We report the history and neuroimaging profile of two patients, CS and KC who developed an unusual bereavement reaction with delusions following the deaths of their husbands. Their neuropsychological profiles met criteria for dementia of Alzheimer type. The delusions about their husbands’ existence were persistent despite a considerable passage of time after their deaths. SPECT investigation showed reduction of blood flow in the frontal area in both patients when compared with demented controls and in particular a significant reduction in perfusion was observed in the right frontal regions. We argue that this significant reduction of blood flow in the right frontal area, in the context of severe cognitive deterioration, might be responsible for their delusional reaction to bereavement which we interpret as result of reality monitoring and episodic memory failure.
Delusions are frequently observed as a primary manifestation of Alzheimer Disease (AD) [17] and [61]. Alzheimer himself [3] reported that one of the first symptoms of his patient August D. was an unjustified ‘strong feeling of jealousy towards her husband’ (Engl. transl. [4], p. 1); August D. had several episodes of hallucinations and delusions [39] and [46]. Long before Alzheimer’s original description, delusions were reported in the course of what now appear to be typical dementing illnesses. A good example is the case of a tax-collector, Johann Christoph Becker, described in 1785 [6] and [23], who became amnesic and demented and was convinced, against all evidence, that ‘he shall be slaughtered and that sausages shall be made from his flesh’ ([23], p. 432). Delusions were also a key feature of King Lear’s dementia1 (see [31] for a detailed analysis of Lear’s cognitive and behavioural failures).
Metanalysis studies by Wragg and Jeste [62], and Absher and Cummings [1] report an average frequency of delusions in AD of about 35%. The links between delusions and demographic variables such as age of the patient (e.g. [35]), gender (e.g. [10]) and level of formal education (e.g. [18]) remain matters for debate. Similarly, authors disagree on the relationship between the presence of delusions and the duration (see e.g. [44]) or severity of the disease (see e.g. [19] and [53]). Delusions are distressing symptoms for AD patients and their carers and are often a reason for institutionalising a patient [16], [45] and [59]. In this paper we report two patients showing an as yet unreported form of delusion with a content relating to their bereavement.
One of the most profound losses experienced by adults is the death of a spouse. Studies of bereavement in healthy elderly emphasise the frequency of visual and auditory hallucinations and illusions concerning the dead spouse [11], [25], [26] and [47]. In normal old people the hallucinations and illusions of bereavement may persist for long periods and are often perceived as comforting and helpful in easing the adjustment to separation and loss. These experiences, although vivid, occur in inner subjective space and insight is usually present. In most instances the mourning process leads to spontaneous resolution. Occasionally, the grief process may take a pathologic form: searching behaviour and denial of loss may then be associated with enduring functional and emotional impairments, and the grief process may be complicated by clinically significant depressive and anxiety states [51]. Fixed delusions and related abnormal behaviours are, however, very unusual in normal elderly people. When bereavement occurs in the setting of an organic amnesic syndrome, a phenomenon which might be called ‘frozen grief’ can appear, with every reminder of loss triggering anew the anguish of separation, and preventing the normally extended and healing processes of mourning. Insight in these cases is variable and, over time and with support and counselling, the death is often accepted. Anecdotes of frank delusional episodes are frequent, however, in old people with more global cognitive impairment [30]. The old person may be described by relatives and staff making preparations for the arrival of a dead spouse who is always about to appear or has recently visited. Examples are the laying of an extra place at table and the purchase and preparation of extra food. The appearance of such nurturing behaviours is clinically very common in old people who are cognitively impaired at the time of bereavement (Shanks and Venneri, unpublished data).
Given the frequency of both bereavement and degenerative brain disease in old people, it is surprising that so little attention has been paid to the effect of dementia on the phenomenology of the reaction to such loss. We report the history and the neuropsychological and neuroimaging profile of two patients with probable AD dementia, CS and KC, who demonstrated a pathological bereavement reaction and persistent delusional beliefs which followed the deaths of their husbands.
