The concept of pathological mourning has been around since Sigmund Freud’s seminal paper “Mourning and Melancholia,” but it began receiving formal attention more recently. In the 1980s and 1990s, researchers noticed that antidepressant medications relieved such depressive feelings as sadness and worthlessness but did nothing for other aspects of grief, such as pining and intrusive thoughts about the deceased. The finding suggested that complicated grief and depression arise from different circuits in the brain (Hughes, 2011).
Two models of grief have been hypothesized: a detachment model and a reunion model (Bowlby, 1980). In the detachment model, the grief emotion is believed to play a role in the acceptance of the reality of the death and therefore assist in recovery from the loss. In the reunion model, the grief is a form of protest against separation from the deceased, and serves to promote reunion with the lost person, not detachment. Freed and Mann (2007) hypothesize that if the detachment model is correct, the pangs of grief would occur with reduced activity in the brain’s reward system over time, as the acceptance of the loss leads to detachment. If the reunion model is correct, the pangs of grief would continue to occur simultaneously with reward activity in the brain, when exposed to “cues of the deceased” (such as memories, photos, etc.), motivating reunion with the deceased.
In 2008, Mary-Frances O’Connor and a team of researchers scanned the brains of women who had lost their mother or a sister to cancer within the past five years, and compared the results of women who had displayed typical grief with those suffering from complicated grief. While both groups displayed activity in neural pathways related to pain, for those with complicated grief their reward centers lit up as well. This is the part of the brain that lights up on imaging scans when addicts look at photographs of drug paraphernalia and when mothers see pictures of their newborn infant. This doesn’t necessarily mean women are addicted to their feelings of grief, but rather they still feel attached to the deceased. This is significant, because it not only supports the hypothesis that attachment activates reward pathways, but also suggests complicated grief is a result of maladaptive attachment patterns and behaviors (the thesis for this text). It also suggests the detachment model may apply to “normal” grief (a slow process of acceptance and integration of the loss), and the reunion model applies to complicated grief (a paradoxical experience where both the pain and pleasure pathways of the brain are activated in grief, because you still feel attached).
Finally, in 2009, Holly G. Prigerson published data collected from nearly 300 grievers she had followed for more than two years. By analyzing which of some two dozen psychological symptoms tend to cluster together in these participants, she finally devised the criteria for complicated grief, which were added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. Sometimes called “persistent complex bereavement disorder,” complicated grief is differentiated from “normal” grief in that the symptoms severely impact the ability of an individual to resume healthy functioning and maintain a quality of life, similar to depression.
Although some symptoms of grief and depression overlap (fluctuations in mood, appetite, activity level, sleep patterns, etc.), the two conditions are thought to be distinct. Grief is tied to a particular event, for example, whereas the origins of a bout of clinical depression are often more obscure. Antidepressants do not ease the longing for the deceased that grievers feel. So in most cases, treating grieving people for depression is ineffective. However, grief may trigger a major depressive episode, in the way that other major life stressors do. Whittling out the differences between normal grief, complicated grief, and depression reflects the fundamental dilemma of psychiatry: mental disorders are diagnosed using subjective criteria. Any definition of where normal ends and abnormal begins will be the object of individual opinion (Hughes, 2011).
Scope
In the general population, the prevalence of complicated grief in those who have experienced loss of significant others has been reported as 2.4 percent to 6.7 percent, which is relatively low, but prevalence is higher among those bereaved by violent death. For example, in a sample of 126 respondents bereaved by the Bosnian conflict, 31 percent expressed complicated grief; in a sample of 704 respondents bereaved by the September 11th attacks, 43 percent expressed complicated grief; and in a study of 128 respondents bereaved by suicide, 75 percent expressed complicated grief symptoms (Kersting et al., 2011). Rynearson (2001) claimed that violent death comprised three Vs—violence, violation, and volition. These interfere with acceptance of death, because of the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community (Norris, 1992). Furthermore, violent death caused by disaster is sudden and unexpected, and sometimes includes additional trauma, such as facing life-threatening situations and witnessing damaged corpses. Raphael, Martinek, and Wooding (2004) called these bereavements “traumatic loss,” which is more stressful, complicated, and difficult to recover from than the bereavement of natural death.
The factors affecting the prevalence of complicated grief are considered to be comorbid mental disorders, lack of readiness for the death, difficulty in making sense of the death, high level of negative appraisal about the self and others, and various social stressors. Post-traumatic stress disorder is, in particular, considered to contribute to the development of complicated grief by suppressing function of the medial prefrontal cortex and the anterior cingulate cortex, which works at facilitating the normal mourning process, when grief distress is activated and interrupts acceptance of death (Nakajima et al., 2012).
For example, Murphy et al. (2003) studied PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children in a longitudinal prospective analysis. This study examined the prevalence of PTSD among parents bereaved by the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of Medical Examiner records and followed for two years. Four important findings emerged: both parents’ gender and children’s causes of death significantly affected the prevalence of PTSD symptoms. Twice as many mothers and fathers whose children were murdered met PTSD full diagnostic criteria, compared with accident and suicide bereavement. Symptoms in the re-experiencing domain were the most commonly reported. PTSD symptoms persisted over time, with 21 percent of the mothers and 14 percent of the fathers who provided longitudinal data still meeting criteria two years after the deaths. Parents who met criteria for PTSD, compared with those who did not, were significantly different on multiple study variables (Murphy et al., 1999).
Although research has confirmed that violent losses can exacerbate grief reactions, few investigations have explored underlying mechanisms. Why is it harder for some, and not others? In this study, the authors used a dataset on bereaved spouses and bereaved parents at 4 and 18 months post loss to examine the mediating effects of self-worth and worldviews (benevolence and meaningfulness beliefs). Individuals bereaved by violent causes had significantly more PTSD, grief, and depression symptoms at 4 and 18 months post loss than persons bereaved by natural causes. Moreover, self-worth—not worldviews—mediated the effects of violent loss on PTSD and depression symptoms cross-sectionally, and PTSD symptoms longitudinally. Findings underscore that self-views are a critical component of problematic reactions to violent loss (Mancini et al., 2011). And where do self-views originate? In our earliest attachment relationships.
Attachment hunger and addiction
To the extent that the individual is able to achieve a sense of mental and emotional separation from the early mother–child union, he will experience his “true self.” But if he never fully achieved this, his feeling of wholeness will depend on someone else. If this is the case, his parents probably provided a distorted mirror, bent by their need to see him as an extension of themselves, or how they wanted to see him, steering him towards any one of three insecure attachment styles