After Laura’s husband died suddenly, grief consumed her for several months. She woke up every morning hoping to find that it was all a terrible nightmare. Leaving the house – other than to visit the cemetery – seemed too difficult. Even grocery shopping seemed unbearable, fueling panic and crying.
“I can’t begin to describe the emptiness I feel,” she told her doctor. “I don’t want to see anyone and it’s a daily struggle. Things don’t get any easier.”
As the winter holidays approach, many families like Laura’s will find themselves facing an empty chair at the holiday table. The fear that accompanies it is a normal emotional reaction for the newly bereaved person. But intense, prolonged grief like Laura’s can progress into another territory called prolonged bereavement disorder (PGD).
This condition, which occurs in approximately 7 to 10 percent of bereaved people, involves 12 months or more of debilitating grief. Sufferers feel unhappy and stuck, as if their lives have been derailed. The idea of returning to normal life seems impossible.
Although grief can encompass many types of devastating losses – such as divorce, unemployment, the death of a pet, or a life-changing diagnosis – PGD always focuses on the death of a special person.
“People respond to grief when faced with different types of losses, but they all involve an emotional response to change,” says psychologist Sue Morris, director of bereavement services at the Harvard-affiliated Dana-Farber Cancer Institute. “But the death of a loved one is a universal experience, and there is a tormenting anxiety about how we adapt to that in our lives.”
Cross the line
PGD was classified by the American Psychiatric Association as a mental health disorder only two years ago, when it was added to the list of mental health disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the manual used by American clinicians to define mental health problems. The designation allows the condition to receive health insurance coverage. But it could also prompt clinicians to take the symptoms of extreme grief more seriously, Morris says.
“Although grieving is a normal response to loss, we worry about people who may suffer more,” she says. “There are now diagnostic criteria that can help them access treatment, especially when they need a diagnosis to get insurance coverage.”
Where is the line between normal grief and PGD? The first tends to follow a wave-like pattern: you feel sad, tearful, and deprived. “The waves come very intensely when someone has just died and are characterized by deep sadness or longing,” Morris explains. “Over time, the waves get smaller and farther away from each other. You kind of learn to ride the wave.”
PGD, however, is more common and can cause people to withdraw from daily activities and neglect their health. (See “The Serious Health Effects of Grief.”) Signs include
- feel like a part of you has died
- marked feeling of disbelief in the face of death
- emotional numbness
- denial or immense difficulty accepting the loss
- extreme loneliness
- the feeling that life has no meaning.
“You might be having a good day, then remember something about your loved one and cry. That’s normal,” Morris says. “But when you feel more and more stuck – and you feel like life has no meaning – that’s when grief turns into something that’s not normal.”
The serious effects of bereavement on healthIf you’ve just lost someone you love, going through grief can feel like molasses. You might feel out of breath and lethargic. Your chest may feel tight and heavy, and your stomach may churn. Headaches, dizziness and fatigue can punctuate your days. Indeed, emptiness can strike in a visceral way. Indeed, grief is not just an emotional process: it can produce intense physical effects, even those that put our health at risk, explains a Harvard expert. “People often underestimate the physical impact of grief,” says Sue Morris, director of bereavement services at Dana-Farber Cancer Institute. Emotional triggers are thought to be linked to increased stress hormones and inflammatory chemicals, causing changes in blood flow that can narrow blood vessels, increase blood pressure and heart rate, and promote clotting . Some of the downstream health effects can be perilous. Intense grief can trigger a heart attack, especially in someone who already has risk factors for cardiovascular disease. A study published in JAMA Internal Medicine found that people who had lost a loved one in the past month were twice as likely to suffer a heart attack or stroke as their peers who were not grieving. Another extreme cardiac consequence is takotsubo cardiomyopathy, known colloquially as broken heart syndrome. This condition can feel like a heart attack, causing chest pain and shortness of breath, but does not involve coronary artery blockage. Broken heart syndrome disproportionately affects women and usually goes away within a month. Grieving people may also be less likely to take care of their health or follow advice to eat healthily, exercise and prioritize sleep, Morris says. They may also become socially isolated, increasing a range of health risks. Morris recommends that anyone who has lost a loved one schedule a visit to their primary care physician soon afterward, even just to “check in.” “Taking care of yourself is a fundamental part of coping after someone dies,” she says, “especially if you’ve been a caregiver, which often happens in couples.” |
Risk factors and warning signs
Certain factors increase the likelihood that a person will experience PGD, such as losing a loved one in a traumatic or unexpected way, or losing a child. But women may also be more prone to it. Although the evidence is mixed, some studies show that women’s grief symptoms tend to become more pronounced over time compared to men, whose symptoms are more likely to improve over time.
People who have suffered from anxiety or depression are particularly vulnerable to PGD, problems that can also make PGD worse. “If a person has depression and is grieving, it can be difficult to determine whether they have prolonged grief disorder,” says psychiatrist Dr. Stephanie Collier, director of education in the Division of Psychiatry. Geriatric Medicine at Harvard-affiliated McLean Hospital.
But certain characteristics distinguish them from each other. “With depression, you can’t imagine feeling better again,” she says. “If you’re grieving, you can.”
When is it time to ask for help? If you are having suicidal thoughts, using more substances like alcohol, or feeling hopeless, it is wise to seek professional help. But even without these warning signs, seeking treatment can help you overcome this obstacle.
Treatment of PGD may involve a mixed approach. Psychotherapy, sometimes combined with antidepressants, has been shown to be effective, Morris says, and some programs offer a specialized form of cognitive behavioral therapy (CBT) focused on complicated grief.
CBT aims to help bereaved people adjust to the absence of their loved ones by helping them understand the grieving process and assimilate the reality of what has happened.
“It works with these common types of thoughts like ‘What could I have done differently?’ » or “What if?” But the exposure component – talking about what happened, looking at photos of the person – seems to be the most helpful part,” says Dr. Collier.
Moving forward
Harvard experts offer these additional ways to cope with grief, which may help prevent PGD:
Practice the fundamentals of health. Getting enough sleep, a healthy diet, and regular physical activity can go a long way in reducing stress. Avoid alcohol or other substances, which will not provide lasting relief.
Socialize. Stay in touch with the people you enjoy being with and participate in community activities. “A lot of people will say they just don’t want to do anything,” Morris says. “It takes a lot of effort to get somewhere, but you should gradually reintroduce that into your life.”
Talk about it. Even if you don’t seek therapy, sharing your pain with others can provide much-needed support. Look at photos together and remember. “Some people hide their grief, but they suffer more because they can’t go,” says Dr. Collier.
Seek support. Joining a support group may seem overwhelming at first, but sharing experiences with others who truly understand what you’re going through can be invaluable and help you form new, meaningful relationships. Palliative care programs often hold support groups or reach out to your local Council on Aging.
“Seek support in any form,” says Dr. Collier. “For some people, it might be church; for others, it’s CrossFit.”
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