A Neuroscientific Approach to Bereavement and Prolonged Grief Disorder With Dr Mary-Frances O’Connor

On Thursday, December 15, at the 37th annual Evolution of Psychotherapy in Orlando, Florida, Mary-Frances O’Connor, PhD, associate professor, University of Arizona, Tucson, presented a session focusing on the brain's role in shaping the experience of bereavement and prolonged grief disorder.

Ahead of her session, reTHINK Emerging Thinker, Dr O’Connor, spoke with Psych Congress Network about the following practical clinical takeaways: 

• The brain’s effect on cognition and emotion in the process of adaptation to bereavement;
• The recent updates to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR);
• How the human experience of acute grief battles with instinct; and
• Updates on the research surrounding evidence-based, grief-focused psychotherapy.

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Editor’s note: Responses have been lightly edited for clarity.

Meagan Thistle, Psych Congress Network: How does the brain affect cognition and emotion in the process of adaptation to bereavement?

Dr Mary-Frances O'Connor: In one sense, your brain is a prediction machine. It compiles thousands of days of experience about the world and updates those predictions based on the feedback it receives. If you wake up alone in bed after thousands of days of waking up next to your beloved, the best prediction is not that they have died. In a sense, for your brain, their death hasn’t really happened until many days, weeks, and months pass. Only then does the brain begin to predict their absence more readily than their presence. It is very painful to learn and relearn, that they are really, truly gone over and over again, and what implications this has for your life.

Healthy adaptation after the death of a loved one includes developing, through experience, an updated mental model that accommodates both past and present. A balanced, adapted state often includes “continuing bonds,” or maintaining an enduring sense of caring and connection with the person who died. Neither the relationship with the deceased nor the grief ever disappear, but they take a different form that can exist side by side with the recognition that one has to find a way to live in the world as it is now.

Thistle: In what ways do humans experience acute grief similar to the bonding and separation experienced by animals?

Dr O'Connor: All social mammals have a problem: we go off and explore our world each day, yet we need to keep track of those we have bonded with in order to reunite with them at the end of the day. This is true for many mammals, including prairie voles, a rodent species that pair-bond for life. Prairie voles share a nest, forage together, and care for offspring together. This long-lasting bond is encoded in the epigenetics of their brain. Once the bond has been encoded, the voles’ neurobiology is primed to release stress hormones, like cortisol, if they are separated from a mate.

For humans, too, the expectation that someone we love will be there for us—and we will be there for them—is a fundamental part of our bond. Just like prairie voles, we have a stress response that creates cardiovascular, hormonal, and immune changes when bonds are broken. When our loved ones are alive and away from us, that yearning is useful, even critical for survival. It motivates us to seek them out or make enough of a fuss that they come to find us. But, the death of a loved one is the rare experience in which that seeking-them-out solution is no longer a solution to their absence.

Thistle: Prolonged Grief Disorder was recently recognized and included by the DSM-5-TR. How will, and how has, the addition of this new diagnosis impact clinical practice?

Dr O'Connor: Randomized control trials funded by NIH over the past dozen years have shown that targeted psychotherapy can help people who have struggled with prolonged grief disorder for years. For example, prolonged grief disorder treatment, includes developing a number of different skills, including understanding grief (psychoeducation), managing emotions, seeing a promising future, strengthening relationships, narrating the story of the death, learning to live with reminders, and connecting with memories of the person who died.

For some people, they are not able to get past the ‘stuck points’ that are quite natural in grieving, but persist longer in some people than others. So, if a year after the death of a loved one a person is flexibly able to move into and out of waves of grief, can find connection with their friends and family, and find moments of enjoyment in the day, then they do not need intervention. Although grief is a natural reaction whenever we become aware of the absence of a loved one, and that never goes away, we can find ways to still have a good life, however we define that personally, even after devastating loss.

Importantly, research has shown us that people can have both major depression and also prolonged grief. But, careful studies have shown us that they are distinct and evidence-based, grief-focused psychotherapy is a better treatment for prolonged grief than evidence-based therapy for depression.

These randomized clinical trials have also shown that anti-depressants do not alleviate yearning, a hallmark of prolonged grief disorder, although they may help symptoms of depression in bereavement.

Mary-Frances O’Connor, PhD, is an associate professor of psychology at the University of Arizona, Tucson, where she directs the Grief, Loss and Social Stress (GLASS) Lab, which investigates the effects of grief on the brain and the body. Her work primarily focuses on trying to tease out the mechanisms that cause ongoing or severe reactions to loss. In particular, she is curious about the neurobiological, immune, and cardiovascular factors that vary between individual grief responses. Dr O’Connor earned a doctorate in clinical psychology from the University of Arizona in 2004. Following a faculty appointment at UCLA Cousins Center for Psychoneuroimmunology, she returned to the University of Arizona in 2012. She is the author of “The Grieving Brain: The Surprising Science of How We Learn from Love and Loss.” Her work has been published in the American Journal of Psychiatry, Biological Psychiatry, and Psychological Science, and featured in Newsweek, The New York Times, and The Washington Post.