Also known as post-bereavement hallucination and grief hallucination. All three terms are used to denote a heterogeneous group of sensory deceptions occurring in the context of grief over the loss of a spouse or other loved one. The following article is taken from the 4th chapter of The Neuroscience of Visual Hallucinations, p 74-85
Trauma and predisposition to visual hallucinations
Some data suggest an association between trauma and predisposition to both auditory and visual hallucinations in otherwise healthy people, as well as in psychotic patients, in patients with dissociative disorders and in full-blown post-traumatic stress disorder (PTSD). Furthermore, predisposition to hallucinatory experiences seems higher in individuals who have experienced multiple traumas. Beyond a purely epidemiological association, it sees relevant to develop this observation by analyzing predisposing factors that determine the emergence of hallucinatory phenomena in some subjects, but not in others who are exposed to similar traumatic experiences. Meta-cognitive beliefs and dissociative processes have been found to predispose subjects to both auditory and visual hallucination (Morrison and Peterson, 2003). Although dissociation is a complex phenomenon that is not always related to trauma, a classical explanation suggests that trauma leads to dissociative phenomena as a defence mechanism. In line with this view, dissociative mechanisms subsequently predispose to psychotic experiences by dampening reality testing and disrupting both the inner self and the individual’s grounding in the external environment. It seems likely that several mechanisms are involved and that hallucinations in dissociative disorders and PTSD have different features and reflect different processes than psychotic hallucinations. These observations appear in line with the finding that grief hallucinations are more common in hysteroid personality subtypes, that is, personalities intrinsically predisposed to dissociation and with the generally recognized theory that psychotic experiences may emerge as a coping strategy for trauma. Among all traumatic life events, bereavement, emotional abuse, bullying, physical assault and sexual assault have shown the strongest association with predisposition to both auditory and visual hallucinations (Morrison and Peterson, 2003).
Visual hallucinations in the course of bereavement
The term bereavement generally refers to the state of being deprived of something, but is commonly used to describe a period of mourning and grief related to the loss of a close relative. Until a century ago, grief was regarded as a cause of death and to this day it is connected to a variety of physical and mental illnesses. Hallucinatory experiences are often reported during bereavement but they have been poorly investigated to date, and little is known about their epidemiological, psychopathological or neurobiological features. Several cases are described of patients whose visual sensory deprivation predisposed them to visual hallucinations as a symptom of grief reaction (Alroe and McIntyre, 1983; Adair and Keshavan, 1988). Most of the literature on visual hallucinations as grief reactions in the absence of visual or cognitive impairment consists of case reports and a few epidemiological studies. Two interesting descriptions are examined in Box 4.1.
The prevalence of visual hallucinations after bereavement is higher in pathological conditions as when abnormal grief reactions, PTSDs, Charles Bonnet syndrome or reactive psychoses are also present. However, the phenomenon is also described in physiological grief reactions and is generally thought to be largely underestimated. Indeed, the bereaved rarely refer to this experience openly, perhaps for fear of being looked upon as mentally insane and because of the negative connotation of the word ‘hallucination’ in Western culture. A large proportion of widows and widowers never disclose their hallucinatory experiences. Grief hallucinations occur irrespective of ethnicity, creed or domicile, even if some cultural differences may exist. In Japan, where hallucinations are considered normal concomitants of bereavement, none of the bereaved express worry over their sanity (Yamamoto et al., 1969). Education, interpersonal support system or the anticipation of grief related to the circumstances of death also do not seem to influence this phenomenon (Grimby, 1993).
The visual sub-type of hallucination is the most commonly reported in the literature (the bereaved individual often ‘sees’ the deceased), followed by the acoustic and olfactory modalities, while tactile experiences are rare. Within a continuum of abnormal experiences, the ‘feeling’ of the deceased’s presence is the most common hallucinatory experience reported. Felt presence is usually referred to as an illusion, although it is clear phenomenological and neurobiological nature remains elusive and largely left to speculation. Felt presence in the course of bereavement is generally helpful and comforting unlike the other, more fear-evoking and distressing experiences that have been associated with sleep paralysis in otherwise healthy subjects. Hallucinatory experiences usually occur when the bereaved is alone and their duration is variable: they can disappear shortly after mourning or persist for years, sometimes even decades, usually occurring intermittently. They seem most common in the early phases of bereavement, with a prevalence of over 80% of elderly people within the first month of the loss. A 30-60% prevalence of hallucinatory experiences can be estimated among elderly bereaved people. Prevalence rates found across different studies in the general population and in bereaved subjects are examined in Tables 4.3 and 4.4. Little is known about grief hallucinations in younger bereaved individuals or in cases where the deceased is not a spouse but a son, relative or close friend. Most studies suggest that incidence increases with age and the degree of affective bond with the deceased (Rees, 1971). However, some authors found a curvilinear model rather than a linear relationship between age at widowhood and the proportion of the age group reporting hallucinations. Specifically, the age groups 30-39 years and 70-89 years seem to be at particular risk of hallucinatory experiences compared with widows in the 40-69 group (Olson et al., 1985). One strong limitation is that none of the studies systematically excluded the presence of cognitive impairment in the older population. It seems plausible to hypothesize that the higher incidence in the elderly subgroup depends on a lower ability to cope with the loss and to a subtle reduction of cognitive functions. The higher incidence in the younger group could depend on the increased severity of stress experienced.
Awareness in the bereaved: grief (pseudo-)hallucinations?
Although usually referred to as ‘grief hallucinations’, the phenomenological nature of these experiences remains elusive. Little is known about the extent to which reality testing is intact in the bereaved, how vivid and real experiences appear to be, if they are perceived as coming from the outside or from the inner space, and so on. Despite the paucity of data to date and the complexity of the problem, when a psychopathological classification is attempted, it is commonly accepted that grief hallucinations are pseudo-hallucinations. No matter how vivid such visions may be, to the extent that some people report that they act in response to them, reality testing seems preserved in the absence of a pathologic grief reaction associated with a depressive episode (low mood, loss of appetite and weight, sleep disturbances, feelings of guilt and/or anxiety).
These phenomena are usually interpreted as a coping mechanism during bereavement that implies an imaginative fulfilment of the desire for reunion. Grief hallucinations occurring immediately after a loss may be an expression of intensive yearnings for the loved one. Especially in cases of sudden traumatic death, grief hallucinations may contribute towards maintaining an intense bond with the lost object for some time. This usually benign form of coping with bereavement could, however, become dysfunctional, for example, in the context of a psychological background of unsolved neurotic conflicts. According to Sigmund Freud, mourning can be understood in terms of an involuntary withdrawal of object cathexis, that is, libidinal investment, denied by the Ego which strives to substitute the object by immersing itself in fantasy or hallucination (Carhart-Harris et al., 2008).
When do grief hallucinations require treatment?
The vast majority of individuals describe grief hallucinatory experiences as being comforting rather than disturbing. Indeed, many authors consider grief hallucinations as a normal and helpful accompaniment of loss. Grief hallucinations hardly ever require psychiatric treatment. However, the potential medical consequences of disclosing these experiences are problematic, given the implications of hallucinations in contemporary diagnostic systems. Many physicians are unaware of the frequency or existence of this phenomenon among the bereaved. The Mood Disorders Work Group for the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) eliminated the ‘Bereavement Exclusion’ criterion of Major Depression, which suggests that depressive symptoms can be considered a physiological reaction during bereavement. According to the previous edition of the Manual (DSM-IV-TR), a major depressive episode could only be diagnosed during bereavement in the presence of specific symptoms (morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation), a longer duration and a more substantial functional impairment. This modification led to worry over the likelihood that clinicians will diagnose depression in people who mourn the death of a loved one after 2 weeks of mild depressive symptoms. The obvious risks of this approach are the medicalization of physiological grief reactions and the consequent encouragement of unnecessary treatment with antidepressant and possibly antipsychotic drugs. As visual hallucinations and illusions should be considered common in the bereaved, early information about the incidence and character of these phenomena is likely to prevent fear of insanity or other negative reactions. Diagnostic uncertainty is confirmed by the presence of a Persistent Complex Bereavement Disorder categorized as a condition for further study that can present with associated auditory or visual hallucinations of the deceased. However, the newly published Manual stresses the need to distinguish between grief and depression, the latter being more clearly accompanied by persistence of low mood, independent of external events and self-critical ruminations (APA, 2013).
The neurobiology of grief
Recent attention in psychiatry to physiological reactions to loss has led to a new line of neurobiological enquiry that points to the activation of a specific neurofunctional network during bereavement. According to the incentive salience model of grief (Freed & Mann, 2007), the dorsolateral prefrontal cortex and the rostral anterior cingulate cortex (ACC) modulate attentional and emotional aspects of amygdala reactivity to separation distress. This functional circuitry is largely distinct from the structures involved in the processing of psychological pain associated with social rejection, exclusion or loss. In this case, activation of the anterior insula and dorsal ACC closely mimic the cortical substrates of the affective and sensory components of physical pain. One possible explanation is that sensory-related regions are involved when psychological pain stems from rejection of the Self by others, but not when it depends on the death of a loved one, in that the Self is not devalued (Eisenberger, 2012). To date, no study specifically explores the neurofunctional correlates of visual hallucinatory phenomena in the bereaved population.
Adair, DK, The Charles Bonnet syndrome and grief reaction, 1988 https://www.ncbi.nlm.nih.gov/pubmed/3381939
Alroe, CJ, Visual hallucinations. The Charles Bonnet syndrome and bereavement, 1983 https://www.ncbi.nlm.nih.gov/pubmed/6669135
Carhart-Harris, R.L., Mourning and melancholia revisited: correspondences between principles of Freudian metapsychology and empirical findings in neuropsychiatry, 2008 https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/1744-859X-7-9
Eisenberger, N.I., The pain of social disconnection: examining the shared neural underpinnings of physical and social pain, 2012 https://sanlab.psych.ucla.edu/wp-content/uploads/sites/31/2015/05/Eisenberger2012NRN.pdf
Freed, PJ & Mann, JJ, Sadness and loss: toward a neurobiopsychosocial model, 2007 http://www.personalitystudiesinstitute.org/images/member_photos/Freed2007The%20American%20journal%20of%20psychiatry.pdf
Grimby, A., Bereavement among elderly people: grief reactions, post-bereavement hallucinations and quality of life, 1993 https://www.ncbi.nlm.nih.gov/pubmed/8424323
Morrison & Peterson, Trauma, Metacognition And Predisposition To Hallucinations In Non-Patients, 2003. https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/trauma-metacognition-and-predisposition-to-hallucinations-in-non-patients/A4C154E0EB3BF226AB4E0A2E2911453D
Olson, P.R., Hallucinations of widowhood, 1985. https://www.ncbi.nlm.nih.gov/pubmed/4020000
Rees, W.D., Hallucinations of widowhood, 1971 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1799198/
Yamamoto, Joe, Mourning in Japan, 2006. https://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.125.12.1660?code=ajp-site&journalCode=ajp