The Widowhood Effect: Explaining the Adverse Outcomes After Spousal Loss Using Physiological Stress Theories,Marital Quality,and Attachment

Abstract

The loss of a loved one is one of the most ubiquitous life experiences. There have been multiple reviews that have found adverse health outcomes for individuals experiencing spousal loss, particularly the widowhood effect that characterizes an increased risk of mortality after loss. However, there is a lack of clarity on the relationship between physiological stress and the widowhood effect. This commentary uses the literature on stress, marital quality, and attachment to explain the widowhood effect and other adverse physical health outcomes. We discuss three points: (1) the chronic nature of stress may be the source of adverse outcomes, (2) the quality and quantity of available resources may moderate the effects of stress, and (3) the level and style of attachment may explain why these outcomes may persist many years after spousal loss.

Keywords

bereavement grief mourning stress attachment widowhood

The loss of a parent, partner, or child is one of the most ubiquitous experiences in life. Every person encounters some form of bereavement, grief, or mourning. But investigating such experiences is a challenging process. Berkum (2009) conceptualized grief work as the “process of confronting loss, going over events and emotions to do with the deceased and the death, focusing on memories and working toward detachment from the deceased” (p. 10). This definition exemplifies how individualized the experience of grief is, contributing to the challenge in conceptualizing its dimensions and determinants.

Spousal loss can be a traumatic experience. There has been a tremendous effort by researchers to look at the factors, associations, and mechanisms of bereavement that may affect health and well-being. A recent systematic review, for example, summarized the physical and physiological outcomes associated with spousal loss (Ennis & Majid, 2019). The majority of articles included in this review found a widowhood effect, an increased risk of mortality that characterizes spousal loss. An increased risk of mortality was also associated with adverse outcomes such as higher blood pressure, heart rate, dysregulated cortisol, prothrombotic changes, and cholesterol levels. This review also added to the literature by clarifying how socioeconomic status, remarriage, time, gender differences, and health care utilization and access patterns influence or are influenced by the onset of widowhood across demographic characteristics. For example, remarriage after widowhood decreased the risk of adverse outcomes after spousal loss, whereas the lack of social support increased risk. Two other reviews have found strong correlations between widowhood and cardiac symptoms and disorders (Buckley et al., 2010, 2011).

Bereavement and spousal loss can be distressing events. Drawing from theories of stress, the loss of a loved one, especially if there is strong affection between the two individuals, can cause an intense physiological stress response that may confer adverse consequences on the physical and mental health of the surviving individual. On the other hand, there is a myriad of research on the clinical outcomes of “high-stress populations,” groups of people characterized by patterns of a chronic physiological stress response. Research on survivors of the Holocaust, for example, has shown that adverse outcomes associated with trauma can have intergenerational effects. In a genetic study, Yehuda et al., 2016 found that psychological trauma experienced by survivors of the Holocaust had similar effects in offspring through alterations in their genomic makeup. In another study on how trauma may affect the health of children of Holocaust survivors, Isserman et al. (2017) found that although trauma exists in the young children, it disappears during late teenage years and then reappears and increases with age.

Emergency service workers such as the law enforcement, paramedics, and firefighters are other examples of high-stress populations. Although these populations do not experience trauma themselves, they are continuously exposed to an elevated level of traumatizing experiences that increase their risk of psychopathologies (Armstrong et al., 2016). For example, Carpenter and associates (2015) found that at low levels of social support, there was a positive association between job stress and suicidal ideation in firefighters. For law enforcement officers, symptoms of job stress include cardiovascular disease, chronic alcoholism, intimate partner violence, and depression (Burke et al., 2007). Burke et al. (2007) emphasized that the constant vigilance needed by emergency support workers contributes to chronic stress, which ultimately creates conditions that confer adverse outcomes on psychological and physical health.

These findings are interesting because of their possible implications for other populations that do not experience traumatic events persistently but experience a one-time event that may cause an intense physiological response such as spousal loss. However, it is unclear how the literature on high-stress populations can improve our understanding of the physical, physiological, and psychological outcomes associated with spousal bereavement. The objective of this commentary is to use the language from the stress literature, and research on high-stress populations, to better understand the outcomes individuals experience during bereavement. In this commentary, we will discuss some of the most applicable theories of stress and attachment and how they can clarify the mechanisms between the experience of spousal and the physical and physiological outcomes found in the literature.

Theories of Stress and Attachment

In this section, we provide brief descriptions of four theories: cognitive activation theory of stress (CATS), identity theory and stress, conservation of resources (COR) theory, and attachment theory. Since we were interested in explaining why there are adverse outcomes associated with bereavement from the lens of physiological stress and attachment theory, we sought to find theories, models, or frameworks that facilitated this analysis. We were not interested in looking at the relationship between cognitive or psychological stress and bereavement since multiple reviews and models have been developed already on this topic (e.g., Schut, 1999). We understand the interconnected nature between cognitive and physiological stress, but we perceived that their distinction would better support the objectives of this report.

CATS

The CATS postulates four components of physiological stress: stress stimulus, stress experience, nonspecific general response, and the experience of stress response (Ursin & Eriksen, 2004). The stress response, in particular, is conceptualized as a “general alarm in a homeostatic system” that increases the level of neurophysiological arousal. This alarm results from a discrepancy between what should be and what is, for example, the loss of a loved one that should be with them but is not anymore. Ursin and Eriksen (2004) emphasize that the unpleasantness of response does not contribute to adverse outcomes, but whether or not the unpleasantness is sustained for long periods of time, increases the risk of illness and disease.

Identity Theory and Stress

Identities are how individuals conceptualize themselves in terms of societal roles and expectations (Thoits, 1991). Identity theory identifies two types of experiences: ones that threaten or enhance the identity of individuals (identity-relevant experiences) and those that minimally affect individuals’ identities (identity-irrelevant experiences). Based on this distinction, an individual will likely experience more adverse outcomes from a particular event if it is aligned with their most essential values, principles, and expectations. As such, the loss of a spouse may be distressing if it is an identity-relevant experience for the surviving spouse.

COR Theory

The main hypothesis of the COR theory is that the stress response is triggered by a loss in resources (Hobfoll, 2001). In this way, the deceased spouse can be conceptualized as a loss of resource, which triggers a stress response that can cause adverse outcomes. This theory also suggests that other resources, for example, family support, can compensate or buffer for resource loss. If the stress response from loss of a resource is not addressed adequately, then more resources will be needed; otherwise, the individual may be at risk for what is termed “rapid and impactful loss spirals” (Hobfoll, 2001).

Attachment Theory

The link between relationship closeness and mourning or grief is a central theme in attachment theory (Carr et al., 2000). Attachment theory is conceptualized on the premise that difficulty in forming relationships in early childhood may influence the individual’s ability to form and sustain relationships later in life (Berkum, 2009; Bowlby, 1969, 1973, 1980; Bretherton, 1992; Sroufe et al., 1999). There are two forms of insecure attachment: anxious (i.e., the degree to which spouse worries that their partner will not be available when needed) and avoidant (i.e., the degree to which spouse distrusts their partners’ attitudes, values, and behaviors; Berkum, 2009).

Integrated Findings

In this section, we discuss how the relationship between physiological stress and adverse outcomes after spousal loss can be explained by attachment and marital quality. We first find that the chronic nature of a physiological stress response is the likely cause of adverse outcomes after bereavement. We also propose that the resources available to individuals facing traumatic experiences such as spousal loss can moderate the extent to which a physiological stress response leads to adverse outcomes. In the last section, we attempt to draw a parallel between physiological stress and adverse outcomes using attachment theory and marital quality. Figure 1 illustrates the relationship between the factors discussed in this section and stress.

Figure 1.

Factors that encourage or compensate for the adverse outcomes associated with chronic stress after spousal loss.

Acute Versus Chronic Stress

Theories of stress propose that traumatic events are only distressing to individuals when they cause a chronic stress response. The assumption is that even though individuals may experience a short-term, acute stress response, adverse physical and physiological outcomes may only be associated with chronic stress. However, it is unclear which factors may cause an acute versus chronic stress response after spousal loss. Shear and Shair (2005) suggest that all grief is acute in nature that can become prolonged and complicated if the surviving spouse does not incorporate the death of spouse in their internal representations of reality. Prolonged grief disorder is a psychiatric illness identified in the DSM-5 (Prigerson et al., 2009), which has been associated with multiple adverse outcomes such as suicidality, depression, and anxiety (Boelen & Prigerson, 2007; Boelen et al., 2010; Latham & Prigerson, 2004).

Using the theories of stress, particularly identity theory and COR theory, we hypothesize that the loss of a spouse, at least initially, will become chronically distressing unless there are factors in the individuals’ life that can maintain acuity. The difference between whether spousal loss causes an acute or chronic stress response depends on not only the characteristics of the loss but more importantly on the extent to which it is an identity-relevant experience and whether or not it can be buffered by other aspects of life (i.e., resources) effectively. If spousal loss is identity-relevant to an individual, then it will affect a wider range of values, beliefs, and priorities and, as such, require a prolonged, cognitive engagement in thinking about the loss and its consequences on daily life. This process will also require more resources to buffer the adverse effects of the loss, for example, social support or remarriage can ameliorate adverse outcomes of spousal loss by addressing the resource gap caused by it (Berntsen & Kravdal, 2012).

The buffers that are available to an individual need to have strong influence on their attitudes and behaviors, as well as meet the cognitive demands of a large discrepancy between what is (i.e., “my spouse is not here anymore”) and what should be (i.e., “my spouse should be here”). In the meaning in life literature, this discrepancy is epitomized by the distinction between global and situational meaning. On the one hand, global meaning refers to how individuals generally view situations in life, whereas situational meaning refers to how individuals associate meaning to specific situations (Park, 2013). Global meaning stays relatively constant throughout life; however, a traumatic event such as spousal loss can cause an individual to focus on a situational meaning that is very different from their global meaning, motivating them to modify their global meaning to align with what they experienced (Park, 2010). This discrepancy is hypothesized to be one of the causes of distress that initiates the meaning-seeking process in order to resolve the discrepancy and reduce distress (Majid & Ennis, 2018). However, depending on the resources and buffers available to individuals, the meaning-seeking process can either lead to positive or negative adjustment to the traumatic event (Majid & Ennis, 2018). The wider the discrepancy between global and situational meaning, the more identity-relevant the traumatic event will be, and accordingly, the more resources and buffers will be required to ameliorate the adverse health outcomes of spousal loss. The width of the discrepancy will also depend on the extent to which spousal loss effects the strength of individuals’ resources for navigating through traumatic life experiences.

The wider the discrepancy, the higher likelihood that individuals will experience positive outcomes in the long-term. Also known as the antithesis of post-traumatic stress disorder, post-traumatic growth occurs when individuals grow positively after experiencing and engaging in thinking about a distressing event (Hefferon et al., 2009). Research has shown that individuals who experience traumatic events tend to become stronger, both physically and psychologically, than before the event (Tedeschi & Calhoun, 2004). The wider the discrepancy, the greater the intensity of meaning-seeking and the higher the likelihood that these positive effects will be realized. Individuals who resolve their discrepancy, irrespective of the width, tend to perform better in future traumatic events (Majid & Ennis, 2018). The implication of this finding is that although a narrower discrepancy may appear to be advantageous initially, it decreases the likelihood that an individual will positively improve from experiencing spousal loss. Therefore, although wider discrepancies may lead to more adverse outcomes in the short-term, they may also lead to improved health and well-being in the long-term, which may ultimately extend life expectancy. This example shows how the psychological location of individuals intersects with physical health and longevity.

It is simpler to think of how resources as a whole contribute to the stress response after spousal loss. However, these resources may be conflicting or unavailable, requiring individuals to engage in a resource prioritization process to ensure that the resources available to them are adequate in addressing their cognitive needs. This resource prioritization process can be distressing itself in nature if multiple “major” resources (i.e., resources that span almost all facets of life) are inadequate or unavailable. It may also be distressing if major resources are intricately connected to one another; spousal loss may affect multiple major resources that play a role in adjusting to the experience (i.e., income, family support, etc.). For example, some research has found that the loss of a spouse can change the social dynamic of widowers when the driver of social engagement was the deceased spouse (Bennett, 1998; Van Grootheest et al., 1999). Similarly, in one study, compared to females, males reported greater benefit from marriage with regard to restraining from unhealthy behaviors (Umberson et al., 1992). Similarly, males report greater benefit from marriage compared to females; for example, reduction in unhealthy behaviors (Umberson et al., 1992). This interconnected nature of resources may also help to explain why some individuals may experience more adverse outcomes after spousal loss than others with similar demographic and health profiles. Therefore, it is important to consider how resources as a whole can act as buffers, and how the loss of a particular resource can affect the buffering capacity of other resources when spousal loss initiates a complex stress response that affects a wide range of life activities and resources.

Attachment and Marital Quality

The assumption in the previous discussion has been that the loss of a loved one inevitably causes adverse physical and physiological outcomes. However, this causal relationship does not have to be present in every relationship; we conjecture based on the extant literature that the degree to which adverse outcomes are present after spousal loss depends on the level and style of attachment and marital quality.

Attachment theory centers on the idea that challenges earlier in life will lead to challenges later in life (Berkum, 2009). This idea is particularly evident in our previous discussion of high-stress populations where we found research that explained trauma that can span throughout life (Isserman et al., 2017). There is also evidence of how trauma in previous generations can lead to adverse outcomes in future generations (Yehuda et al., 2016). This intergenerational trauma can be applied to the context of widowhood, where spousal loss can cause certain changes to the genomic makeup of individuals that makes them more at-risk for dying from a broken heart. This means that individuals who experience more adverse physical and physiological outcomes after spousal loss may already be more prone to these outcomes because of their unique genetic makeup.

Previous research has found that social support plays an important role in achieving resilience when experiencing traumatic events (Bennett, 2010). Without adequate social support, traumatic events such as spousal loss can intensify underlying issues or histories of trauma that may otherwise be hidden. In spousal bereavement, the effects of chronic stress on health may be modulated by the type of attachment between the surviving and deceased spouse (Shear & Shair, 2005). It may also be a result of the relationship quality between spouses (Troxel et al., 2005). Some research has found that higher marital quality defined by increased feelings of mutual affection and support is associated with higher severity of physiological and physical outcomes experienced after spousal loss (Carr et al., 2000). Other research suggests that depending on the attachment style, bereaved individuals either work toward retaining or loosening ties with the deceased spouse (Stroebe et al., 2005). These observations present a similar situation as discussed previously regarding the outcomes of wider versus narrower discrepancy between what is and what should be. High marital quality may present opportunities throughout life to improve health and well-being because of characteristics inherent to the relationship that may not be possible otherwise (Horwitz et al., 1996; Kiecolt-Glaser & Wilson, 2017). But, upon the loss of spouse, high marital quality may actually cause a wider discrepancy because it is more interconnected with resources and life activities, increasing the likelihood of adverse outcomes. The implication of this observation is that having lower marital quality may not cause the adverse outcomes associated with spousal loss. Moreover, it may be the case that the marriage experience is a source of chronic stress itself whereby spousal loss may cause positive improvements in health and well-being.

We know from the previous section that identity-relevant experiences tend to cause the most distress and change in life. Based on this understanding, identity-irrelevant experiences may be considered more benign. However, we hypothesize that with regard to marital quality, identity-irrelevant experiences may improve the health and well-being of individuals. If spousal loss is an identity-irrelevant experience, it may remove a strong stressor in life, which may contribute to improved health. The removal of a source of stress can also act as a buffer that maintains the acuity of a chronically distressing response and reduce the adverse outcomes of spousal bereavement. The removal of stress can also be further explained by the type of attachment style that characterized the relationship.

Based on attachment theory, both types of avoidant and anxious attachment can cause a physiological stress response. Moreover, since these attachment styles are characteristic of the overall relationship between two individuals, the physiological stress response that results will be chronic. Since the anxious style is influenced by perceptions of unavailability of their spouse, the response is marked by depression, longing, rumination, and sadness. Abel and Kruger (2009) hypothesized that the loss of a spouse triggers surviving spouses to seek protection and security from others. Since their spouse is no longer available to provide the needed protection, the surviving spouse may experience emotions characterized by depression, which could help to explain the adverse outcomes since depression alters multiple biological systems simultaneously (Hughes et al., 2016; Jaremka et al., 2013). On the other hand, the loss of a spouse who contributed to a relationship that was characterized by an avoidant attachment style may cause the surviving spouse to experience emotions akin to anger and frustration. The surviving spouse may feel spite toward their deceased spouse due to the distrust that has represented their relationship.

Conclusions

In this commentary, we attempted to use the literature on stress and attachment to explain why adverse outcomes exist after spousal loss. We discussed three arguments: (1) the chronic nature of stress is the source of adverse outcomes, (2) the quality and quantity of available resources moderates the effect of chronic stress, and (3) the level and style of attachment and marital quality can explain why these adverse outcomes may continue to exist after spousal loss.

Future research in this area should continue to identify which adverse outcomes occur after spousal loss and, in particular, outcomes related to the demographic characteristics of relationships between the deceased and surviving spouses. Moreover, although this report deliberately separated cognitive and physiological stress, there is an inextricable relationship between the two concepts. Future work in this area should consider how both cognitive and physiological dimensions can create opportunities for adverse outcomes to manifest after bereavement.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: UM receives financial support from the Canadian Institutes of Health Research and the Government of Ontario, Canada. Neither party was involved in the design and conduct of this research.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Umair Majid

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