People with prolonged grief disorder have increased activity in areas of the brain involved in memory and emotion processing when they see death-related images, such as a cemetery
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For most people, the intense sting of grief diminishes with time. For some, however, persistent and painful grief remains, which develops into long-term grief disorder. A new review of the condition, which affects around 5 per cent of those left behind, sheds light on how it develops. This can help doctors predict which recently bereaved people will benefit from extra support.
The decision to include prolonged grief disorder (PGD) in the American Psychiatric Association’s diagnostic manual in 2022 sparked intense debate over whether it was pathologizing a normal human response to loss and imposing an arbitrary timeline of what constitutes “normal” grief. Now, an analysis of the brain activity of people with and without PGD suggests that it is a condition in its own right.
Richard Bryant of 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 bereavement, such as post-traumatic stress disorder (PTSD), depression or anxiety. They found that while there is overlap, people with PGD repeatedly show more pronounced changes in a greater number of reward-related brain circuits.
For example, several studies have found that people with PGD show significantly greater activation of the nucleus accumbens, which processes reward and motivation, in response to grief-related words and images than people who are bereaved but do not have PGD. The strength of this activation also correlated with self-reported longing for the lost.
Compared to those with PTSD or anxiety, people with PGD also show a bias towards reminders of the deceased. In contrast, those 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 emotion processing and memory – when people with PGD view death-related images, 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 tranquil landscapes. This suggests disturbed emotional regulation along with a reduced ability to experience positive emotions.
In PGD, the brain’s reward system “locks on” to the deceased and fails to find reward elsewhere, Bryant says, producing an intense yearning 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 they don’t adjust in the way most people do,” says Bryant.
Despite the review being comprehensive, there is no simple way that the information could be useful in diagnosing PGD, says Katherine Shear of 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 investigate with a single scan.
Shear says neuroimaging is just beginning to incorporate some of this complexity by doing “two-person neuroscience,” which focuses on brain activity during live interactions, helping us understand how grief is shaped by social context, cultural expectations and levels of support.
Where the review can be useful is to help predict who may go on to experience PGD after a bereavement. In one study, bereaved adults had their brains scanned within a year of the loss and at various times over the next six months. Greater connectivity between the amygdala and regions involved in planning, inhibiting behavior and filtering important information in the first scan predicted worsening grief symptoms over time, suggesting that such patterns—and the behaviors associated with them—can predict a person’s risk for PGD.
Although we know that there are several psychosocial factors that distinguish individuals who are more likely to have PGD, we cannot reliably identify who is on the path to this, says Joseph Goveas of the Medical College of Wisconsin. “Early detection will allow for timely intervention, which can 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-related conditions, while also pointing to ways physicians can tailor treatment.
“Understanding both overlapping and distinct neurobiological mechanisms can help reduce misdiagnosis and inappropriate treatment,” says Goveas. “For example, while PGD is usually unresponsive to antidepressants, it does respond to grief-specific psychotherapies. Conversely, when PGD co-occurs with major depression, combining antidepressants with PGD-targeted therapy can effectively treat depressive symptoms.”
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