Four cases of mania associated with bereavement.

The difficulties of research connecting events in the social field with onset of an illness are illustrated by four case studies exemplifying differing aspects of pathological grief, where the stress of an unresolved bereavement crisis was associated with the onset of a manic illness. The studies are: a) in early bereavement; b) as a repeated anniversary reaction; c) after 10 years, as a result of pathological identification and reparation; d) the loss of a symbiotic relationship. These were associated with widely varying temporal relationships between the loss, the stress, and the illness (8 days, five anniversaries over 6 years, 10 years, and 2 1/2 years, respectively). It is postulated that mania supervenes at a time when stress ("distress") is persistent, and the pathological mourning unresolved and unadaptive. The sequence-pathological grief, distress, mania--is viewed in a psychosomatic model and this view supported. The notion of "switch into mania" is also supported, and the importance of diverse theories to the increased understanding of the natural history and prevention of psychiatric illness is underlined.