Death causes grief. So does estrangement. Both are regularly unseen and unempathized. Let's talk about Prolonged Grief Disorder and its connections to PTSD.
summary
In this conversation, let's explore the concept of 'living deaths' - relationships that have ended but still evoke feelings of grief and loss. We'll explore the research and discuss emotional complexities surrounding these experiences, particularly during the holiday season. The conversation delves into prolonged grief disorder (PGD), its risk factors, and the impact of relational loss, emphasizing the importance of understanding and supporting those who are grieving, whether the loss is due to death or the end of a relationship.
takeaways
- Living deaths refer to relationships that evoke grief despite the person being alive.
- Grief can manifest in various emotional and physical symptoms.
- Prolonged grief disorder can occur when grief reactions become pathological.
- Risk factors for PGD include violent deaths and lack of social support.
- Isolation can exacerbate feelings of grief and prolong the grieving process.
- PTSD and PGD have many similarities, causing one to wonder if they're one and the same.
- Relational loss can be as impactful as the death of a loved one.
- Coping with grief requires understanding and support from others.
- The holiday season can intensify feelings of loss and loneliness.
- It's important to allow oneself to grieve without judgment, especially for "unseen losses."
keywords
grief, prolonged grief disorder, living deaths, emotional loss, mental health, relationships, holiday season, trauma, emotional support, coping strategies
As long as we’re in the holiday season and I’m too earnest for my own good, I thought we might discuss the experience of what I’ve been calling…. “living deaths.”
In other words, people who you once loved or still love, who are alive, but are no longer in your life to such an extent that they feel as distant as those who’ve passed. They’re not dead, but they may as well be.
Family members? You betcha. Old friends? Yap. Maybe even exes who just weren’t the right fit, despite the feels? Truth.
No contact decisions that are often made for self- and other-preservation. And the confusing, complicated, ambivalent, feelings that come from those experiences of loss are significant, yet rarely discussed. Feelings that often come up around significant-other celebrations, especially when old memories start emerging.
And may make you feel more alone than ever, since the living can’t understand the loss you’re experiencing.
Now, there’s no research (that I could find) on this topic.
So today we’re going to discuss (what I’ve found) to be the outcome of those events and emotions.
A grief that can’t be dissolved. Because the mind can’t easily accept that the other person is here… on earth… but not here… in its life. Causing a long lasting suffering that most can’t see.
Grief, in case you need a reminder, often encompasses the following:
Intense emotions: sadness, anger, guilt, shock, denial, loneliness, and even relief or numbness.
Confusion and disorientation: confusion about identity, questioning the loss or feeling lost about the future.
Anxiety and panic: the world may feel less safe or likely to spawn another bad happening.
Fluctuating moods: Emotions often come in waves and can quickly shift
Sleep and appetite disturbances: trouble sleeping or changes in appetite, leading to weight gain or loss.
Fatigue: A lack of energy and general exhaustion.
Physical pain: tightness in the chest, headaches, stomach pains, or muscle aches.
Other symptoms: Heart palpitations, trembling, and a feeling of weakness are also possible physical reactions.
Cognitive issues: Difficulty concentrating, poor memory, and jumbled thoughts.
Restlessness and agitation: trouble sitting still or relaxing.
Withdrawal: isolation from friends and family or avoidance of social situations.
Other behaviors: Grief can also manifest as being unusually dependent on others, absent-mindedness, or creating changes in usual routine.
If those sound like symptoms we encounter with OTHER mental disorders, you’re onto something. Now let’s get into something empirical.
Our paper of the ep?
Bereavement issues and prolonged grief disorder: A global perspective
Hilberdink et al
2023
And let’s talk about the unspoken experience of persistent, unfading grief, as they say:
The death of a loved one is one of the most painful experiences in one’s life. Most bereaved individuals experience distressing grief reactions to such a loss, including intense longing for the deceased, emotional pain and/or pangs of grief, loss of interest in ongoing life, and social withdrawal (Bui, 2018).
These ‘acute grief’ responses are normal reactions to the death of a loved one that occur during the period that immediately follows the loss (Shear, 2012).
This… phase usually subsides in the first few months following the loss, and most individuals will successfully adjust, regaining their interest and engagement in their ongoing life (Bonanno and Kaltman, 1999; Shear et al., 2011).
Yet, a substantial minority of bereaved individuals do not successfully adapt, in which grief reactions become pathological and symptomatic, and they exhibit continued, prolonged, distressing, and impairing grief reactions that can last years and sometimes decades after the death (Shear et al., 2013; Lundorff et al., 2017 Djelantik et al., 2020).
And let’s pause there.
With most deaths or, I think we can say, breakups, there’s a somewhat “normal” grief response. It lasts a few months. And then life continues.
In some cases, though, the grief doesn’t rise and fall “as expected.” Prolonged Grief Disorder, as they call it, sets in.
What are some of the risk factors, according to the research?
Risk factors for prolonged grief disorder in the global context
Violent deaths
Higher prevalence estimates have been found in bereaved after losing a loved one due to an unnatural cause of death. Djelantik et al. (2020) found a pooled PGD prevalence of 49% (95% CI 33.6– 65.4%) in N = 4,774 adults across the globe who experienced an unexpected and/or violent death (traumatic accidents, suicide, homicide, or disasters)..
Studies in bereaved individuals due to unnatural deaths predominantly investigated PGD after the (unexpected) loss of a child, the loss of a family member, close friend, or other relative in bereaved caregivers, or survivors of a (natural) disaster.
Unexpected, violent, deaths carry greater risk of PGD.
Do you agree, it makes sense that a mind is extra tortured by grief when a loved one is lost through traumatic means?
Considering what we know about brain mechanisms, there’s a good chance that the bereaved mind cannot settle up the memories and expectations with what happened in reality. Actual and anticipated don’t align. The pain of the abrupt loss can also contribute to rumination and self-blame. And depression will keep all of this information at the top of the mind, unclearable from working memory.
Because of the disturbing and frightening story contained in the loss, it’s not unlikely to create PTSD or PTSD-like symptoms. It creates a narrative that no one is safe, danger is imminent, and loss or personal destruction could be right around every corner.
Altogether, none of this is going to assist with processing or adapting “in a normative several month period” as one might hope. It’s going to disturb and corrupt the mind in a lingering fashion that could even contribute to mental disordering for the remainder of their life. Creating a story and an anticipated event to fear, forever.
What else can contribute to prolonged grief?
Pre-loss risk factors
Studies found several demographic factors that increase the risk for development of PGD, such as lower socioeconomic status, being female, and being older.
As these factors vary across cultural contexts and are related to cultural diversity, such as race, common mental health problems, socioeconomic constructs, and cultural norms and beliefs, they might affect the experience of losing a loved one and consequently the likelihood of developing PGD.
For example, a study that compared Westernized French and (non- Westernized) Togolese bereaved populations found that being male was a significant predictor for PGD in Togolese, but not in French adults (Kokou-Kpolou et al., 2020).
Other personal characteristics present before the loss, such as exposure to childhood adversity, psychological and physical health history, pre-loss alcohol consumption, and maternal age in case of losing an infant, appear to influence PGD risk
Ah, so minority status, age, female gender, and history of trauma… the same factors that increase one’s risk for PTSD also increase the risk of PGD.
Almost like the two are related. (cough) almost.
Let’s keep learning about risk factors and see if that trend continues.
Loss-related risk factors
Studies also found factors that are related to the loss and increased risk for PGD, such as the type and duration of the relationship with the deceased (Kokou-Kpolou et al., 2020; Smith and Ehlers, 2020).
Burke and Neimeyer (2012) reported in their review that PGD is more severe in individuals that have lost a close family member, spouse, or life partner compared to those who have lost a distant relative.
The number of family members additionally appears to be a significant predictor for PGD, as more core family members lost was associated with PGD severity...
Also, elderly who had lost a spouse were at increased risk for developing grief symptoms than those who lost someone else (Fujisawa et al., 2010).
Furthermore, as discussed above, an increased prevalence of PGD has been reported in the case of unexpected and/or violent death (traumatic accidents, suicide, homicide, or disasters [Djelantik et al., 2020]).
…Peritraumatic reactions (distress and dissociation) have been shown to consistently predict the development of posttraumatic stress disorder across populations (e.g., Bui et al., 2010; Vance et al., 2018), and recent data suggest that they may also predict the development of PGD in adults.
Ahhhh there it is. Just like PTSD, PGD is associated with life stressload and subjective experiences of distress. The more life changes or appears to be changing after a loss, the more drawn out the grieving process will be. Therefore, the closer the individuals were, the greater the likelihood of prolonged grief.
Because, I think we can say, under these circumstances the mind is dealing with PTSD and grief, comorbidly. That means it isn’t capable of “normal operations as usual” – it is disturbed in its perspective and cumulative understanding of life which interfere with emotional regulation and cognitive functioning.
Bringing on the same or similar challenges as we see with post-traumatic stress.
But… Now that we seem to really be onto something with this data… How much crossover exists between PGD and PTSD, exactly?
Let’s look at the post-loss risk factors.
Post-loss risk factors
The lack of social support after a loss has been identified as a risk factor for the development of PGD (Stroebe and Schut, 2001; van der Houwen et al., 2010).
Culture could be a determining factor in social support, as for example more individualistic societies were hypothesized to isolate themselves more and have more difficulties with receiving and asking for professional support (Kumar et al., 2012).
Yet, some cultural norms could also be of importance for this, as in Asian populations, it is less common to ask for and accept social support for coping with stress, which could increase PGD risk
And with that we find… Lack of social support? Another risk factor that PGD and PTSD share.
Isolation after the event? Check.
We can read into both of these and suggest that being left alone with one’s own mind after a significant loss is potentially related to PGD. Perhaps, due to rumination taking over in the void of supportive and comforting voices and the increased emotionality that likely co-occurs, when feelings are unable to be processed among safe others.
And although this is a shorty, let’s leave it a goodie. From these findings, lettuce:
Wrap
So today we learned that grief is expected to follow some “normative trajectory” that lasts a few months. In some cases, though, the grief doesn’t rise and fall “as expected.”
Those factors, per the research and if the lines are read between, are:
- When the death doesn’t come as expected – when it’s violent and unpredicted.
- When the bereaved structured their life around the lost one – when they’re a parent or caregiver, now left without the tasks and emotions that were centerpoints of their existence.
- When a damaging story, such as the dangers inherent in the world, is suggested by the loss
- When it involves a close emotional partner or a sheer number of relationship partners
- When life changes significantly after the loss
- When life stressors were already significant
- When social support isn’t available
- When isolation is an outcome or reaction to the loss
And we can say, from everything we know:
Overall, 9) when the loss is reminiscent of trauma. When the life story and trajectory of the individual are now called into question in the aftermath of the loss. When fear is part of the experience. When increased isolation within one’s self is part of the result.
These are the conditions under which we can expect prolonged grief.
It’s a transformative experience that alters more than one relationship or component of life for the individual. If it affects their entire comprehension of existence. Or sews dangerous fearful seeds into their mindset.
Just like trauma leading to PTSD.
…. And, to bring this back to the beginning of the ep, I propose that risk factor 10) an un-definitive and emotionally ambivalent ending, such as deciding “this abusive person isn’t good for me, despite all the loving feelings I have for them” can be another causative factor of prolonged grief, without death needing to be part of the equation.
Perhaps it’s “death of a relationship” that can be the root of prolonged living grief. Which can happen separate from death of a person.
This is the case, partially, I posit, because that experience contains many of the risk factors noted above.
The unexpected letting go of a loved one when there are large and mixed feelings involved, which contributes to a large change in life structure, and often increased isolation with limited social support or understanding for the impact of the loss… a breakup or no-contact decision may have even come with violence between the individuals, leading to the dissipation of relationship… and altogether, the story that it suggests to the relationship-loser can be rather cataclysmic – implicating unworthiness, abandonment, or future loss and suffering are now predictable around multiple turns….
Meanwhile, support for leaving a bad relationship? Isn’t free flowing. Often, outsiders believe that it was a fine relationship, for one thing. Alternatively, if they recognize it was abusive or otherwise toxic, the assumption is that the loss of the relationship is a relief – a partial truth, but not the entirety of it.
Loss is loss. Whether the individuals are still walking the planet or not. A breakup or no contact order can be just as definitive. Though, perhaps even more mentally straining, as the mind estimates that the missing party could be reached out to. Creating a painful back and forth argument within the individual that, in a way, forces them to “choose” the “death option” for everyone.
Logically, it may not make sense. Emotionally, the experience of relational loss amongst the living can be devastating.
So, Fuckers, in this somewhat difficult season, remember…
When we make the decision to let people out of our lives – to leave them out, for our own sake – we aren’t “just” losing a relationship or going through a breakup or throwing a wrench into the family dynamic.
We’re encountering loss, grief, trauma, and massive shifts in thought and expectation that change one’s outlook on life entirely.
It’s not a flippant decision. It’s not easy. It can feel like being torn apart from the inside.
And it’s a grief that can’t easily be understood from the outside… Short of having experienced one’s own traumatic loss and prolonged grief. An experience I wouldn’t wish on any.
So this holiday season?
Get off your own ass for how you’ve been doing and feeling.
Grieve, as needed.
For as long as needed.
Choose activities to support yourself and let go of extraneous expectations.
Connect with people who have the emotional capacity you require.
Communicate broadly and consistently, instead of isolating.
And give yourself some credit for everything that you’ve gone through. In one event, you might be experiencing about ten mentality- and safety-corrupting risk factors. That not only contribute to prolonged grief disorder, but also PTSD.
As if you needed any more of it.
Remember, Fucker. If you’re still here, you’re doing a great job. Keep going. With grace. For your self. For your mind. And everything you’re persevering through.
You don’t need to feel any particular way or recover on any normative timeline.
If you’ve felt like saying goodbye to someone, even for abuse-reasons, was like an entirely separate trauma… it is.
And your ability to care deeply is a gift – a sign of your heart – not something to punish. It’s part of being here and being human. It’s life on earth.
SO.
Take care this holiday season, however you need it.
Don’t be a stranger if you’re enduring the experience of grief and need a little support.
Be good to those you have.
And cheers, y’all.
I’ll talk to you soon.