities and cognitively he was severely
disabled. He moved from the ward to accommodation
with 24 h support.
In this case Mr R had a significant genetic compo-
nent to his illness (A1). Neurodegeneration had
robbed him of significant symbolic functioning
(A2). His mental capacities decreased, and the
only defences available to him were primarily primi-
tive in nature. At no time did Mr R express anger or
sadness. He remained in denial about his illness.
Case vignette 2: Delusional disorder (ICD-11 6A24,
DSM-5 F22)
Miss L was a 60-year-old woman presenting for the
first time to psychiatric services. She had developed
a psychotic illness following her mother’s death. She
came from a wealthy background and had never left
home, continuing to live with her mother and never
finding a partner, studying or working. She believed
that her mother had not died but was being experi-
mented on at the local hospital. She lived the rest of
her life with a high level of support from psychiatric
services and maintained this delusion.
In this example Miss L had difficulties in
developmental containment and had never
managed to develop a mature capacity for mourn-
ing. Separation from her mother had not been pos-
sible (A3). The death of her mother was therefore
too large a loss for her to cope with (A4). She
remained stuck in stage 1 of mourning, with a per-
sistent delusion.
Case vignette 3: Psychotic disorder unspecified (ICD-11
6A25, DSM-5 F298.9)
Mr P was detained in prison. He was a man in his 30s
who had no history of psychiatric illness and no previ-
ous criminal record. He had been working success-
fully in retail before his arrest. He was charged with
the murder of his pregnant girlfriend. He made no
attempt to cover up the crime. When seen by the
prison psychiatric team, his behaviour was bizarre.
He was clearly perplexed and disordered in thought
and speech. He believed his girlfriend was still alive
and he denied all knowledge of the crime. He was
diagnosed with a psychotic illness. He remained
unwell and was transferred to a forensic hospital,
where he remained for the next 10 years.
In this case Mr P developed a psychotic illness
because the loss itself and the role he had played in
it was too great for him to acknowledge (A4). He
had to remain in a state of total denial to retain his
unawareness. This therefore was an arrest in stage
1 of mourning and the symptoms were of psychosis.
Bipolar affective disorder (ICD-11 6A60, DSM-5
F31).
According to ICD and DSM, bipolar affective dis-
order is characterised by two or more episodes in
which mood and activity levels are significantly dis-
turbed, this disturbance consisting on some occa-
sions of an elevation of mood and increased energy
and activity (hypomania or mania) and on others
of a lowering of mood and decreased energy and
activity (depression).
The classic symptoms of mania when it predomi-
nates are:
•elevated mood
•increased energy
•increased mental and physical activity, including
pressure of speech and distractibility
•decreased sleep
•loss of social inhibitions, such as increased spend-
ing and sexual disinhibition
•inflated self-esteem and grandiosity, which can
become delusional.
Bipolar affective disorder has strong biological and
developmental factors (A1, A3) and can be challen-
ging to diagnose because in practice, the symptoms
vary. In many cases there are significant psychotic
symptoms which are exacerbated by the lack of
sleep and overactivity inherent in the illness.
Cognitive dysfunction also increases as the illness
progresses (A2).
In this disorder ‘manic defences’predominate.
These are a ubiquitous group of mental manoeuvres
used in stage 1 of mourning to deny the psychic
reality of loss. The defences of denigration, denial,
projection and omnipotence are used to control, main-
tain contempt for and triumph over the lost object.
Self-aggrandisement, omnipotent self-sufficiency and
wish fulfilment are used to maintain thissuperior pos-
ition. If what has been lost has little meaning or value,
then there is little to grieve for (Klein 1935; Rivierre
1936). When manic defences are excessively strong,
vicious circles are set in motion. The individual feels
unconsciously guilty for their attacks, the anxieties
underlying the disorder increase and fixation occurs.
Symptoms of mania and psychosis develop, and gran-
diose delusions are common.
Case vignette 4: bipolar affective disorder, current
episode manic (ICD-11 6A60.1, DSM F31.2)
Mr M was a 31-year-old high-functioning lawyer who
was admitted to a psychiatric ward with florid manic
symptoms. He had a family history of significant
mental illness. He had a difficult early life. His
parents divorced when he was 9 and his father had
no subsequent contact with the children or their
mother. Mr M said that this had little effect on him
and that it was only his mother who was important.
His father died around 18 months before his
The mourning process and mental illness
BJPsych Advances (2023), page 1 of 9 doi: 10.1192/bja.2023.8 7
https://doi.org/10.1192/bja.2023.8 Published online by Cambridge University Press
admission. It was after this loss that he gradually
became ill with symptoms of a manic episode.
In this case Mr M had genetic vulnerability (A1) and
a lack of containment in early childhood with the loss
of his father from the family (A2). This loss was not
acknowledged and mourned. Later, the death of his
father was the primary factor in Mr M’s illness.
There was a build-up of denied grief and Mr M
arrested in stage 1 of mourning, developing symp-
toms of a manic episode. He subsequently recovered
with mood-stabilising medication and psychother-
apy. He suffered a subsequent episode 10 years
later when he stopped taking his medication.
Anxiety disorder (ICD-11 6B, DSM F40–F41)
According to ICD and DSM the manifestation of
anxiety is the primary symptom in these disorders.
The arrest in mourning is between stages 1 and 2
and there is still a denial of the source of the loss.
The defences utilised are primarily immature,
although some more neurotic defences from stage
2, such as regression, isolation of affect and reaction
formation, are also employed.
Case study 4: hypochondriasis (ICD-11 6B23, DSM
F45.21)
Dr J was born in the UK just after both his parents fled
from Germany in 1933. When he was 3 years old his
mother became terminally ill. Throughout the years of
her illness, the young boy was told that he could not
see her because she was ‘poorly’. After her death, Dr J
became an anxious child and during much of the rest
of his childhood was preoccupied with anxieties about
his health. He would repeatedly ask his father ‘Am I
poorly, will I die like my mother?’This drove his
father to distraction because no matter what he said
and how much he reassured his son, the boy repeatedly
asked him the same question. His father lost his temper
andtoldDrJwhenhewas10thatifhecontinuedlike
this he would be sent to boarding school.
Throughout his adult life, Dr J worked as a doctor and
hid his hypochondriasis. He often quietly thought that
he was dying of various diseases. When Dr J’s father
died, he said he felt ‘nothing’. With retirement, his
anxiety became worse and he had various agitated
depressive breakdowns which became delusional at
times, when he thought he was dead or dying.
In this case, there was an early lack of containment
for Dr J following the loss of his mother (A3). In
adulthood, Dr J found a way to manage his illness
by working hard and projecting the ill part of
himself into his patients. He had two losses in later
life, with the loss of his father and his retirement,
and he developed a more overt mental illness. He
denied the feelings about the loss of his father and
projected more profoundly into his body the anxieties
about death that his patients had previously held for
him. With age he also had some cognitive decline and
developed additional psychotic symptoms (A2).
Depressive disorder (ICD-11 6A7, DSM-5 F32)
In depression the arrest is in stage 2 of mourning,
when a greater symbolic capacity is achievable and
neurotic defences are mobilised. There is some
degree of acknowledgement of loss. The anger and
hatred meant for the lost object generated in this
stage of mourning are turned on the self through
the defence of anger turned inwards. This results
in the recognised symptoms used for diagnosis,
including low mood, anhedonia, guilt and
worthlessness.
Case vignette 5: Major depressive disorder, current
episode moderate (ICD-11 6A70.1, DSM-V F32.1)
Mr H was sent to boarding school when he was 7. He
was initially very distressed but learned to survive by
joining in with the sadomasochistic games and bully-
ing of his classmates. He achieved well academically
and worked in the financial markets. He married a
woman whom he met at university, and they had
children. When the children left home, his wife told
him that she wanted a divorce. This brought about
a depressive breakdown for Mr H. He attacked
himself, blaming himself for the marital breakdown
and disappointing his wife. He expressed suicidality
and hopelessness. His wife felt she could not leave
because he might harm himself.
In this case Mr H had a lack of developmental con-
tainment as a result of premature separation (A3).
He lacked the capacity to mourn the breakdown in
his marriage and he retreated from reality (A4).
The anger directed at his wife, which resonated
with the anger he had felt earlier towards his
mother for being sent to boarding school, was
turned against himself. His suicidality served to
control his wife, stopping her from leaving, and
maintained his illness (A5).
Conclusions
An understanding of the importance of the role of
mourning in psychiatric illness allows for clarity of
formulation and renders diagnosis understandable
at a deeper level. The symptoms of illness can be
understood as resulting from the overuse of different
constellations of psychic defences activated in differ-
ent stages of the mourning process. Looking for the
loss event that underpins the disorder helps deter-
mine therapeutic treatment options. It increases
the chance of authentic therapeutic engagement
and recovery. This article is intended to make
some sense of clinical pictures that can at times
seem incomprehensible and to bring to the fore the
importance of loss and mourning in clinical practice.
Acknowledgements
I thank John Steiner for his wise council during the
years of developing this article.
Gibbons
8BJPsych Advances (2023), page 1 of 9 doi: 10.1192/bja.2023.8
https://doi.org/10.1192/bja.2023.8 Published online by Cambridge University Press
Funding
This research received no specificgrantfromany
funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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MCQs
Select the single best option for each question stem
1 According to psychoanalysts, the template
for lifelong mourning is developed:
athroughout childhood
bin the womb
cduring adolescence
din the first few years of life
eafter losses in childhood.
2 The suggested five stages of mourning are:
aanger, denial, sadness, bargaining, acceptance
bdenial, anger, sadness, bargaining, acceptance
cguilt, sadness, denial, loss, acceptance
dnumbness, guilt, sadness, loss, acceptance
edenial, anger, bargaining, sadness, acceptance.
3 The most dangerous stage of mourning is:
adenial
bhatred, anger, persecutory guilt and blame
ctransition and bargaining
dsadness and neurotic guilt
eacceptance.
4 If only psychotic defences can be used, as in
dementia and some forms of schizophrenia,
the stage in which arrest in mourning usually
occurs is:
adenial
bhatred, anger, persecutory guilt and blame
ctransition and bargaining
dsadness and neurotic guilt
eacceptance.
5 The primary psychic defence used in
depressive illness is:
aanger turned inwards
bprojection
csublimation
drationalisation
ehumour.
MCQ answers
1d2e3b4a5a
The mourning process and mental illness
BJPsych Advances (2023), page 1 of 9 doi: 10.1192/bja.2023.8 9
https://doi.org/10.1192/bja.2023.8 Published online by Cambridge University Press
