The Links Between Trauma and Grief
When you go through something difficult, it can feel like your brain is swept up in a gale of emotion. These experiences of stress, trauma and grief are often intense and distressing, but they exist along a continuum: Your responses might be healthy, natural reactions to help you adapt. But some people may experience more severe or persistent responses that can lead to conditions such as post-traumatic stress disorder (PTSD) or prolonged grief disorder (sometimes referred to as PGD).
“It’s like the difference between a storm and a hurricane,” said Holly Prigerson, PhD, endowed professor of diagnostics at Weill Cornell Medicine and director of the Cornell Center for Research on End-of-Life Care in New York City.
Understanding how our bodies and minds deal with challenge starts with understanding the differences between trauma and stress.
Stress is “a reaction to life events that trigger change,” according to The Friedman Brain Institute at Mount Sinai’s Icahn School of Medicine in New York City. Compare that to trauma, which is “the experience of severe negative stress” often brought about by loss—of a home, a relationship, a feeling of safety.
Types of trauma include:
- Acute: resulting from a single incident
- Chronic or repetitive: from recurring and prolonged exposure to events like domestic violence or abuse
- Complex: from exposure to multiple, often interpersonal, traumatic events, such as family violence
- Historical and/or intergenerational: from war, slavery, racism, colonization, loss of culture or other systemic oppression
While trauma is almost always negative, stressful or potentially traumatic events don’t always lead to trauma, and stress isn’t always bad.
A framework used by neuroscientist Bruce S. McEwen, PhD, in his 2017 article “Neurobiological and Systemic Effects of Chronic Stress” classifies stress into three types:
- Good stress results from rising to a challenge or experiencing resilience in the face of adversity.
- Tolerable stress occurs when bad things happen to someone who is able to cope thanks to healthy brain architecture and the support of loved ones.
- Toxic stress arises when bad things happen to someone who has limited support and a brain architecture that reflects negative early-life events. This makes it more difficult to cope and likelier to fuel behavioral and physiological challenges.
When you are experiencing stress or trauma, you may first have acute symptoms. These are intense and normal. And they happen soon after a triggering event, called a stressor. In contrast, chronic or long-term symptoms are repeated, prolonged or delayed experiences. They could signal an increased risk of certain psychiatric disorders.
Brain areas affected by trauma disorders include the amygdala, hippocampus, thalamus and medial prefrontal cortex. These structures play critical roles in our real-time experiences of emotion—as well as our emotionally driven behaviors and our memories of emotionally important events.
The hippocampus—a seahorse-shaped structure in the medial temporal lobe of the brain—is a particularly useful marker of trauma disorders because it is sensitive to stressful events. MRI studies have shown smaller hippocampal volume in certain groups affected by trauma-related conditions, including people with PTSD. (Learn more about a form of PTSD, called complex PTSD.)
Where Grief Fits In
There’s a difference between grief and trauma—and a difference between emotions and disorders. It’s worth recognizing these differences so researchers and clinicians can determine how best to intervene for each one and which to address first when someone has both, said Mary-Frances O’Connor, PhD, associate professor of psychology at the University of Arizona and author of “The Grieving Brain” and the forthcoming “The Grieving Body.”
“Physiologically, [grief is] going to look similar to acute stress or trauma,” said Katherine Shear, MD, professor of psychiatry at Columbia University and director of the Center for Prolonged Grief in New York City. Both can lead to spikes in heart rate, blood pressure and cortisol (the “stress hormone”). But the brain knows better.
When we lose a loved one, “the brain recognizes part of us is missing,” Dr. O’Connor explained. “We can see the neural correlates of bonding, of grief, and we can see their functional changes in the moment that we are thinking about our deceased loved one.”
Dr. O’Connor’s fMRI studies have shown a correlation between self-reported yearning for the person who has died and the activation of nucleus accumbens, which is a tiny mid-brain region that is a part of the reward system. That system is crucial to creating the bond between loved ones.
Dr. O’Connor pointed to a 2021 functional neuroimaging study that highlighted the neurological differences in people with three distinct conditions—PTSD, prolonged grief disorder and major depressive disorder—when they were shown pictures of faces displaying different emotions.
“The neurobiological reactions to emotional faces that participants were looking at used distinct brain regions for people with those three different diagnoses,” Dr. O’Connor said. “So we know that, even neurobiologically, they are distinct.”
There are similarities, too, such as smaller hippocampal volumes in people with prolonged grief disorder, even when they don’t have PTSD, she added.
Types of Grief
Grief and grieving share similarities and differences. “Grief is that in-the-moment wave that sort of knocks you off your feet, and you feel all this yearning and sadness, or anger, or whatever you feel,” Dr. O’Connor said. “Grieving, on the other hand, is how grief changes over time.”
The five stages of grief were never intended to explain everyone’s experience with grief. A person may feel some, but not all, of the five stages. Or, an individual might experience some stages over and over or for longer periods.
Grief is a moment, while grieving is a trajectory. For 80% to 90% of people, grieving “becomes less frequent and intense over time,” even if there’s a lot of up and down along the way, Dr. O’Connor said.
The experiences of people with normal, continuing grief and those with prolonged grief disorder begin to split around the one-year mark, she said. “Some people are on a trajectory where they are restoring a life for themselves. Other people are on a trajectory that just is not changing. It’s as though the death [or other loss] just happened.
“Prolonged grief is really yearning—wanting our loved one to be back, wanting our life to be the way it was,” Dr. O’Connor continued.
The distinction is helpful because people with typical grief will “have a terrible, terrible day—an anniversary, or a birthday, or something, and they’ll think, ‘Oh no, I thought I was so much better, but obviously I’m just like I was before,’” she said. “But that’s only if you take a snapshot of that moment rather than looking at the whole trajectory.”
Further complicating matters is our cultural understanding of the stages of grief.
Psychiatrist Elisabeth Kübler-Ross introduced the five stages of grief in her 1969 book “On Death and Dying.” However, what gets lost in today’s interpretation is that these stages—denial, anger, bargaining, depression and acceptance— were used to describe the experiences of terminally ill patients who knew they were dying. They were never intended to explain everyone’s experience with grief.
Nevertheless, the book marked a watershed moment in grief research because, until that point, many people did not realize how complex and multifaceted grief could be, Dr. Shear said.
Looking at society as a whole, Dr. Prigerson said her research supports that most people do go through the five stages. However, on the individual level, it doesn’t always feel that way. A person may feel some, but not all, of the five stages. Or, an individual might experience some stages over and over or for longer periods.
For this reason, it’s important to remember that the stages theory is a historical model intended to be descriptive—even though it’s often misused today as a “prescription for grieving,” Dr. O’Connor said.
“We now know through much larger studies … not everyone goes through all of those experiences, and they certainly don’t go through them in order, nor is there an end point where people don’t have grief any longer,” Dr. O’Connor said.
Although grief may not go away completely, people with prolonged symptoms have a growing array of treatment options. Dr. Shear’s center trains therapists on the prolonged grief treatment that her team developed with funding from the National Institute of Mental Health. It’s a 16-week, evidence-based program that treats people differently than if they had depression (which prolonged grief disorder is often confused with).
Cognitive behavioral therapy has also shown strong results when led by a therapist who’s familiar with prolonged grief disorder, Dr. Shear said.
“It’s really not a question of making the grief less,” Dr. Shear said. “It’s really a question of helping people come to terms—learn to live with a loss.”
