Beyond bereavement

An upset woman is comforted by two friends.

After Laura's husband died unexpectedly, grief consumed her for many months. She woke up every morning hoping to find it was all a terrible nightmare. Leaving the house — other than to visit the cemetery — felt too hard. Even grocery shopping seemed overwhelming, fueling panic and crying jags.

"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 struggle to get through each day. Things aren't getting any easier."

With the winter holidays approaching, many families like Laura's will be facing an empty chair at the holiday table. The accompanying dread is a normal emotional reaction for the newly bereaved. But intense, extended mourning like Laura's can veer into different territory called prolonged grief disorder (PGD).

The condition, which occurs in an estimated 7% to 10% of bereaved people, involves 12 months or longer of debilitating grief. People with it feel miserable and stuck, like their life is derailed. The notion of returning to normal life seems impossible.

While grief can encompass many devastating types of losses — such as divorce, unemployment, the death of a pet, or a life-changing diagnosis — PGD always centers on the passing of a special someone.

"People have grief reactions to different types of losses, but they all involve an emotional response to change," says psychologist Sue Morris, director of bereavement services at Harvard-affiliated Dana-Farber Cancer Institute. "But the death of a loved one is a universal experience, and there's a tormenting anguish about how we adjust to this in our life."

Crossing 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 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the handbook used by American clinicians to define mental health conditions. The designation allows the condition to qualify for health insurance coverage. But it may also spur clinicians to take symptoms of extreme grief more seriously, Morris says.

"While grief is a normal response to loss, we do worry about people who potentially will suffer more," she says. "Now there are diagnostic criteria that can help them access treatment, especially when they need a diagnosis to get insurance coverage."

Where's the line between normal grief and PGD? The former tends to follow a wave-like pattern: you feel sad, tearful, and bereft. "The waves come very intensely when someone has just died and are characterized by a deep sadness or yearning," Morris says. "Over time, the waves lessen and become farther apart. You're kind of learning how to ride the wave."

PGD is more pervasive, however, and can cause people to withdraw from everyday activities and neglect their health. (See "Grief's serious health effects.") Signs include

feeling as though part of you has died
marked sense of disbelief about the death
emotional numbness
denial or immense difficulty accepting the loss
extreme loneliness
feeling that life is meaningless.

"You could be having an okay day and then remember something about your loved one and cry. That's normal," Morris says. "But when you're increasingly feeling stuck — and you feel life is meaningless — that's when grief ticks over into something that's not normal."

Grief's serious health effects

If you've just lost someone you loved, moving through grief can seem like walking through molasses. You may feel short of breath and lethargic. Your chest can feel tight and heavy, and your stomach may churn. Headaches, dizziness, and fatigue can punctuate your days.

Indeed, the void can hit in a visceral way. That's because grief isn't just an emotional process: it can produce intensely physical effects, even ones that endanger our health, a Harvard expert says.

"People often underestimate the physical impact of grief," says Sue Morris, director of bereavement services at Dana-Farber Cancer Institute.

It's believed that emotional triggers are linked to increases in stress hormones and inflammatory chemicals, prompting blood flow changes that can narrow blood vessels, raise blood pressure and heart rate, and promote clotting.

Some of the downstream health effects can be perilous. Intense grief may trigger a heart attack, particularly 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 peers who weren't grieving.

Another extreme heart-related outcome is takotsubo cardiomyopathy, known colloquially as broken heart syndrome. This condition can mimic a heart attack, producing chest pain and shortness of breath, but doesn't involve a coronary blockage. Broken heart syndrome disproportionately strikes women and typically resolves within a month.

Grieving people may also be less likely to take care of their health or heed advice to eat healthfully, exercise, and prioritize sleep, Morris says. They may also become socially isolated, which is known to increase an array of health risks.

Morris recommends that anyone who has lost a close loved one schedule a visit with her primary care doctor shortly after, even just to "check in."

"Self-care is a fundamental part of adjusting after someone has died," she says, "especially if you've been a caregiver, which often happens in couples."

Risk factors and red flags

Certain factors increase the likelihood that someone will experience PGD, such as losing a loved one in a traumatic or unexpected way, or losing a child. But women may be more prone as well. While evidence is mixed, some studies show that women's grief symptoms tend to build over time compared to men's, whose symptoms are more likely to ease as months pass.

Especially vulnerable to PGD are people who've coped with anxiety or depression—issues that can also worsen PGD. "If a person has depression and they're grieving, it can be tricky to tease out if they have prolonged grief disorder," says psychiatrist Dr. Stephanie Collier, director of education in the Division of Geriatric Psychiatry at Harvard-affiliated McLean Hospital.

But certain characteristics distinguish one from the other. "With depression, you can't imagine feeling better again," she says. "If you're grieving, you can."

When is it time to seek help? If you're having suicidal thoughts, using more substances such as alcohol, or feeling hopeless, it's wise to see a professional. But even without such red flags, seeking treatment can help you get over the hump.

Treating PGD may involve a blended approach. Psychotherapy, sometimes combined with antidepressants, has proven effective, Morris says, and some programs offer a specialized form of cognitive behavioral therapy (CBT) focusing on complicated grief.

CBT aims to help bereaved people adapt to the absence of their loved ones by helping them understand the grief process and process the reality of what happened.

"It works with those common types of thoughts like 'What could I have done differently?' or 'What if?' But the exposure component — talking about what happened, looking at pictures of the person — seems to be the most helpful part," Dr. Collier says.

Moving forward

Harvard experts offer these additional ways to cope with grief, which may help prevent PGD:

Practice health fundamentals. Sufficient sleep, healthy foods, and regular exercise can go a long way toward easing stress. Skip alcohol or other substances, which won't provide lasting relief.

Socialize. Stay connected with people you enjoy being around, and join in community activities. "Many people will say they just don't feel like doing anything," Morris says. "It takes a lot of effort to go somewhere, but you should gradually introduce that back into your life."

Talk about it. Even if you don't seek therapy, sharing your pain with others can bring much-needed support. Look at photos together and reminisce. "Some people hide their grief away, but they suffer more because they're not able to go there," Dr. Collier says.

Seek support. Joining a support group might seem overwhelming at first, but sharing experiences with others who truly understand what you're going through can be invaluable and help you form meaningful new relationships. Hospice programs often run support groups, or ask your local Council on Aging.

"Seek support in whatever form it takes," Dr. Collier says. "For some people, that might be church; for others, it's CrossFit."