Prolonged Grief: Navigating the Labyrinth of Loss in Adolescence and Adulthood - Luuk L. Westerhof, MSc

Prolonged Grief in Adolescence and Adulthood: Differential Manifestations

While the core features of PGD remain similar across development, its manifestations can vary between adolescents and adults:

• Adolescence: Adolescents experiencing PGD may exhibit increased irritability, anger outbursts, withdrawal from peers, academic decline (e.g., difficulty concentrating), risk-taking behaviors, and struggles with identity formation (Shear et al., 2011). They may also express grief more through somatic complaints (e.g., headaches, stomachaches) rather than explicit emotional distress. The loss profoundly disrupts the adolescent's developmental trajectory, impacting social development, future planning, and self-perception (Stroebe & Schut, 2015). They might be more vulnerable to developing mental health issues like depression and anxiety.
• Adulthood: Adults with PGD typically present with persistent yearning for the deceased, intrusive thoughts about the loss, intense emotional pain, feelings of emptiness, difficulty accepting the finality of the loss, and a sense that life is meaningless. They may struggle with daily tasks, experience social isolation, and have an impaired sense of self (Shear et al., 2005). Adults with PGD may also experience an inability to create new routines and attachments as they feel they are betraying the deceased by moving forward. There might be a greater tendency to dwell in the past, leading to a stagnation in personal growth.

Neurobiological, Physiological, and Immunological Correlates of Prolonged Grief

The experience of PGD is not just emotional; it has tangible effects on the body and brain:

• Neurological: Research has identified altered brain activity in individuals with PGD, particularly in areas related to:
  • Reward and Motivation: Reduced activity in the nucleus accumbens, a core structure for processing pleasure and motivation, is found in grieving individuals (O'Connor et al., 2008). This may contribute to the lack of pleasure and motivation in daily life.
  • Emotional Processing: Increased amygdala activity (related to emotional reactivity, predominantly negative emotions) and decreased activity in the prefrontal cortex (regulates emotional responses) have been observed (Wager et al., 2009). This may lead to emotional dysregulation and difficulty managing intense feelings of grief.
  • Memory and Rumination: Overactivity in the hippocampus (memory formation), coupled with impaired connections to prefrontal regions, may contribute to rumination about the loss and an inability to integrate it into the bigger picture of life (Lindquist et al., 2020).
• Physiological: PGD is associated with:
  • Autonomic Nervous System Dysregulation: An imbalance in the autonomic nervous system (ANS), marked by increased sympathetic nervous system activation (fight-or-flight responses) and decreased parasympathetic nervous system activity (rest and digest), is common (Thoma et al., 2011). This can manifest as increased heart rate, blood pressure, and feelings of tension and anxiety. Chronic dysregulation of the autonomic nervous system can have long-term health consequences.
  • Hormonal Imbalances: Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the body's stress response, is observed. Increased cortisol (stress hormone) levels, particularly the failure to return to baseline after a stress response, can result in chronic stress symptoms (Zisook et al., 2015).
• Immunological: PGD may be associated with an altered immune response.
  • Inflammation: Increased levels of proinflammatory cytokines, suggesting an inflammatory state, are observed in those with chronic grief, which can be related to a dysregulated autonomic nervous system and might increase the risks of heart disease and other autoimmune diseases (O'Connor et al., 2017).

Dissociation: A Double-Edged Sword in Prolonged Grief

Dissociation, a mental process involving a detachment from one's thoughts, feelings, memories, and identity, serves as a protective mechanism against overwhelming trauma and pain. In the context of grief, it may initially allow the individual to cope with the intensity of the loss. However, when this response becomes prolonged and maladaptive, it can contribute to PGD.

• Manifestation of Dissociation: Dissociation can manifest in several ways:
  • Depersonalization: Feeling detached from one's own body or experiences, like being an observer of one's life.
  • Derealization: Feeling like the world is unreal, foggy, or dreamlike.
  • Emotional Numbing: A reduction in the ability to experience emotions, positive or negative.
  • Memory Loss: Difficulty recalling events associated with the loss.
• Without Dissociation: Without dissociation, the individual might be completely overwhelmed by the intensity of the grief, unable to function, and potentially develop more severe mental health issues. While dissociation can offer respite, without proper integration of the grief, it can contribute to long-term issues.
• Prolonged Dissociation and Visceral Function/Relationships:
  • Visceral Function: Prolonged dissociation can maintain a state of chronic stress and ANS dysregulation. This impacts visceral function by altering heart rate, digestion, respiratory patterns, and sleep cycles and can lead to various chronic health issues (van der Kolk, 2014).
  • Relationships: Dissociation can interfere with the ability to form or sustain close relationships. The emotional numbing, lack of presence, and inability to connect with others make it hard to establish intimacy and trust. This can lead to isolation, loneliness, and difficulty creating new attachments (Schimelpfening, 2022).

Therapeutic Approaches to Prolonged Grief: An Integrative Perspective

Addressing PGD requires a holistic, integrative approach that integrates various therapeutic modalities to help individuals process grief, reconnect with their lives, and build healthy relationships.

1. Internal Family Systems (IFS):
   • Concept: IFS views the mind as composed of various "parts," each with its own needs and motivations (Schwartz, 1995). PGD may involve grief-related parts that are stuck in the pain of the loss and other parts that are stuck in defensive mechanisms, like dissociation.
   • Application: IFS therapy helps individuals identify, understand, and work toward integrating these parts. It fosters self-compassion and helps individuals gain insight into protective parts' roles. IFS helps individuals achieve self-acceptance concerning their internal experience and facilitates healing. (Schwartz, 2001).
2. Systems Approach:
   • Concept: Systems theory considers the individual within the context of their family, community, and broader social systems (Minuchin, 1974). PGD can disrupt family dynamics and relationship patterns.
   • Application: Therapy focuses on identifying systemic patterns influencing the grieving process. It helps individuals understand how grief impacts relationships and how to communicate needs within the system. It can also assess the role of the family when some members are struggling with grief while others may be trying to encourage the grieving member to "move on" (Walsh & McGoldrick, 2017).
3. Social Constructionism:
   • Concept: This framework emphasizes how social and cultural contexts shape our experiences and understanding of grief. It acknowledges that grief is not just a personal experience but is influenced by social narratives, expectations, and cultural rituals (Burr, 2015).
   • Application: Therapy can encourage individuals to explore how cultural norms may shape their grief and challenge maladaptive social constructions. It helps individuals to create their own personal narrative of grief that is authentic and aligns with their individual experience of loss instead of allowing social norms to dictate how their grieving should be processed. It can also help individuals find or create supportive communities where their grieving process is validated.
4. Polyvagal Theory:
   • Concept: The Polyvagal Theory describes the interplay of the vagus nerve ( a significant component of the Parasympathetic Nervous System) in regulating our physiological state and ability to connect socially (Porges, 2011). Trauma and prolonged grief can lead to a dysregulated nervous system and reduce the capacity for social engagement.
   • Application: A Polyvagal-informed approach involves practices that promote self-regulation, such as breathing exercises, mindfulness, and gentle movement. It helps individuals connect with their bodies, calm the nervous system, and gradually increase their capacity for social engagement and safety (Dana, 2018).
   • Integration: It is important to see these modalities as mutually reinforcing. IFS can help individuals understand the underlying emotional patterns, Systems Theory addresses the impact of grief on relationships, Social Constructionism helps understand culture and social influences, and Polyvagal Theory addresses the physiological aspects of the grief journey and promotes self-regulation.

Conclusion

Prolonged grief is a complex and debilitating condition that has far-reaching implications for emotional, physical, and social well-being. The biopsychosocial impact of PGD varies across different life stages and highlights the importance of early identification and intervention. An integrative therapeutic approach incorporating IFS, systems theory, social constructionism, and a polyvagal understanding offers a robust framework for helping individuals navigate the labyrinth of loss, heal deep wounds, find a way back to life, and establish secure relationships. Further research is necessary to continue to improve the standards of care for individuals living with the debilitating effects of prolonged grief.

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