Grieving as a form of learning
Grieving as a form of learning
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other will always be one’s partner, with the emphasis on safety and comfort [4,13]. Death of a loved one poses a
‘always’. Built into the encoded characteristics consti- unique and rare challenge because the stream of infor-
tutive of the mate are their everlasting nature, and mation from semantic knowledge (persistence of the
absence is just a temporary state, requiring proximity attachment figure’s existence) now conflicts with
seeking. In contrast to cognitive stress theory, we episodic knowledge of the death of the person
interpret this evidence to suggest the automaticity may (e.g. memory of the death event or funeral). We propose
mean the stress of bereavement is primary and outside the gone-but-also-everlasting theory to emphasize the
of awareness. Thus, rather than the appraisal, ‘I realize dissonance between those two sources of information.
the other part of me is missing, and so I feel terrible’, This new theory emphasizes that grieving can be
more likely the order is ‘I feel terribledoh, that must considered a form of learning, requiring time and feed-
mean that the other part of me is missing’. back in the form of real-world experience. The first
morning that a widowed husband wakes up alone after
We hypothesize that the neural architecture of the bond thousands of mornings of waking up next to his wife, the
supports the belief (or semantic knowledge) that the best prediction is not to assume that she has died. In
other persists, despite any sensory evidence to the fact, many experiences will be required to convince him
contrary. This belief serves a great evolutionary that he will never again wake up next to her again and
needdthose who persisted in their belief that the other enable him to predict that her absence means he must
existed remained in place to have a caregiver return with change his way of understanding himself, the world, and
food, for example, or sought out their partner to main- the future [14,15].
tain their sexual or co-parenting relationship and pass on
their genes. The typical rewarding experience of daily The importance of the conflict between these dual
reunion with a loved one after separation (liking) con- streams of information is that the conflict will interfere
firms the prediction made during their absence with learning (updating the model of the attachment
(wanting, yearning). Neurohormones instantiate the figure) and with making new predictions that reflect the
reaction to reunion, which elicits a reduction in cortisol, reality of the permanent absence of the attachment
and release of oxytocin and dopamine. The reason that figure (applying the model). Acutely, difficulty with
the emphasis on this semantic knowledge is important learning the new reality will lead to (a) emotional in-
and novel is because it determines how the brain makes tensity and lability, when the reality is confronted over
predictions about where the attachment figure is and and over, and (b) confusion, disbelief, magical thinking,
when a reunion will happen. These predictions deter- and counterfactuals (if only, what if), as the brain at-
mine how the bereaved will function and behave in the tempts to accommodate the two sources of information.
world after the rare but permanent separation of death. Furthermore, the experience of bereavement involves
multiple mechanisms that drive intrusive thoughts in
The human mind functions as a predicting, generative grief: emotional salience, inability to complete the
agent, which maintains relatively stable ‘models’ or seeking-reunion process, environments that stimulate
representations of both external and internal environ- cue-elicited retrieval, and dissonance between the
ments, constantly making predictions about the predicted/desired and actual experience [16].
environment and updating these models with new
stimuli and life events via a learning mechanism [12]. At Evidence for the new theory in
a neurobiological level, once a pair bond or caregiving neuroscience of grief
bond has been formed, the neural circuitry is reset At different levels of complexity, learning to make new
(e.g. through epigenetic changes) to include both predictions means (1) new automatic habits must be
members of the dyad as the functioning unit. Viewing learned [17], (2) the self must be updated to include
separation and loss as the subtraction (and then the absence of the person or a revision in predicting
absence) of a functioning aspect of the individual’s ‘self ’ their presence/availability, and (3) other bonds must be
is illuminated when considering subsequent prediction. developed/strengthened to meet ongoing attachment
How does awareness of loss change the expectations of needs (revising the attachment hierarchy [4]). Note
where the missing other is, and whether future pre- that each of these requires new neural connections in
dictions should be changed based on the absence? When the brain, a biomechanical process requiring time,
there can be no reward of reunion given the loved one’s feedback through experience, and a brain with struc-
death, prediction error is experienced until the updated tural integrity.
semantic knowledge can be learned.
Incorporating new knowledge into predictions goes
The gone-but-also-everlasting theory of beyond habit. At one level, it is a long time before a
grieving daughter stops picking up the phone to relay a funny
The brain’s model of the world must change in order for incident to her deceased mother. This behavior suggests
the person to fulfill their goals and achieve a state of an automaticity that must be relearned. In addition,
however, changes in nucleus accumbens seen in animal the death, due to the emotional pain of grief [25,29],
and human functional magentic resonance imaging and complications develop in how the death information
(fMRI) research suggest that regions of the reward is brought to awareness [30]. These complications,
network (including caudate, orbitofrontal cortex, etc.) including avoidance and grief-related rumination, may
are important for predicting their presence and moti- lead to prolonged grieving or lack of learning over
vating us to seek/yearn for them [18e22]. time [31].
Evidence for the new theory in Spousal dependence predicts feelings that life is empty
neuroscience of prolonged grief disorder or meaningless, a sense of diminished identity, and dif-
By focusing on grieving as a form of learning, we can see ficulty imagining the future [32]. Dependence before
how complications in adaptation may occur. Laboratory- the loss may be a risk factor for PGD because of the
based behavioral tasks can show us where functional increased risk for preoccupying thoughts related to the
problems in learning (e.g. using reward feedback, deceased and a sense that one’s identity, meaning in life,
avoiding experience) may lead to prolonged grief disor- and plans for the future are lost without the deceased
der (PGD; [23]), and structural neuroimaging can help [33]. These findings are in keeping with Maccallum and
us see where problems in structural integrity of the brain Bryant’s [34] cognitive attachment model in which they
can lead to PGD (Figure 1). posit that a merged identity with the deceased will
enhance the accessibility of deceased-related memories
An excellent systematic review of the neurobiology of and reduce the ability to imagine the future. In addition,
disordered grief has conceptualized PGD as a disorder of a robust predictor of PGD severity is the extent to which
reward [24]. Reward is inherently a process by which the self-concept of the bereaved is dominated by the
learning develops, as one’s predictions about the world deceased [35].
are either rewarded or not, leading to accommodation
and consolidation of information and future predictions. Learning requires experience, and avoidance of things
Those who develop PGD may have (1) a pre-existing that remind the bereaved of the loved one’s death or
reward system that strongly supports the anxiety and absence will prevent accommodation of the information.
attention to the ‘everlasting’ aspect of attachment as a Only through learning does the integration of the loss
diathesis (dependency [25], attachment style [26], and experience enable the restoration of a meaningful life.
separation anxiety as predictors [27]). Attachment style Ironically, grief-related rumination may actually serve the
may also be a diathesis for brain function [28] and may same function as avoidance. Grief-related rumination
predict complications when layered with bereavement. focuses on the counterfactuals (what ifs and would have/
Another possibility is that (2) complications arise after could have/should have), all of which are virtual reality
Figure 1
Graphical depiction of the complications that may precede or result from the death of an attachment figure, using trajectories described in Refs. [40,47].
scenarios that end in the loved one not dying [36]. Grief- neural encoding of an attachment bond, and the
related rumination may maintain the ‘everlasting’ aspect required brain structure and function for that learning,
of the attachment relationship, enabling the bereaved to enables novel predictions that can be tested to further
avoid the painful evidence of ‘gone’ [37,38]. Of course, advance our understanding of grief and loss.
these counterfactual outcomes only create grief anew
each time that the reality of the loss resurfaces. CRediT author statement
Mary-Frances O’Connor: Conceptualization, Writing-
Structural neuroimaging shows us another reason why Original draft preparation. Saren H. Seeley: Writing-
learning may be disrupted in PGD. As with functional Original draft preparation, Writing- Reviewing
predictors of PGD, differences in brain structure could and Editing.
(1) precede the death as a diathesis or (2) follow from
the stress of the bereavement experience. A prospective Conflict of interest statement
study showed that a smaller hippocampus before the Nothing declared.
death predicted disordered grieving [39]. Most studies
are more equivocal as to whether structural differences Acknowledgements
precede or follow the loss. Importantly, all of this This project was supported by a grant from the National Institute of Aging
learning/grieving must be done while there is concurrent (R13 AG066368; PI: O’Connor). The authors would like to thank Jessica
AndrewseHanna and Matt Grilli for comments on an earlier draft of
excessive cortisol, blood pressure, and inflammation as a this manuscript.
physiological stress response to the death event [40].
Cortisol impacts brain structures such as the hippo- References
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