Prolonged grief disorder: Why some people cannot move on from the death of a loved one

For most people, the intense pain of grief eases over time. For some, however, persistent and painful grief remains, progressing into prolonged grief disorder. A new study on this disease, which affects around 5 percent of bereaved people, sheds light on its progression. This could help doctors predict which recently bereaved people will benefit from additional support.

The decision to include prolonged grief disorder (PGD) in the American Psychiatric Association’s diagnostic manual in 2022 has sparked intense debate over whether it pathologizes a normal human response to loss and imposes an arbitrary timeline on what constitutes “normal” grief. Today, an analysis of the brain activity of people with or without PGD suggests that it is a pathology in its own right.

Richard Bryant of the University of New South Wales in Sydney, Australia, compared brain activity in PGD to that seen in other psychiatric disorders that can follow bereavement, such as post-traumatic stress disorder (PTSD), depression or anxiety. They found that while there is some overlap, people with PGD repeatedly show more pronounced changes in more reward-related brain circuits.

Several studies, for example, have shown that people with PGD show significantly greater activation of the nucleus accumbens, which processes reward and motivation, in response to words and images related to grief, than people who are bereaved but do not have PGD. The strength of this activation was also correlated with the lost people’s stated desire.

Compared to people with PTSD or anxiety, people with PGD also show a bias toward reminders of the deceased. In contrast, people with PTSD or anxiety tend to exhibit neural activity that promotes avoidance behaviors.

Other studies show increased activation in the amygdala and right hippocampus – regions involved in emotion processing and memory – when people with PGD view death-related images, such as a cemetery, compared to those experiencing typical grief. In contrast, these same regions show greater deactivation in response to positive images, such as serene landscapes. This suggests disrupted emotional regulation as well as a diminished ability to experience positive emotions.

In PGD, the brain’s reward system “locks in” to the deceased and fails to find reward elsewhere, Bryant explains, producing an intense desire for the lost loved one. “The main distinction between PGD and normal grief is the time frame – that is, the person is ‘stuck’ in their grief to the point of not coping like most people do,” says Bryant.

Although the exam is comprehensive, there is no simple way that the information can be helpful in diagnosing PGD, says Katherine Shear of Columbia University in New York. This is partly because most grieving people will never be offered a brain ultrasound, but also because grief is so complex and variable that it is difficult to examine with a one-off scan.

Shear says neuroimaging is just beginning to incorporate some of this complexity by doing “two-person neuroscience,” which focuses on brain activity during live interactions, helping us understand how grief is shaped by social context, cultural expectations, and levels of support.

Where the test can be useful is in helping to predict who might experience PGD after a bereavement. In one study, bereaved adults underwent brain scans within a year of their loss and at different times over the next six months. Greater connectivity between the amygdala and regions involved in planning, inhibiting behaviors, and filtering out important information during this initial scan predicted worsening grief symptoms over time, suggesting that such patterns – and the behaviors associated with them – could predict a person’s risk for PGD.

Although we know that there are several psychosocial factors that differentiate which individuals are most likely to suffer from PGD, we cannot reliably identify who is headed there, says Joseph Goveas of the Medical College of Wisconsin. “Early detection would enable rapid interventions, which could range from supportive approaches such as bereavement groups to more specialist care. »

Evidence for specific neurobiological mechanisms also strengthens the case for recognizing PGD as something distinct from other bereavement-related conditions, while also indicating how doctors can tailor treatment.

“Understanding distinct and overlapping neurobiological mechanisms can help reduce diagnostic errors and inappropriate treatments,” says Goveas. “For example, although PGD generally does not respond to antidepressants, it does respond to grief-specific psychotherapies. Conversely, when PGD coexists with major depression, combining antidepressants with PGD-targeted therapy can effectively treat depressive symptoms.”

Need a listening ear? UK Samaritans: 116,123; US 988 Suicide & Crisis Lifeline: 988; telephone helplines in other countries.