By Umair Majid & Adedoja Akande
Imagine you have just experienced the loss of a loved one.
Such an experience has profound short- and long-term implications for your mental, emotional, and physical health. Losing a loved one leads to many consequences for the surviving person, such as depression and increased risk of cardiovascular disorders (1,2). For individuals who lose a spouse or partner, these physical health consequences represent a 30 to 70% increase in the risk of dying which is referred to as the widowhood effect (3).
As grief can last from days to years after a loss, it can progress to prolonged grief disorder (PGD)―also referred to as complicated grief, persistent complex bereavement disorder, or traumatic grief―in approximately 10% of cases (4,5).
Unresolved grief that leads to PGD often involves feelings of yearning, loneliness, insecurity, survivor guilt, bitterness and numbness, as well as difficulty moving on, trusting others and accepting that a part of you died (6).
Unresolved grief that leads to PGD often involves feelings of yearning, loneliness, insecurity, survivor guilt… and accepting that a part of you died (6).
The Mayo Clinic (7) also identifies several negative consequences related to PGD such as the decline in mental health, lifestyle changes (e.g., sleep disturbances), and increased risk of developing physical health conditions (e.g., cancer) (7).
While some research has examined the impact of therapeutic interventions on mental and emotional health, few studies have investigated the effects on physical health. We present a hypothetical case vignette of Dr. James to highlight potential physical health challenges experienced by someone with PGD. We also discuss strategies that rehabilitation practitioners, individuals with PGD, family, and friends can use to help alleviate symptoms and decrease the risk of serious consequences.
Case Vignette: Dr. James
Dr. James has a history of health conditions affecting his everyday living. At a young age, he was diagnosed with Ehlers-Danlos syndrome―a disorder that causes degeneration in tissues that connect skin, bones, and blood vessels (8)―that has led to over 20 surgeries in his extremities. Dr. James also experiences chronic lower back pain which makes his work challenging.
Dr. James is a happy and intelligent physician who treats patients with the utmost respect and understanding. He cares for those dealing with chronic pain and other degenerative disorders while taking pride in how he is usually in worse physical condition than his patients and yet able to provide respite to those who are often un- or mis-diagnosed by others. Dr. James loves his wife, kids, and friends.
Around his 66th birthday, Dr. James is diagnosed with prostate cancer. Although he recovers through chemotherapy and surgery, prostate cancer is just one of the physical and mental health challenges he will face that year.
Following his recovery from prostate cancer, Dr. James learns that his wife has late-stage breast cancer. Although the initial prognosis gives some hope, complications lead to his wife’s transfer to palliative care and they await the inevitable outcome.
It is at this moment that Dr. James faces anticipatory grief―grief that arises before loss―and begins to consider the life he had with his wife and recognize the uncertainty in his future. Anticipatory grief happens at four points: (a) diagnosis or realization of imminent death; (b) movement to palliative care; (c) nearing death or when the behaviour of the loved-one changes considerably; and (d) the moment of death (9).
Shortly after his wife’s death, Dr. James becomes comatose for several days which is unexplainable by his healthcare team. They hope he will eventually wake up, and he does. It turns out that short-term coma can be one of the first signs of PGD (3).
Upon waking, Dr. James faces new challenges. Having been extremely attached to his wife, he has now lost his primary source of social life and leisure activities. Research indicates that losing a spouse could explain Dr. James’ disengagement from social activities previously shared with his wife (10). Dr. James switches his full attention to his work. Indeed, grieving individuals can distance themselves from family and friends, making it harder for them to connect and discover new hobbies (11).
Over the next half-year, Dr. James struggles with health challenges; he describes the worsening of his chronic pain and connective tissue degeneration since the loss of his wife, a common complaint of those with PGD (3). He also discovers that his kidneys are failing and that the prostate cancer has returned. He seeks support from his new partner, which proves to be an effective way to reduce the physical health symptoms associated with PGD (3). Nonetheless, after months of struggle, he experiences a stroke and is hospitalized for several weeks. With the support of his new partner, Dr. James successfully recovers but begins to recognize these physical challenges as signs that his life is coming to an end.
Given his many struggles including social withdrawal, apathy, insufficient engagement from most of his family, friends, and healthcare professionals (10), Dr. James signs a “Do Not Resuscitate” form. About eight months after losing his wife, Dr. James passes away.
Strategies That Could Have Helped Dr. James
Research on PGD has identified strategies to help individuals like Dr. James cope with and avoid a tragic response to suffering, as well as for healthcare providers and family to understand and alleviate the effects of PGD.
- Recognize That Almost Everyone Will Experience Grief
Grief is a shared human experience. Almost everyone experiences grief in some way at some point in their lives, albeit differently. While some individuals may develop PGD, not all experience long-term negative physical consequences, and PDG does not directly cause any condition. For example, Dr. James’ worsening health was likely caused by the combination of pre-existing disorders, genetics, older age, and PGD. Notwithstanding, healthcare providers, family, friends, and you, Reader, must be prepared to recognize the symptoms of grief, be mindful of its long-term, serious consequences, and be ready to provide or seek out helpful resources.
- Recognize Grief Early by Knowing Its Symptoms
Recognizing the symptoms of PGD can save a person’s life. In Dr. James’ case, while the healthcare team had difficulties identifying his coma as a symptom of PGD, they could have intervened early if they were better informed about PGD and notified his family. Healthcare providers and the public might consider acquainting themselves to the possible adverse consequences that grieving individuals may experience. More information is available on the widowhood effect and its diverse impacts on health after spousal loss (3).
- Understand that PGD Can Exacerbate Pre-Existing Conditions
If grieving individuals have pre-existing health conditions such as chronic pain, cancer, diabetes, or heart disease, rehabilitation practitioners should monitor for exacerbations after a loss. The grieving individual may be paying more attention to their loss and ignoring health-related self-management activities (11). For others, the loss of a partner who was responsible for maintaining their health creates ambiguity, stress, and confusion as these responsibilities shift to the grieving individual (11).
- Inquire About Social Support
If you are someone who has recently experienced a loss or are the friend, family, and/or caregiver of someone who has, please seek help. Help can come in the form of social engagement (e.g., regular communication, shared hobbies) or medical support (e.g., therapy). Please do not ignore the symptoms of PGD. Practitioners can also routinely inquire about the social supports available after individuals leave their care. If individuals do not have social support, we recommend offering dedicated hospital support.
- Organize Dedicated Hospital Support
Hospitals may formulate a plan to support grieving individuals, such as by routine calls and check-ins. While these calls are not formal therapy, callers can employ certain strategies to reduce the effects of PGD.
PGD is a serious condition with many potential long-term physical health consequences such as the increased risk of cancer, cardiovascular conditions, and early death. We have shared research findings including our own, on the experiences of individuals living with PGD. The case of Dr. James highlights the complexities of detecting and coping with PGD symptoms, the importance of being informed and of finding relevant support.
We hope this article reaches those in need, informs healthcare professionals, and leads to hospital supports for those who have lost a loved one.
Featured illustration by Jennifer Shao for rehabINK.
To refer to this article, it can be cited as:
Umair M, Akande A. Am I more likely to die while I’m grieving? Prolonged grief disorder and its health consequences. rehabINK. 2020:Issue 9. Available from: https://rehabinkmag.com
- Asgeirsdóttir HG, Valdimarsdóttir U, Fürst CJ, Steineck G, Hauksdóttir A. Low preparedness before the loss of a wife to cancer and the widower’s chronic pain 4-5 years later-a population-based study. Psychooncology. 2013;22(12):2763-70.
- Buckley T, Morel-Kopp MC, Ward C, Bartrop R, McKinley S, Mihailidou AS, et al. Inflammatory and thrombotic changes in early bereavement: a prospective evaluation. European Journal of Preventive Cardiology. 2012;19(5):1145-52.
- Ennis J, Majid U. “Death from a broken heart”: A systematic review of the relationship between spousal bereavement and physical and physiological health outcomes. Death Studies. 2019;1-14.
- Jordan A, Litz B. Prolonged grief disorder: diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice. 2014;45(3).
- Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I, O’Connor M. Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. Journal of Affective Disorders. 2017;212:138-49.
- Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine. 2009;6(8):e1000121.
- Complicated grief [Internet]. United States: Mayo Foundation for Medical Education and Research; 2017 Oct [cited 2020 Mar 6]. Available from: https://www.mayoclinic.org/diseases-conditions/complicated-grief/symptoms-causes/syc-20360374
- Brady AF, Demirdas S, Fournel-Gigleux S, Ghali N, Giunta C, Kapferer-Seebacher I, et al. The Ehlers–Danlos syndromes, rare types. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175(1):70-115.
- Akande A, Majid U. Four stages of anticipatory mourning: a qualitative systematic review of grieving individuals’ experiences. Unpublished.
- Ennis J, Majid U. The widowhood effect: explaining the adverse outcomes after spousal loss using physiological stress theories, marital quality, and attachment. Journal of Family. Forthcoming 2020.
- Majid U, Ennis J. “Continuing the connection” or “carrying on”? A qualitative evidence synthesis of how widows explain the physical health outcomes after spousal loss. International Journal of Mental Health. Forthcoming 2020.