What is Grief Reaction and Prolonged Grief Disorder?
Grief, which is a natural response when someone loses a loved one, is not just a single event but a process. Most people properly move on within a year after the loss. However, for some people, the grieving process may last longer. This condition, called prolonged grief disorder, occurs when a person fails to move on from the acute stage of grief to the integrated stage. Acute grief can be signaled by sadness, crying a lot, and in some cases, trouble sleeping, but it usually doesn’t need treatment. Prolonged grief disorder, however, involves feelings of intense distress and difficulty adjusting to the loss, which continues for more than a year in adults and more than 6 months in young people. As many as 7% of people who have lost someone they care about are affected by this condition.
It’s helpful to clarify the meanings of a few terms related to losing a loved one:
- Grief is the emotional response a person exhibits when they lose someone.
- Mourning refers to the visible signs of grief, including the rituals and customs practiced after someone’s death, and the process of adjusting to life without that person.
- Bereavement is the period of grief and mourning following a loss.
- Anticipatory grief occurs in response to an expected loss and can affect both a person diagnosed with a terminal illness and their family.
Disenfranchised grief is a term coined by Kenneth Doka in 1989. It describes the grief someone experiences when they endure a loss that is not openly recognized, mourned in public, or supported socially. The loss of a pet, a perinatal loss (loss of a baby during pregnancy), or the loss of a body part are examples of this type of grief. Healthcare workers can also experience this type of grief, particularly when they lose a patient.
It’s crucial to mention that intense grief can cause physical problems too. For instance, it might cause a heart attack, especially in those who already have an increased risk of heart problems. There is also a link between complicated grief and acute coronary syndrome, a range of conditions resulting in a lack of blood flow to the heart. Another heart issue triggered by intense grief is Takotsubo cardiomyopathy, commonly known as broken heart syndrome or stress cardiomyopathy. This syndrome is a temporary weakening of the heart muscle, which produces a distinctive shape that resembles a Japanese octopus trap known as a “takotsubo”. It’s typically brought on by intense emotional or physical stress, such as losing a loved one or surviving a severe accident or natural disaster. Nine out of ten times, this condition affects women, especially those who are postmenopausal, and it generally lasts only a month.
What Causes Grief Reaction and Prolonged Grief Disorder?
Grief is a natural response to loss, but in some situations, it can last longer than usual. Certain experiences or circumstances can cause prolonged grief.
Difficult experiences, such as the loss of a spouse or child, losing a parent during childhood or teenage years, sudden and unexpected deaths, or those linked with traumatic events, can all contribute to long-term grief. The same applies to situations where multiple deaths occur, especially during disasters, or deaths due to murder.
People who may be more vulnerable to prolonged grief include those with low self-esteem or trust issues, individuals with a history of mental health problems, or people who have previously expressed suicidal thoughts or actions. Other factors that can extend the grieving period are if the person who passed away was very young, or if the bereaved person had a complicated relationship with the deceased, depended too much on them, or felt insecure in their relationship. Lack of social support can also lengthen the grieving process, as can a history of fear or inadequacy in relationships stemming from childhood experiences.
Risk Factors and Frequency for Grief Reaction and Prolonged Grief Disorder
When it comes to prolonged grief, different studies have different findings on gender differences. Some studies don’t show much difference between the genders. However, others show that men tend to display greater levels of distress initially, which decrease over time. Women, on the other hand, often experience an increase in symptoms over time. Some studies have even suggested that being female and having poor social support could increase the risk of prolonged grief. However, these results can vary greatly based on individual and cultural factors.
Grief can look different depending on the age of the person experiencing it. Especially for children and teens, the way they grieve is closely linked to their stage of development. Recognizing prolonged grief in children can be difficult due to their varying abilities to express what they’re feeling and needing. If a child loses someone they’re very close to, such as a primary caregiver, it can be expected that their grief and distress will be more intense. Grieving children might show developmental delays or anger due to not having their needs met. They often depend heavily on adults and their social support network to help them get through the grieving process. Certain types of distress can be commonly seen in children after a loss, such as distress related to separation and struggles with their sense of identity or existence.
If the loss was due to a traumatic event, children can experience repeated traumatic images or complex emotions, from self-blame to fear or even desires for revenge. Adults often try to protect children by not giving them too much information about the death. This can, however, limit children’s ability to process the loss as they may not have a clear understanding of what has happened. How a child understands loss and death depends on their stage of development and their capacity to understand abstract concepts. To effectively support a child’s grief, it is recommended to consult with a professional who has been trained in how developmental stages influence the grieving process.
Signs and Symptoms of Grief Reaction and Prolonged Grief Disorder
During a medical evaluation, it’s important to provide patients with a comfortable environment where they can talk about their grief. Some patients might be hesitant to discuss their grief and could benefit from encouragement or a direct question. They might not always realize that their grief is causing physical symptoms.
Grief reactions, or the responses to loss, can vary greatly among individuals and even change over time within the same person. These reactions can lead to a mix of physical and psychological symptoms.
- Feelings: A person going through loss might feel shock, numbness, sadness, denial, anger, guilt, helplessness, depression, and longing. Unprompted crying can occur.
- Thoughts: Grief can lead to disbelief, confusion, difficulty focusing, obsession, and even hallucinations.
- Physical sensations: Common physical symptoms of grief include tightness and heaviness in the chest or throat, nausea, dizziness, headaches, numbness, muscle weakness, stomach issues, tension, and fatigue.
- Behaviors: Changes in behavior can occur, such as difficulty sleeping, loss of interest in daily activities, and increased aggression or irritability.
- Somatic symptoms: Some might experience chest tightness and choking, shortness of breath, abdominal discomfort, decreased muscle strength, and lethargy.
- Psychological symptoms: On the psychological side, people might experience feelings of guilt and anger, hostility, restlessness, difficulty concentrating, and trouble starting and maintaining activities.
- Takosubo cardiomyopathy: In some severe stress cases, such as with intense grief, a person might experience chest pain and shortness of breath, abnormal electrocardiogram readings that mimic a heart attack (but no blocked arteries), movement abnormalities in the left ventricle of the heart, and ballooning of the left ventricle.
Testing for Grief Reaction and Prolonged Grief Disorder
Prolonged grief disorder is a condition defined by authoritative sources like the DSM-5 and ICD-11. This disorder is typically characterized by an intense and persistent sense of grief following the death of someone close to you at least a year ago (or 6 months ago in the case of children and teenagers). The grief often includes a strong longing for the deceased or a fixation on memories of them. Other symptoms may include a disrupted sense of self, disbelief about the death, avoiding reminders of the deceased, severe emotional pain, struggles with reintegrating into everyday activities or relationships, inability to feel happiness, and emotional numbness.
This intense grieving can significantly interfere with social interactions, education, work, or other important aspects of life. The patient’s symptoms exceed what is considered normal grieving in their culture or religion and can’t be attributed to the use of substances or another mental disorder.
To identify this disorder, doctors use screening questionnaires such as the Brief Grief Questionnaire (BGQ) and the Inventory of Complicated Grief (ICG). Some tools, like the Family Adaptability and Cohesion Evaluation Scale (FACES III) and the Brief Symptom Inventory (BSI), were designed to predict complicated grief in spouses of cancer patients. These scales evaluate family and psychological functioning and the reaction to grief.
The grief evaluation measure (GEM) can also help detect complicated grief symptoms in mourning adults. It takes into account numerous factors including the individual’s personal and medical history, financial status before and after the loss, and circumstances of the death. This tool offers detailed insight into the person’s subjective experiences and symptoms of grief.
Treatment Options for Grief Reaction and Prolonged Grief Disorder
When people lose a loved one, they typically adapt and begin to heal after 6 months to a year. This is considered as normal grief.
If someone continues to struggle with their grief beyond this time, their condition may be referred to as complicated grief. Complicated grief is best treated through therapy that focuses on helping the person adapt to their loss. This can involve techniques to slowly accept the loss and restore a sense of purpose and satisfaction in life without the loved one. Furthermore, people experiencing complicated grief may find medications helpful in managing depression related to their loss.
Furthermore, those suffering from a heart condition called Takosubo cardiomyopathy (a temporary heart condition triggered by severe stress) should consult a cardiologist. The treatment for this heart condition is typically supportive and focuses on relieving physical and emotional stress. However, in severe cases where the patient may be in shock or experiencing heart failure, they may need more intensive medical treatment.
Lastly, it is important for healthcare providers to check on the bereaved to ensure they have, or they can develop the skills or resources they need after their loss, especially on practical matters like driving, cooking, or managing finances. These tasks might have been managed by the deceased loved one and could pose a challenge now.
What else can Grief Reaction and Prolonged Grief Disorder be?
It’s important to distinguish complicated grief from major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). This can be done based on the specific symptoms of complicated grief, which include:
- Longing and sadness
- Obsessive thoughts about the deceased
- Difficulty accepting the reality of their death
These distinct features help doctors tell it apart from conditions like MDD and PTSD.
What to expect with Grief Reaction and Prolonged Grief Disorder
Your progress will depend on how you adjust to your new situation. This adjustment largely depends on your capacity to bounce back, the support you receive from those around you, and any mental health help you may be getting.
Possible Complications When Diagnosed with Grief Reaction and Prolonged Grief Disorder
Physical complications like a weakened immune system, heightened adrenal gland activity, and an increased risk of heart disease-related death (particularly in older, widowed people) may arise.
List of Physical Complications:
- Weakened immune system
- Heightened adrenal gland activity
- Risk increased of heart disease-related death, especially in older and widowed individuals
On the other hand, nonspecific psychiatric disorders could include depression (which may or may not come with a risk of suicide), anxiety, panic disorders, other varied psychiatric disorders, and Post Traumatic Stress Disorder (PTSD).
List of Possible Psychiatric Disorders:
- Depression (with or without risk of suicide)
- Anxiety
- Panic disorders
- Other various psychiatric disorders
- Post Traumatic Stress Disorder (PTSD)
Preventing Grief Reaction and Prolonged Grief Disorder
When sharing difficult news, it’s necessary to keep some important factors in mind. You and your doctor should be in a comfortable place with supportive people around you. Trust and respect between you and your doctor are essential. The doctor should share the information in a way that’s easy for you to understand and at a pace that suits you. They need to know what you and your family already know about the situation.
Your doctor should encourage you to ask questions and make sure you’re fully grasping the difficult news. It’s normal to need time to take in and understand negative news. Your doctor should reassure you that any reactions you have are normal. They should also make sure you and your family get time to respond emotionally. Your doctor should stay with you until you’re ready to leave and continue to provide opportunities for asking questions or getting further info or support.
When it comes to end-of-life care, it’s critical to prepare mentally, especially for loved ones of terminally ill patients. Being ready for the end of life and coping with losing a loved one are key factors in dealing with intense grief.
