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Grief is a “place none of us knows until we reach it,” writes Joan Didion in A Year of Magical Thinking, her 2005 memoir about grieving the sudden loss of her husband of 40 years, John Gregory Dunne. Didion refuses to give away her husband’s shoes, because, she thinks, “he might need them again.” She cannot help but think his death will somehow be reversed. Didion finds her grief profoundly isolating: She’s afraid people will think she’s dwelling on it.
Grief is deeply disorienting for most of us. But for some, it can become a trap. In the early 2000s, researchers coined the term “prolonged grief disorder” to describe this kind of grief, which imprisons people in their distress. It was a controversial diagnosis. Some argued that to call grief a disorder was to pathologize a normal if profoundly painful part of human experience.
In the meantime, scientists have begun to discover what prolonged grief does to the brain. A team of researchers from Australia recently reviewed the neurological literature to see what kind of consensus has emerged in the short time the disorder has been studied. What they found is that prolonged grief disorder has a distinct neurological signature associated with reward and addiction.
I spoke with Richard Bryant, a psychologist at the University of New South Wales in Australia, who co-authored that review. Bryant has studied trauma for 30 years and played a role in getting prolonged grief disorder recognized by the World Health Organization in 2018. We talked about what love addiction has to do with disordered grief, why some communities in India don’t seem to experience prolonged grief, and why traditional treatments for depression and addiction don’t work for grief.
What is the current definition of prolonged grief disorder?
It’s not that different from normal acute grief that we all experience when we lose a loved one. It’s intense emotional pain. Often, one has a sense of a loss of the meaning of life, a feeling that one has lost a part of oneself. But in normal grief, the pain starts to ease six to 12 months later. With prolonged grief, it just goes on and on. For about five to seven percent of people, the intense pain doesn’t go away.
How do you measure intense pain? At what point do the scales tip a person’s pain into the clinically disordered category?
Most days of the week, they’re constantly thinking about the deceased. In severe cases, they’re making dinner for the deceased every night, refusing to change anything in the home, going through rituals that minimize the reality that the person is gone. There are all these signs that the person simply cannot accept it and have a life.
In your review, you found that researchers have identified specific changes in the brains of people with prolonged grief disorder. Can you explain what you found?
There aren’t that many studies out there, so it’s hard to draw firm conclusions, but we did find two things. One, there’s a lot of commonality between how the brain’s functioning in prolonged grief and in PTSD, depression, and anxiety. That’s not surprising, because we see commonalities in terms of how people function in all of these mental disorders. They tend to have poor emotion regulation, to ruminate, so we’d expect to see these things reflected in brain processes.
But we also found an important difference. PTSD and anxiety are characterized by avoidance, whereas prolonged grief tends to be far more focused on approach. The person is seeking out the deceased, they want to be reunited. From a brain point of view, there’s craving involved, much like in alcoholism. In brain imaging studies, we find that the reward-processing functions—areas in the striatum like the nucleus accumbens, the orbital frontal cortex—tend to be more disturbed in people with prolonged grief than in other disorders.
Does prolonged grief disorder tell us anything about the nature of love? The New York Times magazine just published a piece this week about a surge of people calling themselves love addicts on dating apps and on social media. The author is skeptical. Popular psychology has long been obsessed with this idea of co-dependency, how certain kinds of attachment aren’t healthy. And the Stoic and Buddhist traditions have argued that the wisest love is one that isn’t undone by loss. On the other hand, love has been described for centuries by poets and musicians and some philosophers as a naturally addictive thing.
I didn’t read that New York Times piece, but I think the so-called love addict is what we would see as the sitting duck for developing prolonged grief. The sort of person who’s emotionally dependent, who becomes very deeply attached to people, they’ve got these poorly regulated emotional needs. And statistically, if you look at all the studies that have been done, the biggest risk factor for developing prolonged grief is what we’d call an “enmeshed” emotional attachment, where someone says, “Oh, that person is everything to me.” That sounds nice on a Hallmark card, but in reality, if one person is everything to me and then they die, what do I have left? One needs other emotional resources in one’s life. So that’s a very big risk factor. These people aren’t necessarily going to develop prolonged grief, but they’re more likely to.
You’ve studied trauma responses all over the world, including among indigenous groups in Australia. As far as you can tell, is prolonged grief disorder primarily a Western phenomenon, or does it exist in other cultures as well?
We don’t know the answer to that question. People have done studies all over the world and said it’s actually quite ubiquitous. But we’re doing a study in a part of India at the moment, and we’re discovering it’s very hard to find. At the same time, we’re observing quite elevated rates, for example, in places like Ukraine at the moment. We haven’t worked in Gaza yet, but I’m suspecting we’re going to find elevated rates there. We certainly found elevated rates after the Syrian war. But in some lower-middle income countries, there’s a hierarchy of needs. If I don’t have enough food to eat, or too many medical complaints, I don’t prioritize my mental health or even recognize my mental health. So in India, for example, it’s possible that grief is a luxury they can’t afford.
Read more: “Why I Couldn’t Get Over My Brother’s Death”
Wouldn’t the same be true of people in a war zone, such as Ukraine or Gaza, where presumably just staying alive would take priority?
Indeed. To be honest, we’re stumped about the low rates in India. It’s probably a cultural phenomenon that has more to do with how one asks about mental conditions and psychological states. We also see very low rates of PTSD in India.
Is it possible that in the West we also have a culture that’s less equipped to cope with and process death and mortality? Fewer rituals?
That’s one explanation that’s been given. There’s probably a multifactorial explanation. I don’t think there’s any one thing.
You mentioned that there seem to be high rates of prolonged grief in war zones. Is this because these are places where people are already on high alert, their lives upended, or because of how the loved ones die?
The type of death, and the amount of death, are big factors. I’ve worked in environments where people are going to funerals literally every two weeks. If it’s a suicide, or a homicide, or the death of a child, the rates of prolonged grief disorder are very high. If the death is traumatic, the survivors are more likely to develop prolonged grief.
What kind of therapy works for prolonged grief?
What has been shown to work is outpatient grief-focused cognitive therapy that goes for about 12 to 14 sessions. The first half is about emotionally processing the loss. A lot of people avoid it. So they need to talk with the therapist about the death, which does mean getting upset. They work on processing the loss, the cause of the loss, their reactions to the loss. Sometimes there’s guilt if it was a suicide, or anger over how the loved one looked after their own health—emotions that often don’t help the person cope with the death.
The second half is very much about restorative work, where we’re helping the person develop new activities, new relationships. We also try to help them develop a more positive relationship with the deceased, so that it’s not inducing pain, but it’s actually nurturing and reassuring, so that they can remember that person but also have a life.
Are there any overlaps with the kind of treatment that people get for alcoholism or other addictions?
Not really. Historically, this treatment evolved out of PTSD treatment. Where a lot of this developed historically was 9/11, when the Twin Towers got hit in New York. Thousands died, and so a lot of grief work took place there. One of the first treatment programs published was developed by Katherine Shear, a professor of psychiatry at Columbia University in New York, who was historically an anxiety researcher. She teamed up with a PTSD researcher. The treatment program she developed was influenced by PTSD because by definition that was traumatic grief. It’s been replicated now with many different populations. So it’s got far more in common with how we’d treat anxiety than alcohol addiction.
If studies suggest that the reward centers in the brain are involved, and people with “love addiction” are among the most vulnerable to the disorder, why wouldn’t treatment have more in common with addiction therapies?
There’s still a degree of avoidance in prolonged grief disorder, so all evidence-based treatments involve an element in which the patient needs to engage with the memories of the death and the loss. Only after this is done can the person begin to address maladaptive thoughts and address future goals. In this sense, prolonged grief disorder can also be considered a form of separation anxiety, which is very different from addictive disorders.
You’ve spent your career studying trauma. How did you get into the field?
My first job 30 years ago was working on a burn trauma unit. Back then, the study of post-traumatic stress disorder, or PTSD, was in its infancy. When you start to see people with PTSD, a lot of them are also traumatically bereaved. They had suffered trauma due to homicide, war, humanitarian crisis, natural disasters, suicide of a loved one, where there’s often a loss of life. We started looking at how to develop treatment programs to help people with prolonged grief.
What do you say to those who still argue we’re over-pathologizing grief?
There’s always a risk of over-pathologizing, with anything. Today, we hear the word trauma thrown around left, right, and center, as if everybody were traumatized. That’s probably not helpful. One of the reasons we introduced prolonged grief disorder was to try to get people more helpful treatments. We know that antidepressants aren’t that helpful for prolonged grief. It’s good for depression after bereavement, but not prolonged grief. We’ve got good evidence from many trials now that grief-focused cognitive behavior therapy can be effective. Being able to identify people and then linking them to that particular treatment, that’s a good thing to do. Any risk of pathologizing has to be weighed against the possibility of getting people the help they need. 
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