Have I Grieved Too Long?

More than one-third of the bereaved may have Prolonged Grief Disorder. Yet, in a recent study, nearly all respondents agreed that their overall emotional responses to their loss were normal and understandable.

After the sudden loss of her young and healthy husband, Sheryl Sandberg said, “Option A is not available. So, let's just kick the [s***] out of Option B.” Life deals everyone painful and devastating consequences. At some time, we all must settle for option B.

Andrew Lozovyi/DepositPhotos

Bereavement and Grief

Bereavement refers to an event: the fact of the loss. Grief is not an emotional state; it is a process that continues in fits and starts. It varies from person to person and from barely noticeable to profound anguish. Grief is not time-limited. But when does it go on too long?

Although medical professionals deal with death on a regular basis, very little is taught about grief in medical school or psychiatric training.

How grief progresses varies depending on several factors:¹

• Personality and genetic makeup
• Age and health
• Spiritual and cultural identity
• History of prior losses
• Circumstances of the loss
• The attachment to the deceased

Overwhelming feelings of shock, guilt, anger, regret, and loneliness accompany normal, uncomplicated grief. It is fluid and progresses in a wave-like fashion. Initially, the waves are frequent and intense. But over time, the waves diminish in frequency and amplitude. Then, birthdays, anniversaries, or simply a photo can trigger a tsunami of sadness.

Grief diminishes as the finality and consequences of the loss are accepted and understood, and future hopes and plans are revised.

kimaragaya/DepositPhotos

Complicated Grief Disorder (CGD)

CGD is also known as prolonged grief disorder or persistent chronic grief disorder. It occurs after a life-shattering experience: Option A is no longer available, and there is no Option B.

When the happiness of the bereaved was inextricably tied to the deceased, CGD may develop. It is found in 10 percent of people who have lost a romantic partner and a higher percentage of those who have lost a child.²

CGD is characterized by an endless loop of intense longing and sorrow. A marked difficulty accepting death becomes the focus of the loved one’s life. It is prolonged and severely impairs work, health, and function. It leads to avoidance of persons and places associated with the deceased. Symptoms are beyond expected norms for grief.

Symptoms can include:

• Emotional numbness
• Feeling life is empty and meaningless
• Positive reminiscing is nearly impossible
• Feeling bitter or angry
• Feeling alone

Bereavement-Related Major Depressive Disorder (MDD)

Uncomplicated grief is complex, with both positive and negative emotions, but the waves of sadness diminish over time. Clinical depression—known as major depressive disorder (MDD)—can be difficult to diagnose in the presence of bereavement. Symptoms overlap. But the implications of a definitive diagnosis are profound.

MDD is a stable cluster of symptoms associated with an enduring low mood. Somatic symptoms like sleep and appetite disturbance are common. Clinicians must recognize MDD in the presence of grief and treat bereavement-related MDD as vigorously as MDD following any precipitating event.

Chronic Post-Traumatic Stress Disorder (C-PTSD)

CGD also must be distinguished from C-PTSD (although both can be present.) Therapists who laser-focus on trauma may miss the diagnosis of CGD. Trauma dominates the intrusive thoughts of those with C-PTSD, and the predominant emotion is fear. The predominant emotion in CGD is unyielding sadness.

Although they share many of the same symptoms, CGD must also be distinguished from C-PTSD. Both MDD and C-PTSD share many of the same symptoms, but their treatments are different. Clinicians can reliably identify CGD by using the Inventory of Complicated Grief.

Grieving the Undead

Humans can project themselves backward in memories. They can also project themselves forward by a simulated future.

Grief is not limited to the death of a loved one. Divorce, job loss, and aborted hopes and dreams have traditionally been overlooked as prompts for grief. These are called non-bereavement grief. One can re-read this essay, substituting “ex-spouse” or “former job” for the word deceased.

Grief Essential Reads

The Pain of Loss Becomes Part of Life

I Need to Make a Call: Using a Wind Phone to Express Grief

Nostalgia is a longing for a romanticized past. It is accompanied by apprehension about the future.

Anticipatory nostalgia is time travel: the expectation of feeling nostalgic in the future.³ Bittersweet feelings are experienced now while looking toward the future: e.g., the empty nest syndrome. Those who experience anticipatory nostalgia maximize the negatives and minimize the positives. If a person faces a predicament with no suitable options, they may consider suicide.

Non-bereavement grief and anticipatory nostalgia may also be uncomplicated or complicated.

Treatment of CGD

CGD may be life-threatening, so treatment is essential. But interpersonal psychotherapy, traditional grief therapy, and medications alone are not effective. No evidence-based treatment is available for CGD, but targeted intervention shows promise. [Mental health professionals will find a detailed description of this treatment in the references.]⁴

The primary goals of treatment are to process the loss in a new way and restore functioning. The recommended treatment is cognitive behavioral therapy (CBT). It begins with educating the bereaved about CGD.

Treatment then focuses on repeatedly retelling the story of the loss while the therapist addresses errors in the bereaved’s ruminations. This helps the bereaved integrate the loss into their life and develop a new narrative about the loss. Then, the bereaved can carve out an identity that separates them from the deceased. The goal is to create a meaningful and satisfying life without the deceased.

The final phase of treatment reduces avoidance behaviors. Interpersonal therapy and motivational interviewing are also elements of this treatment.

Medications are not essential for uncomplicated grief. They are critical for MDD. They may also help those with sleep and appetite disturbances associated with CGD or C-PTSD.

The Return of Joy

There is no single way to grieve, and there are no predictable stages that everyone goes through. Grief does not mean the deceased is forgotten. Grief is never fully completed; the longing and sadness remain but are less intense.

Integrating grief moves it away from center stage. The permanence of the loss is accepted. Pleasant memories of the past accompany the deceased as they re-enter the life of the bereaved.

Joy returns once option B is implemented.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.