Disrupted prefrontal activity during emotion processing in complicated grief: An fMRI investigation

The impact of psychosocial adversity on brain and behaviour: an overview of existing knowledge and directions for future research

Environmental experiences play a critical role in shaping the structure and function of the brain. Its plasticity in response to different external stimuli has been the focus of research efforts for decades. In this review, we explore the effects of adversity on brain's structure and function and its implications for brain development, adaptation, and the emergence of mental health disorders. We are focusing on adverse events that emerge from the immediate surroundings of an individual, i.e., microenvironment. They include childhood maltreatment, peer victimisation, social isolation, affective loss, domestic conflict, and poverty. We also take into consideration exposure to environmental toxins. Converging evidence suggests that different types of adversity may share common underlying mechanisms while also exhibiting unique pathways. However, they are often studied in isolation, limiting our understanding of their combined effects and the interconnected nature of their impact. The integration of large, deep-phenotyping datasets and collaborative efforts can provide sufficient power to analyse high dimensional environmental profiles and advance the systematic mapping of neuronal mechanisms. This review provides a background for future research, highlighting the importance of understanding the cumulative impact of various adversities, through data-driven approaches and integrative multimodal analysis techniques.

Neural correlates of deceased-related attention during acute grief in suicide-related bereavement

BACKGROUND

Individuals who have lost a loved one to suicide demonstrate an attentional bias to deceased-related stimuli during early grief. Regulating attention toward reminders of the deceased during acute bereavement may be linked to grief trajectory and pathological grief development. Despite the potential prognostic importance, little is known about underlying neural circuitry correlates of deceased-related grief processing. The current study examines neural substrates of deceased-related attentional processing during acute grief in individuals bereaved by suicide.

METHODS

Thirty-seven participants grieving the loss of a first-degree relative or partner to suicide in the prior six months, underwent functional magnetic resonance imaging (fMRI) while performing an emotional Stroop task using words related to the deceased and a living attachment figure, in order to examine neural correlates of deceased-specific attentional processing. Clinical interviews were conducted at baseline.

RESULTS

Deceased-related attentional bias was associated with blood oxygen level-dependent (BOLD) activation in a brain network, including dorsolateral prefrontal cortex (dlPFC), ventrolateral prefrontal cortex (vlPFC), orbitofrontal cortex (OFC), and insula. Greater activation of a bilateral prefrontal cluster during deceased-specific attention was negatively correlated with self-reported grief avoidance behaviors.

LIMITATIONS

Lack of non-suicide grief control and small sample size.

CONCLUSIONS

These data, if confirmed, indicate a neural network specific to deceased-related attention, and that cognitive control regions within this network appear to be related to grief avoidance behaviors during acute bereavement.

From love to pain: is oxytocin the key to grief complications?

While most adults confronted with the death of a loved one manage to grieve, about 10-20% of individuals develop complicated grief, characterized by persistent distress and impaired social skills, or pathological grief, defined by the onset or decompensation of a psychiatric disorder. Little is known about the biological causes of these grief complications. Recent work suggests that oxytocin, a major neuroendocrine hormone regulating many neurocognitive mechanisms, may be involved in this process. Oxytocin is widely studied and well known for its impact on the mother-child bond and hormonal and brain systems related to attachment and social interactions. In this article, we propose a neurocognitive model of grief complications based on existing data on the role of oxytocin in interpersonal attachment and its impact on brain activity. We suggest that complicated grief is associated with dysfunctional cerebral oxytocinergic signaling and persistent hyperactivation of the nucleus accumbens. This mechanism is involved in limiting the reduction of interpersonal attachment to the deceased during acute phases and in searching for new interpersonal relationships during the recovery phase. We show how the exploration of cerebral oxytocinergic signaling would improve the understanding of physiological grief mechanisms in the general population and could allow the development of new therapeutic perspectives against the complications of grief.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Neurobiology of Loneliness, Isolation, and Loss: Integrating Human and Animal Perspectives

In social species such as humans, non-human primates, and even many rodent species, social interaction and the maintenance of social bonds are necessary for mental and physical health and wellbeing. In humans, perceived isolation, or loneliness, is not only characterized by physical isolation from peers or loved ones, but also involves negative perceptions about social interactions and connectedness that reinforce the feelings of isolation and anxiety. As a complex behavioral state, it is no surprise that loneliness and isolation are associated with dysfunction within the ventral striatum and the limbic system - brain regions that regulate motivation and stress responsiveness, respectively. Accompanying these neural changes are physiological symptoms such as increased plasma and urinary cortisol levels and an increase in stress responsivity. Although studies using animal models are not perfectly analogous to the uniquely human state of loneliness, studies on the effects of social isolation in animals have observed similar physiological symptoms such as increased corticosterone, the rodent analog to human cortisol, and also display altered motivation, increased stress responsiveness, and dysregulation of the mesocortical dopamine and limbic systems. This review will discuss behavioral and neuropsychological components of loneliness in humans, social isolation in rodent models, and the neurochemical regulators of these behavioral phenotypes with a neuroanatomical focus on the corticostriatal and limbic systems. We will also discuss social loss as a unique form of social isolation, and the consequences of bond disruption on stress-related behavior and neurophysiology.

Grieving as a form of learning: Insights from neuroscience applied to grief and loss

Recent grief research suggests that the influential cognitive stress theory should be updated with evidence from cognitive neuroscience. Combining human and animal neuroscience with attachment theory, we propose that semantic knowledge of the everlasting nature of the attachment figure and episodic, autobiographical memories of the death are in conflict, perhaps explaining the duration of grieving and generating predictions about complications in prolonged grief disorder (PGD). Our gone-but-also-everlasting model emphasizes that grieving may be a form of learning, requiring time and experiential feedback. Difficulties before loss, such as spousal dependency or pre-existing hippocampal volume, can prolong learning and predict PGD. Complications such as avoidance, rumination, and stress-induced hippocampal atrophy may also develop after loss and create functional or structural mechanisms predicting PGD.

Why do mothers never stop grieving for their deceased children? Enduring alterations of brain connectivity and function

A child's death is a profound loss for mothers and affects hundreds of thousands of women. Mothers report inconsolable and progressive grief that is distinct from depression and impacts daily emotions and functions. The brain mechanisms responsible for this relatively common and profound mental health problem are unclear, hampering its clinical recognition and care. In an initial exploration of this condition, we used resting state functional MRI (fMRI) scans to examine functional connectivity in key circuits, and task-based fMRI to examine brain network activity in grieving mothers in response to pictures of their deceased child and as well as recognizable deceased celebrities and unfamiliar individuals. We compared nine mothers who had lost an adult child and aged-matched control mothers with a living child of a similar age. Additionally, we collected diffusion imaging scans to probe structural connectivity and complemented the imaging studies with neuropsychological assessments. Increased functional activation in Ventral Attention/Salience Networks accompanied by a reduced activation in the medial prefrontal cortex in response to the deceased child's picture robustly distinguished the grieving mothers from controls. Heightened resting-state functional connectivity between the paraventricular thalamic nucleus (PVT) and the amygdala distinguished the grieving mothers from the controls and correlated with subjective grief severity. Structurally, maternal grief and its severity were associated with alterations in corticolimbic white matter tracts. Finally, grieving mothers performed worse than controls on neuropsychological tests of learning, memory, and executive function, linked with grief severity. Reduced activation in cortical regions inhibiting emotions and changes in the PVT circuitry-a region involved in long-term emotional memories and decision making under conflict-distinguish grieving mothers from controls. Notably, the magnitude of neurobiological changes correlates with the subjective severity of grief. Together, these new discoveries delineate a prevalent and under-recognized mental health syndrome and chart a path for its appreciation and care.

Grief: Aetiology, Symptoms and Management

Grief is a process provoked as a response to different losses, such as death, loss of job, relationship breakdown, some unexpected life events and changes, etc. The experiences of loss and bereavement are very individual. Even though loss is expected, the person feels traumatized, especially if death is provoked by violence, natural disasters, or war. This pandemic, like other disasters (wars, tsunami, earthquakes, floods, etc.) has provoked intensive reactions of grief, reactions that could persist for years. The core symptoms of grief are described in the ICD-11 and DSM-5 manuals. The term "complicated grief" in the medical sense refers to a superimposed process that alters grief and modifies its course for the worse. Prolonged grief disorder (PGD) is characterized by normal grief symptoms, but these are symptoms that remain too intense for too long of a period. This article is a review of the manifestations and duration of grief in different occasions, and it is based on over 50 published papers, and discoveries in the Medline and Psych-Net databases. Commonly described reactions to grief are: shock, disbelief or denial, a high level of anxiety, distress, anger, sadness, insomnia, and a loss of appetite. As predictors for a high/slow decreasing trajectory of grief process are: female gender, reported symptoms of depression before the traumatic event, and higher scores on avoidance. However, grief is transient, even as we are is in the midst of its clutches. People should expect to fluctuate between moments of sadness and mourning, and moments of acceptance, or even happiness for being alive. Researchers suppose that when a crisis passes; most people will be able to bounce back and move on with their lives.

Risk and protective factors of relapse in patients with first-episode schizophrenia from perspectives of health professionals: a qualitative study in northeastern Thailand

Background:  Schizophrenia is a serious mental illness that can relapse after treatments. Risk and protective factors for relapse are dependent on multicultural contexts.

Objective: To identify risk and protective factors related to relapse in first-episode schizophrenia (FES) in northeastern Thailand from perspectives of health professionals.

Methods: This qualitative research collected data from 21 health professional staff members (psychiatric nurses, psychiatrists, psychologists, social workers, occupational therapists and nutritionist) of a tertiary psychiatric hospital of northeastern Thailand who had been involved in mental health care for schizophrenia for at least 5 years by in-depth interviews and group interview using semi-structured interview schedule. Content analyses was used to identify staff perception of factors that put patients at risk of relapse.

Results: Data analyses demonstrated that factors related to relapse in FES patients were drug adherence (drug discontinuation, limited access to new generation drugs, self-dose reduction and skipping medication, and poor insight), family factors (stressful circumstances and family supports), substance abuses (narcotics, addictive substances, caffeinated drinks), concurrent medical illness (insomnia, thyroid diseases, and pregnancy-related hormonal changes), and natural course of disease. 

Conclusion: Factors affecting relapse in FES was not only drug adherence. Family factors, drug abuses, and concurrent health status should be also taken into account. A comprehensive mental health care program should be developed for FES patients in the region.

Neuropsychological Comparison of Guilt and Grief: A Review of Guilt Aspects in Prolonged Grief Disorder

Taking an integrative approach toward developmental psychology and neurophysiology, this review selects findings from the psychological and medical literature on guilt and bereavement that are relevant to considering whether and how guilt contributes to the development of prolonged grief disorder (PGD) in bereaved persons. Mention of guilt is ubiquitous in literature on general grief and PGD, including 54 articles related to the neuropsychological development and manifestations of guilt and grief, as well as their neuroimaging correlates, that met scoping review criteria. However, mechanisms connecting guilt to development of PGD are scarce. Aspects of guilt are conceptually connected to many PGD criteria, opening avenues to explore treatment of PGD by targeting guilt. Positive and prosocial aspects of guilt are especially neglected in the treatment of psychiatric disorders, and consideration of these aspects may improve interventions for PGD such as complicated grief treatment.

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

Distinct neural mechanisms of emotional processing in prolonged grief disorder

BACKGROUND

Prolonged grief disorder (PGD) has recently been recognized as a separate psychiatric diagnosis, despite controversy over the extent to which it is distinctive from posttraumatic stress disorder (PTSD) and major depressive disorder (MDD).

METHODS

This study investigated distinctive neural processes underpinning emotion processing in participants with PGD, PTSD, and MDD with functional magnetic resonance study of 117 participants that included PGD (n = 21), PTSD (n = 45), MDD (n = 26), and bereaved controls (BC) (n = 25). Neural responses were measured across the brain while sad, happy, or neutral faces were presented at both supraliminal and subliminal levels.

RESULTS

PGD had greater activation in the pregenual anterior cingulate cortex (pgACC), bilateral insula, bilateral dorsolateral prefrontal cortices and right caudate and also greater pgACC-right pallidum connectivity relative to BC during subliminal processing of happy faces. PGD was distinct relative to both PTSD and MDD groups with greater recruitment of the medial orbitofrontal cortex during supraliminal processing of sad faces. PGD were also distinct relative to MDD (but not PTSD) with greater activation in the left amygdala, caudate, and putamen during subliminal presentation of sad faces. There was no distinction between PGD, PTSD, and MDD during processing of happy faces.

CONCLUSIONS

These results provide initial evidence of distinct neural profiles of PGD relative to related psychopathological conditions, and highlight activation of neural regions implicated in reward networks. This pattern of findings validates current models of PGD that emphasize the roles of yearning and appetitive processes in PGD.

History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis

Prolonged grief disorder (PGD) is a diagnostic entity now included in the International Classification of Diseases 11th Revision (ICD-11) and soon to appear in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). A characteristic feature of PGD is distressing, disabling yearning that persists a year or more after the loss. Other characteristic symptoms include disbelief and lack of acceptance of the loss, emotional detachment from others since the loss, loneliness, identity disturbance, and sense of meaninglessness. In this review, we detail psychiatric views on grief and their evolution over the twentieth century. We then discuss the development of diagnostic formulations for disordered grief, which culminated in PGD's status as a mental disorder in the DSM. After summarizing recent evidence that may suggest that PGD is linked to the neural reward system, we suggest further areas of research. In particular, we note the need for studies that extend the evidence base concerning PGD across cultural and sociodemographic boundaries and that investigate novel treatments.

Amygdala Functional Connectivity Features in Grief: A Pilot Longitudinal Study

OBJECTIVE

Acute grief, in an important minority of older adults, can become protracted, intense, and debilitating, leading to the development of complicated grief (CG). However, the neurobiologic mechanisms underlying a maladaptive grief response after an attachment loss are unknown. The current study aimed to examine the amygdala brain network features that cross-sectionally explain the symptom variance and longitudinally relate to grief symptom trajectories after an attachment loss.

METHODS

Baseline amygdala functional connectivity (Fc) was assessed using a seed-based resting-state functional magnetic resonance imaging method in 35 adults who were within 1-year after death of a loved one and 21 healthy comparison (HC) participants. Magnetic resonance imaging scans were obtained at baseline, and clinical assessments, including the inventory of complicated grief (ICG) were completed at weeks 0, 8, 16, and 26 (endpoint).

RESULTS

Relative to HC participants, grief participants showed increased amygdala Fc in the posterior default mode (bilateral medial temporal lobes and left precuneus) and thalamus. Amygdala Fc in the default mode and ventral affective regions positively correlated with ICG scores at baseline. Furthermore, increased baseline amygdala functional connections with the dorsal frontal executive control and salience network regions correlated with worsening ICG scores over time. These longitudinal findings persisted after controlling for covariates, including baseline depressive and anxiety symptoms.

CONCLUSION

These results provide novel preliminary evidence suggesting amygdala-based brain network measures to cross-sectionally explain symptom variance and longitudinally correlate with grief symptom trajectories in grievers. Amygdala brain network function measures may have the potential to serve as biomarkers of CG.

The neurobiological reward system in Prolonged Grief Disorder (PGD): A systematic review

Prolonged Grief Disorder (PGD) is a debilitating condition affecting between 7% and 10% of bereaved individuals. Past imaging and psychological studies have proposed links between PGD's characteristic symptoms - in particular, profound yearning - and the neural reward system. We conducted a systematic review to investigate this connection. On December 19, 2019, we searched six bibliographic databases for data on the neurobiology of grief and disordered grief. We excluded studies of the hypothalamic-pituitary-adrenal (HPA) axis, animal studies, and reviews. After abstract and full-text screening, twenty-four studies were included in the final review. We found diverse evidence for the activation of several reward-related regions of the brain in PGD. The data reviewed suggest that compared to normative grief, PGD involves a differential pattern of activity in the amygdala and orbitofrontal cortex (OFC); likely differential activity in the posterior cingulate cortex (PCC), rostral or subgenual anterior cingulate cortex (ACC), and basal ganglia overall, including the nucleus accumbens (NAc); and possible differential activity in the insula. It also appears that oxytocin signaling is altered in PGD, though the exact mechanism is unclear. Our findings appear to be consistent with, though not confirmative of, conceptualizing PGD as a disorder of reward, and identify directions for future research.

Do Coping Strategies Differentially Mediate the Relationship Between Emotional Closeness and Complicated Grief and Depression?

Although complicated grief (CG) following the death of a loved one has traditionally been viewed as avoidance-driven, recent research implicates approach behavior. Researchers have investigated how coping styles predict CG; however, emotional closeness remains unexamined. This study investigated the differential relationship of approach- and avoidance-focused coping on CG and depressive symptoms. Bereaved adults ( n = 340) completed questionnaires about their loss, coping styles, CG, and depression. Results suggest that approach-, but not avoidance-, focused coping mediates the relationship of emotional closeness on CG, while emotional closeness of the relationship had no direct impact on depressive symptoms. This suggests closeness of the relationship plays a unique role in CG.

Two Cases of Persistent Complex Bereavement Disorder Diagnosed in the Acute Inpatient Unit

Pathological grief has been noted to have considerable adverse effects on affected individuals. In the DSM-5, the diagnosis of complicated grief is included under conditions for further study as Persistent Complex Bereavement Disorder (PCBD). PCBD can be easily missed because it is a relatively new and developing diagnosis. It can also be overlooked when it is comorbid with more common psychiatric disorders. We present 2 patients with PCBD diagnosed in the inpatient unit, while the patients were admitted for comorbid disorders. PCBD contributed immensely to both patients' suffering and decline in functioning. This report highlights the presentation, diagnoses, and management of these patients. We theorize that paying attention to separation distress, reactive distress to loss, and identity disruption in individuals who have been bereaved for over 12 months will enhance treatment specificity and lead to better patient outcomes.

Increased Amygdala Activations during the Emotional Experience of Death-Related Pictures in Complicated Grief: An fMRI Study

Complicated grief (CG) is associated with alterations in various components of emotional processing. The main aim of this study was to identify brain activations in individuals diagnosed with CG while they were observing positive, negative, and death-related pictures. The participants included 19 individuals with CG and 19 healthy non-bereaved (NB) individuals. Functional magnetic resonance imaging (fMRI) scans were obtained during an emotional experience task. The perception of death-related pictures differed between the CG group and the NB group, with a greater activation in the former of the amygdala, putamen, hypothalamus, middle frontal gyrus, and anterior cingulate cortex. Amygdala and putamen activations were significantly correlated with Texas Revised Inventory of Grief scores in the CG group, suggesting that the higher level of grief in this group was associated with a greater activation in both brain areas while watching death-related pictures. A significant interaction between image type and group was observed in the amygdala, midbrain, periaqueductal gray, cerebellum, and hippocampus, largely driven by the greater activation of these areas in the CG group when watching death-related pictures and the lower activation when watching positive-valence pictures. In this study, individuals with CG showed significantly distinct brain activations in response to different emotional images.

Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans

BACKGROUND

Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes.

METHODS

To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial.

RESULTS

CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011).

CONCLUSIONS

Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.

Grief: A Brief History of Research on How Body, Mind, and Brain Adapt

OBJECTIVE

Using an integrative view of psychology, neuroscience, immunology, and psychophysiology, the present review of literature curates the findings that have had an impact on the field of bereavement research and shaped its development.

METHODS

Beginning with pivotal systematic descriptions of medical and psychological responses to the death of a loved one by Lindemann in the mid-1940s, this selective review integrates findings in bereavement research from studies that investigate medical outcomes after loss, their psychological predictors, and biopsychosocial mechanisms.

RESULTS

Morbidity and mortality after the death of a loved one have long been a topic of research. Early researchers characterized somatic and psychological symptoms and studied immune cell changes in bereaved samples. More recent research has repeatedly demonstrated increased rates of morbidity and mortality in bereaved samples, as compared with married controls, in large epidemiological studies. Recent developments also include the development of criteria for prolonged grief disorder (also termed complicated grief). Newer methods, including neuroimaging, have observed that the greatest impact of the death of a loved one is in those who have the most severe psychological grief reactions. Research addressing the mechanisms tying bereavement to medical outcomes is relatively scarce, but differences in rumination, in inflammation, and in cortisol dysregulation between those who adapt well and those who do not have been offered with some evidence.

CONCLUSIONS

Recommendations to propel the field forward include longitudinal studies to understand differences between acute reactions and later adaptation, comparing samples with grief disorders from those with more typical responses, and integrating responses in brain, mind, and body.

Emotion, Social Relationships, and Physical Health: Concepts, Methods, and Evidence for an Integrative Perspective

Emotional characteristics and processes are robust predictors of the development and course of major medical illnesses and premature mortality, as are a variety of indicators of the presence and quality of personal relationships. Despite clear evidence of close interconnection between these two domains of risk and protection, affective characteristics and relationships have largely been studied separately as influences on health. After a recent conference on integrative perspectives on emotions, relationships and health co-sponsored by the American Psychosomatic Society and the Society for Affective Science, the present review builds on prior calls for integration, related theory, and current research to outline what is known about the interconnection of these domains as it specifically relates to their overlapping influences on health. Areas of interest include the following: their interconnected roles over the course of development, which may inform current efforts to understand the influence of early life events on adult health; the parallel positive and negative factors in both domains that could have distinct influences on health; the role of emotion regulation in relationship contexts; and measurement, design, and analysis approaches to capture the dyadic and dynamic aspects of these interconnected influences on health. We conclude with a discussion of an emerging research agenda that includes the following: common biological foundations of affective and relationship processes, the cultural embeddedness of affective and relationship processes, the potential contribution of affective-relational processes to health disparities, and implications for intervention research.

Prolonged grief disorder: Its co-occurrence with adjustment disorder and post-traumatic stress disorder in a bereaved Israeli general-population sample

BACKGROUND

Prolonged grief disorder (PGD) is a new disorder included in the WHO International Classification of Diseases 11th version (ICD-11). This study is the first to use these new ICD-11 PGD guidelines to examine prevalence rates, predictors of PGD and disorder co-occurrence with other stress-related disorders in a survey of 544 bereaved Israelis.

METHODS

Descriptive statistics, correlation, linear regression and mediation analysis examined the validity of the ICD-11 diagnostic algorithm.

RESULTS

Prevalence of PGD in the Israeli population sample is low (2%). The prevalence rate of post-traumatic stress disorder (PTSD) was 7.2% and for adjustment disorder (AjD) was 17.8%. A significant positive correlation found between scores on these measures indicates concurrent validity. Mediation analysis found that symptoms of PGD were predicted by serious life events, and significantly mediated by symptoms of PTSD and AjD. A regression analysis found significant predictors of PGD symptom severity, including socio-demographic and person-specific predictors.

LIMITATIONS

This study did not assess the index-death of the grief questionnaire. No conclusions could be made regarding the relationship between the type of loss and grief severity. Furthermore, the time since loss (time criterion) was not assessed.

CONCLUSIONS

This study is the first to examine prevalence rates of ICD-11 PGD in a population-based survey. The mediation relationship between serious life events, AjD, PTSD and PGD supports a vulnerability model of stress related disorders whereby the number of stressful life events may predict symptoms of stress related disorders.

Yearning predicts subgenual anterior cingulate activity in bereaved individuals

Complicated grief, or persistent complex bereavement disorder, is a condition that affects approximately 10% of bereaved individuals and is marked by intense longing and yearning for the deceased. Little is known about the neurocognitive mechanisms contributing to this syndrome, but previous research suggests that reward pathways in the brain may play a role. Twenty-five older adults were categorized based on grief severity into one of three groups: complicated grief (CG), non-complicated grief (NCG) and non-bereaved married controls (NB). Neural activation was examined using fMRI while participants viewed a countdown on the screen (anticipation) followed by a photo of their (living or deceased) spouse. There was no significantly differential activation between the three groups for the spouse v. stranger photo contrast, nor for anticipation period v. spouse photo. Post-hoc analyses were conducted using self-reported yearning scores as a regressor across all bereaved participants, which revealed that greater symptoms of yearning predicted greater activation in the subgenual anterior cingulate cortex (sgACC). Given the small sample size, the results should be considered preliminary and in need of replication, but may suggest a more nuanced, transdiagnostic role of the sgACC. This region of the brain has been previously linked to depression and suggests that symptoms of yearning may present an opportune place to intervene to improve outcomes in CG.

Self-generated Unconscious Processing of Loss Linked to Less Severe Grieving

BACKGROUND

The intense loss processing that characterizes grieving may help people to adapt to the loss. However, empirical studies show that more conscious loss-related thinking and greater reactivity to reminders of the deceased correspond to poorer adaptation. These findings raise the possibility that loss processing that is unconscious rather than conscious and is self-generated rather than reactive may facilitate adaptation. Here, we used machine learning to detect a functional magnetic resonance imaging (fMRI) signature of self-generated unconscious loss processing that we hypothesized to correlate with lower grief severity.

METHODS

A total of 29 subjects bereaved within the past 14 months participated. Participants performed a modified Stroop fMRI task using deceased-related words. A machine-learning regression, trained on Stroop fMRI data, learned a neural pattern for deceased-related selective attention (d-SA), the allocation of attention to the deceased. Expression of this pattern was tracked during a subsequent sustained attention fMRI task interspersed with deceased-related thought probes (SART-PROBES). d-SA pattern expression during SART-PROBES blocks without reported thoughts of loss indicated self-generated unconscious loss processing. Grief severity was measured with the Inventory for Complicated Grief.

RESULTS

d-SA expression during SART-PROBES blocks without conscious deceased-related thinking correlated negatively with Inventory for Complicated Grief score (r₂₅ = -.711, p < .001, 95% confidence interval = -0.89 to -0.42), accounting for 50% of variance. This relationship remained significant independent of demographic correlates of Inventory for Complicated Grief (B₂₅ = -30, t = -2.64, p = .02, 95% confidence interval = -56.2 to -4.6). Unconscious d-SA pattern expression also correlated with activity in dorsolateral prefrontal cortex and temporal parietal junction during the SART-PROBES (voxel: p < .001, cluster: p < .05).

CONCLUSIONS

Self-generated unconscious loss processing correlated with reduced grief severity. This activity, supported by a cognitive social neural architecture, may advance adaptation to the loss.

Bereavement hallucinations after the loss of a spouse: Associations with psychopathological measures, personality and coping style

Bereavement hallucinations (BHs) were assessed in 175 conjugally bereaved participants 4 years post loss, to explore whether BHs were: (a) associated with psychological distress and (b) predicted by sociodemographic variables, personality and/or coping style. Participants with BHs scored significantly higher than those without BHs on prolonged grief, post-traumatic stress, depression symptoms, and emotional loneliness. Hierarchical logistic regression analysis showed avoidant coping, openness to experience, and length of marriage to significantly predict BHs, while detached coping was negatively associated with BHs. This study suggests that BHs may be an indicator of psychological distress in bereavement.

The iconography of mourning and its neural correlates: a functional neuroimaging study

The present functional neuroimaging study focuses on the iconography of mourning. A culture-specific pattern of body postures of mourning individuals, mostly suggesting withdrawal, emerged from a survey of visual material. When used in different combinations in stylized drawings in our neuroimaging study, this material activated cortical areas commonly seen in studies of social cognition (temporo-parietal junction, superior temporal gyrus, and inferior temporal lobe), empathy for pain (somatosensory cortex), and loss (precuneus, middle/posterior cingular gyrus). This pattern of activation developed over time. While in the early phases of exposure lower association areas, such as the extrastriate body area, were active, in the late phases activation in parietal and temporal association areas and the prefrontal cortex was more prominent. These findings are consistent with the conventional and contextual character of iconographic material, and further differentiate it from emotionally negatively valenced and high-arousing stimuli. In future studies, this neuroimaging assay may be useful in characterizing interpretive appraisal of material of negative emotional valence.

Attentional Bias to Reminders of the Deceased as Compared With a Living Attachment in Grieving

BACKGROUND

Grieving individuals demonstrate attentional bias toward reminders of the deceased versus neutral stimuli. We sought to assess bias toward reminders of the deceased versus a living attachment figure and to evaluate similarities and differences in the neural correlates of deceased- and living-related attention. We also sought to identify grief process variables associated with deceased-related attentional bias.

METHODS

Twenty-five subjects grieving the death of a first-degree relative or partner within 14 months performed an emotional Stroop task, using words related to a deceased or a living attachment figure, and a standard Stroop task, to identify general selective attention, during functional magnetic resonance imaging. Subjects rated word sadness, complicated grief symptoms, depression severity, attachment style, emotional pain, nonacceptance, yearning, and intrusions.

RESULTS

We identified an attentional bias to deceased-related versus living-related words, independent of age, depression severity/history, loss type, word sadness, medication use, and time since loss. Attentional bias correlated with complicated grief severity and intrusive thinking. A conjunction analysis identified joint activation in the fusiform gyrus, posterior cingulate, and temporal parietal junction across living- and deceased-related attention versus general selective attention. Insecure-avoidant attachment style correlated with decreased engagement of this network in deceased-related attention.

CONCLUSIONS

We have demonstrated an attentional bias to reminders of the deceased versus a living attachment in grieving. Overlapping neural circuits related to living- and deceased-related attention suggest that the bereaved employ similar processes in attending to the deceased as they do in attending to the living. Deceased-related attentional bias appears to be linked primarily to intrusive thinking about the loss.

Assessment of Emotional Experience and Emotional Recognition in Complicated Grief

There is substantial evidence of bias in the processing of emotion in people with complicated grief (CG). Previous studies have tended to assess the expression of emotion in CG, but other aspects of emotion (mainly emotion recognition, and the subjective aspects of emotion) have not been addressed, despite their importance for practicing clinicians. A quasi-experimental design with two matched groups (Complicated Grief, N = 24 and Non-Complicated Grief, N = 20) was carried out. The Facial Expression of Emotion Test (emotion recognition), a set of pictures from the International Affective Picture System (subjective experience of emotion) and the Symptom Checklist 90 Revised (psychopathology) were employed. The CG group showed lower scores on the dimension of valence for specific conditions on the IAPS, related to the subjective experience of emotion. In addition, they presented higher values of psychopathology. In contrast, statistically significant results were not found for the recognition of emotion. In conclusion, from a neuropsychological point of view, the subjective aspects of emotion and psychopathology seem central in explaining the experience of those with CG. These results are clinically significant for psychotherapists and psychoanalysts working in the field of grief and loss.