Complicated Grief and the Inner Clock

Originally published in:
Abigail Strubel, MA, LCSW, CASAC​

Complicated Grief and the Inner Clock

When is poor sleep a sign of a broken heart?


One of my most poignant patient interactions in the methadone program where I used to work was with a 73-year old woman I’ll call Maria. She suffered from numerous health problems in addition to her heroin addiction, including obesity, diabetes, a bout with breast cancer in her 40s, high blood pressure and elevated cholesterol levels.

But when I met with Maria to discuss enrolling in a geriatric case management program to help her better handle her health issues, all she could talk about was her late daughter, Isabel. How beautiful Isabel had been, how young when she passed away, what a perfect companion she was, and how lost and lonely Maria felt without her.

“I don’t care if the cancer comes back,” she told me. “Without Isabel, my life is pointless. I just want her with me again. I miss her so much. It feels like she died just yesterday.”

In fact, Isabel had died more than 15 years prior to our conversation. Maria’s feelings were typical of someone experiencing complicated grief, which is defined as negative feelings related to a loss that persist for at least six months, and impair a person’s ability to cope with and enjoy life. One prominent symptom of complicated grief is sleep problems.

“Are you having trouble sleeping?” I asked.

“I don’t fall asleep for a long time,” Maria said. “I toss and turn. I wake up at 2, 3 a.m. and I can’t fall back asleep.”

“Are you tired during the day?” I asked.

“Always,” she admitted.

Maria was describing problems with the four essential components of sleep:

  • Sleep quality, or feeling rested after waking up in the morning;
  • Sleep duration, or the total number of hours slept;
  • Sleep efficiency, or the amount of time spent asleep while in bed; and
  • Sleep disturbance, which includes the terminal insomnia Maria experienced

Trauma leaves an impact on the brain. MRI’s of individuals suffering from complicated grief shows abnormalities in the areas of the brain that involve emotion regulation, memory, and concentration. The loss of a loved one leaves a hole in our emotional safety net: the closeness and support we depend on to manage our lives.

More than just an emotional void, however, the physical absence of a loved one can lead to dysregulation in our body’s circadian rhythms, which constantly respond to events and elements in our environment to regulate our bodily functions. Research suggests that beyond the emotional deprivation, a change in the environment confuses the body’s biological clock. These changes may seem small — for example, no longer sleeping next to a spouse, or having someone remind us it’s bedtime. However, they can be significant because they disturb our patterns of rest and activity, and can affect any of the four components of sleep.

Survivors of loss may feel disoriented, out of control, and unable to function — and dysregulation of circadian rhythms can make them more vulnerable to a host of physical problems in addition to emotional pain. If our body’s homeostasis — the metabolic balance it strives to maintain — is disturbed by this dysregulation, medical issues may develop or be exacerbated.

A woman in her late fifties when she lost her daughter, Maria was demographically close to the group most at risk for developing complicated grief: women in their 60s. And her prolonged grief might have been contributing to her health issues — not the diabetes, which was diagnosed prior to Isabel’s passing, but almost certainly her cardiovascular health and poor sleep quality.

Complicated grief is an abnormal reaction to bereavement, but it is treatable. There is hope for people like Maria who suffer from complicated grief and experience difficulty recovering optimal functioning. The Center for Complicated Grief at Columbia offers therapists trained in bereavement counseling, as well as training for mental health professionals and information and resources about grief and bereavement. Treatment for the emotional and cognitive components of complicated grief often leads to sleep improvement as well.