Echoes of the Rupture: Anguish in Prolonged Grief Disorder

Abstract

Background: Prolonged Grief Disorder (PGD) is a newly recognized diagnostic category in the ICD-11 and DSM-5-TR, defined by persistent yearning and preoccupation with the deceased. Despite established diagnostic criteria, there remains a gap in capturing the lived experience of patients, who often report a profound suffering that exceeds standard symptom checklists. This profound suffering aligns with the phenomenological concept of “anguish,” an affective state where existence feels threatened, constricted, and stripped of its future horizons.
Methods: This article utilizes a conceptual and historical framework to argue that anguish deserves standing as a core affective construct in PGD. The paper synthesizes existential philosophy and phenomenological with contemporary clinical, epidemiological, and neurobiological research concerning severe grief.
Results: The phenomenology of anguish in PGD is organized across four distinct dimensions: embodied anguish characterized by somatic constriction and chest tightness, temporal rupture involving deep desynchronization where time feels frozen, self-world disturbance marked by a breakdown of identity and affective trust, and diffuse existential insecurity. Neurobiologically, this phenomenological state corresponds to alterations in the brain’s reward and pain circuits hypothalamic-pituitary-adrenal (HPA) axis dysregulation and autonomic disarray. While anguish can operate as a transdiagnostic affective process, its presentation in PGD is uniquely characterized by the paradox of the deceased’s “presence in absence”.
Conclusions: Standard assessment tools operationalize diagnostic criteria but do not directly assess the distinct existential and somatic features of anguish. Utilizing a phenomenology-informed case formulation allows clinicians to capture the depth of this self-world disturbance. To effectively treat PGD, evidence-based therapies must integrate narrative, temporal, and body-oriented interventions to address the profound ruptures in the patient’s relational and embodied existence, ultimately facilitating a more comprehensive healing process.