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

For most people, intense grief will ease over time. However, some remain with persistent and painful grief that develops into prolonged grief disorder. A new overview of the condition, which affects about 5 percent of drunk people, sheds light on how it develops. This could help clinicians predict which recently bereaved individuals will benefit from additional support.

Decision to include prolonged grief disorder (PGD) in the American Psychiatric Association’s diagnostic manual in 2022 sparked intense debate over whether this was pathologizing the normal human response to loss and imposing an arbitrary timeline on what constitutes “normal” grief. Now, analysis of the brain activity of people with and without PGD suggests that it is a condition in its own right.

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

For example, several studies have found that people with PGD show significantly greater activation of the nucleus accumbensthat processes reward and motivation in response to grief-related words and pictures from people who are bereaved but do not have PGD. The strength of this activation also correlated with his self-reported desire for the lost.

Compared to people with PTSD or anxiety, people with PGD also show bias towards the deceased’s comments. In contrast, people with PTSD or anxiety tend to show neural activity that promotes avoidance behavior.

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

In PGD, the brain’s reward system becomes “locked in” to the deceased and unable to find reward elsewhere, Bryant says, causing an intense longing for the lost loved one. “The key difference between PGD and normal grief is the time frame—that is, the person is ‘stuck’ in their grief so that they don’t adjust the way most people do,” says Bryant.

Although the review is comprehensive, there is no direct way the information can be useful in diagnosing PGD, he says Katherine Shear at Columbia University in New York. This is partly because most grieving people will never be offered a brain scan, but also because grief is so complex and variable that it is difficult to examine with a single scan.

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

Screening can be useful in helping to predict who might experience PGD after drinking alcohol. In one study, adult survivors had brain scans within a year of their loss and at various times over the following six months. Greater connectivity between the amygdala and areas involved in planning, behavioral inhibition, and filtering important information in this initial scan predicted worsening grief symptoms over timesuggesting that such patterns—and the behaviors associated with them—could predict a person’s risk of PGD.

Although we know that there are several psychosocial factors that distinguish individuals who are more likely to have PGD, we cannot reliably determine who is headed for it, he says Joseph Goveas at the Medical College of Wisconsin. “Early detection would allow early intervention, which could range from supportive approaches such as grief groups to more specialized care.”

Evidence of specific neurobiological mechanisms also strengthens the case for recognizing PGD as distinct from other bereavement conditions, while pointing to ways in which clinicians can tailor treatment.

“Understanding both overlapping and distinct neurobiological mechanisms can help reduce misdiagnosis and inappropriate treatment,” says Goveas. “For example, while PGD does not usually respond to antidepressants, it does respond to grief-specific psychotherapy. Conversely, when PGD co-occurs with major depression, combining antidepressants with PGD-targeted therapy can effectively treat depressive symptoms.”

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