A Cognitive Attachment Model of prolonged grief: integrating attachments, memory, and identity

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.

Preparedness for the death of an elderly family member: A possible protective factor for pre-loss grief in informal caregivers

BACKGROUND

Pre-loss grief (PLG) has been identified as a robust risk factor for Prolonged Grief Disorder, which will be added to the DSM 5-TR. Therefore, identifying treatment targets to reduce PLG is warranted. "Preparedness" has been found to strongly predict PLG. The work is nascent and a consensus has not been reached about how best to assess for preparedness, and no reliable measure of this construct exists. Before examining the relationship between preparedness and PLG, an in depth understanding of how family members define preparedness is warranted.

OBJECTIVES

The purpose of this study was to develop a preliminary theoretical framework of preparedness for the loss.

METHODS

This was achieved through prospective semi-structured interviews with family members of Stage 4 Cancer (N = 16) and Advanced Dementia (N = 24) patients.

RESULTS

The overarching theme related to preparedness for the loss was the need to reduce uncertainty, both before the person passes away (i.e., present certainty) and after the person passes away (i.e., future certainty). Factors associated with the need to establish certainty in the present included, religiosity and spirituality, good relationship quality with the person with the life limiting illness, having access to support, good communication with person with life limiting illness, and acceptance of the impending death. Certainty for the future included, knowing what to expect due to past experience of loss, having plans for life without the person, and social support.

CONCLUSION

This study provides a preliminary framework of preparedness for family members of individuals with life limiting illness.

Ecological Grief as a Response to Environmental Change: A Mental Health Risk or Functional Response?

The perception of the impact of climate change on the environment is becoming a lived experience for more and more people. Several new terms for climate change-induced distress have been introduced to describe the long-term emotional consequences of anticipated or actual environmental changes, with ecological grief as a prime example. The mourning of the loss of ecosystems, landscapes, species and ways of life is likely to become a more frequent experience around the world. However, there is a lack of conceptual clarity and systematic research efforts with regard to such ecological grief. This perspective article introduces the concept of ecological grief and contextualizes it within the field of bereavement. We provide a case description of a mountaineer in Central Europe dealing with ecological grief. We introduce ways by which ecological grief may pose a mental health risk and/or motivate environmental behavior and delineate aspects by which it can be differentiated from related concepts of solastalgia and eco-anxiety. In conclusion, we offer a systematic agenda for future research that is embedded in the context of disaster mental health and bereavement research.

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.

DSM-5-TR prolonged grief disorder and DSM-5 posttraumatic stress disorder are related, yet distinct: confirmatory factor analyses in traumatically bereaved people

BACKGROUND

Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results.

OBJECTIVE

In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes.

METHODS

Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted.

RESULTS

For PTSD, a seven factor, so-called 'Hybrid' model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD).

CONCLUSIONS

This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.

Prolonged grief, emotion regulation and loss-related factors: An investigation based on cognitive and behavioral conceptualization

The study aimed to examine the variables that play a role in the process of prolonged grief within the framework of the cognitive-behavioral model. Participants (N = 475) from Turkey took part in a cross-sectional questionnaire survey. The study used structural equation modeling to test a hypothesized model via AMOS v23. After testing two options, the final model was found to be good fit for the data. Results suggested the importance of adopting a comprehensive approach to prolonged grief interventions which includes the loss- and relationship-related factors as well as emotion regulation difficulties, autobiographic memory characteristics, and the grief cognitions.

Understanding the Relationship Between Complicated Grief Symptoms and Patterns of Personality Disorders in a Substance Users' Sample: A Network Analysis Approach

BACKGROUND

The presence of personality disorders is greatly prevalent among substance users. Personality disorders could increase vulnerability to complicated grief symptoms. Bereavement is commonly overlooked among substance users. We used network analysis to estimate the structure of relations between patterns of personality disorders and complicated grief symptoms among a bereaved substance-using population.

METHODS

Complicated grief and personality disorders were assessed in a sample of 196 bereaved substance users. We use the graphical least absolute shrinkage selection operator (LASSO) to compute a regularized partial correlation network revealing associations among different patterns of personality disorders and complicated grief symptoms.

RESULTS

In a network involving nodes for personality disorders and symptomatology of complicated grief, patterns of depressive and paranoid personality disorder showed small relationships to complicated grief symptoms. All other personality disorders showed negligible to no relationship to complicated grief symptoms. Further, in the overall network, complicated grief showed the lowest level of centrality, suggesting that it is independent of personality disorders, whereas depressive and paranoid personality disorder symptoms showed the highest centrality.

CONCLUSION

Network analysis can be used to understand the relationships among higher-level constructs such as disorders. We found that complicated grief is largely independent of patterns of personality disorders with the exception of depressive and paranoid. Findings have implications for assessment and appropriate treatment of complicated grief symptoms and substance use disorder.

Grief and Posttraumatic Growth Among Chinese Bereaved Parents Who Lost Their Only Child: The Moderating Role of Interpersonal Loss

Objective: Losing the only child is considered as the most severe kind of bereavement. It can trigger intense grief symptoms along with loss of psychosocial resources, but meanwhile, it can also lead to posttraumatic growth (PTG). The current study aimed to examine (a) whether a curvilinear relationship exists between grief and PTG and (b) the moderating role of resources-loss among Chinese bereaved parents who lost their only child (shidu parents). Methods: One hundred and ninety-nine shidu parents from five provinces completed the assessment packet covering prolonged grief symptoms and PTG, as well as resource loss. Hierarchical regression analyses were computed to examine the curvilinear relationship and the moderating effect of interpersonal loss and socio-economic loss. Results: There was no significant curvilinear relationship between grief and PTG in shidu parents. Under the high levels of interpersonal loss, shidu parents' PTG scores decreased as the severity of grief increased. However, the socio-economic loss did not show a significant moderating effect. Conclusion: The results of the current study did not show a significant curvilinear relationship between grief and PTG in shidu parents. High levels of grief coupled with high levels of interpersonal loss may interfere with their ability to achieve PTG. Therefore, evaluating degrees of interpersonal loss seems to be an important part of the treatment process when working with shidu parents. To facilitate their adaptation from a positive perspective, helping them maintain existing or develop new interpersonal relationships may be helpful.

A framework of meaning attribution following loss

The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor's functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.

A qualitative analysis of loss-related memories after cancer loss: a comparison of bereaved people with and without prolonged grief disorder

Objective: The study aimed to explore the content and features of loss-related memories in a sample of individuals bereaved by cancer with and without a probable diagnosis of prolonged grief disorder/persistent complex bereavement disorder (PGD/PCBD). Methods: Semi-structured interviews with 28 bereaved adults (PGD/PCBD = 12, NoPGD/PCBD = 16) were analysed using thematic analysis. Results: Three superordinate themes were identified: (1) intrusive imagery, (2) qualities of memory, and (3) triggers. Results showed that individuals suffering from probable PGD/PCBD reported a predominance of negative and upsetting memories, happy memories triggering pain and more negative intrusive imagery than those without PGD/PCBD. Conclusions: Bereavement by cancer can result in troubling intrusive memories that overshadow positive memories. Sufferers of PGD/PCBD are more likely to experience loss-related memories as negative and upsetting. Clinical approaches that utilise memory processing may be of particular relevance in this group.

"They're in My Heart, Mind, and Cells": What Continuing Bonds Reveal About Social Networks

BACKGROUND AND OBJECTIVES

Research suggests that robust social networks have positive effects on peoples' well-being. An instrumental methodology for studying networks is the social convoy model, a diagram of concentric circles that illustrate network size, structure, and satisfaction. Convoys have been described as dynamic. Specifically, as people age, their convoys become stronger and smaller due to focusing on what matters most and accumulating losses. Therefore, convoys only include meaningful, living persons. The continuing bonds model posits that it is normal for people to maintain connections with the deceased. The objective of the current study was to integrate the social convoy and continuing bonds models in order to examine the presence of deceased loved ones in convoys.

RESEARCH DESIGN AND METHODS

Eighteen individuals (M = 66 years), recruited via fliers and snowball sampling, participated in one semistructured interview regarding the death of a loved one and their convoy. Participants also completed a convoy model, identifying where the deceased fit (if anywhere) when they were alive and at present. Interviews were transcribed, coded, and analyzed for themes.

RESULTS

Three themes emerged: communication (i.e., writing or speaking to the deceased), continuity (i.e., a continuing relationship), and reciprocity (i.e., perceived exchange of support(s)). Eighty-nine percent of participants felt their loved one's death did not change their convoy presence and 88% reported that their positioning in the convoy remained unchanged.

DISCUSSION AND IMPLICATIONS

This research offers a new way to think about convoys and may prompt the development of supportive interventions for bereaved individuals.

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation

BACKGROUND

While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration.

METHODS

In a sample of refugees receiving psychological treatment in Switzerland (N = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties.

RESULTS

In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors.

CONCLUSION

These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.

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.

Identity confusion in complicated grief: A closer look

Complicated grief (CG) is characterized by a wide range of symptoms, including identity confusion or a sense that a part of oneself has died with the decedent. Although identity confusion is a commonly reported feature of CG, little is known about which specific aspects of self-concept are compromised. In the current study, we used qualitative coding methods to investigate which aspects of the sense of self differed between those with and without CG in a sample of 77 bereaved adults. Relative to individuals without CG, those with CG provided fewer descriptors of their self-concept overall (lower self-fluency), provided sets of descriptors that consisted of fewer categories (lower self-diversity), and had lower proportions of self-relevant preferences and activities. However, group differences were not observed for proportions of any other categories of self-concept descriptors, including references to the loss, the past, or distress-related self-statements. Directions for future research and clinical implications are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Prolonged Grief Disorder and Positive Affect Improved by Chinese Brush Painting Group in Bereaved Parents: A Pilot Study

Traditional Chinese art practices such as brush painting and calligraphy are thought to promote self-development through holistically engaging both physical and mental health. This pilot study investigated the beneficial effects of a community-based self-help group incorporating Chinese art practices as a culturally adapted bereavement intervention. Twenty-six Chinese parents aged over 49 years and who had lost their only child participated in a 20-session Chinese brush painting group over a 6-month period. Ten bereaved parents from the same community who did not participate in the art course but received living support were recruited as a control group. Compared with the control group, the art practice group exhibited a pre-post intervention effect in terms of promoting positive affect and preventing deterioration of prolonged grief symptoms, particularly through the improvement of accessory grief symptoms (e.g., "emotional numbness due to the loss", and "feeling that life is unfulfilling, empty or meaningless after the loss"). No effect was found on negative affect. These findings indicate that a culturally adapted community-based art group may be an effective means of improving grief-related health.

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.

When a child dies: a systematic review of well-defined parent-focused bereavement interventions and their alignment with grief- and loss theories

BACKGROUND

The availability of interventions for bereaved parents have increased. However, most are practice based. To enhance the implementation of bereavement care for parents, an overview of interventions which are replicable and evidence-based are needed. The aim of this review is to provide an overview of well-defined bereavement interventions, focused on the parents, and delivered by regular health care professionals. Also, we explore the alignment between the interventions identified and the concepts contained in theories on grief in order to determine their theoretical evidence base.

METHOD

A systematic review was conducted using the methods PALETTE and PRISMA. The search was conducted in MEDLINE, Embase, and CINAHL. We included articles containing well-defined, replicable, paediatric bereavement interventions, focused on the parent, and performed by regular health care professionals. We excluded interventions on pathological grief, or interventions performed by healthcare professionals specialised in bereavement care. Quality appraisal was evaluated using the risk of bias, adapted risk of bias, or COREQ. In order to facilitate the evaluation of any theoretical foundation, a synthesis of ten theories about grief and loss was developed showing five key concepts: anticipatory grief, working models or plans, appraisal processes, coping, and continuing bonds.

RESULTS

Twenty-one articles were included, describing fifteen interventions. Five overarching components of intervention were identified covering the content of all interventions. These were: the acknowledgement of parenthood and the child's life; establishing keepsakes; follow-up contact; education and information, and; remembrance activities. The studies reported mainly on how to conduct, and experiences with, the interventions, but not on their effectiveness. Since most interventions lacked empirical evidence, they were evaluated against the key theoretical concepts which showed that all the components of intervention had a theoretical base.

CONCLUSIONS

In the absence of empirical evidence supporting the effectiveness of most interventions, their alignment with theoretical components shows support for most interventions on a conceptual level. Parents should be presented with a range of interventions, covered by a variety of theoretical components, and aimed at supporting different needs. Bereavement interventions should focus more on the continuous process of the transition parents experience in readjusting to a new reality.

TRIAL REGISTRATION

This systematic review was registered in Prospero (registration number: CRD42019119241).

A Network Approach to Understanding Quality of Life Impairments in Prolonged Grief Disorder

Prolonged grief (PGD) is a potentially debilitating consequence of bereavement that is experienced by 7%-10% of bereaved individuals. In recent years, PGD has been the focus of increasing interest as it is associated with a range of significant negative physical and mental health outcomes. To date, however, there is little understanding of how impairment is associated with individual PGD symptom interactions. Network analysis is an innovative statistical approach that has been productively applied to examine how symptoms of psychopathology influence and reinforce each other. In this study, we examined the association between PGD symptoms and quality of life (QoL) impairments. Data from 215 bereaved individuals were used to construct networks comprising PGD symptoms and different facets of QoL. The results showed that PGD symptoms of meaninglessness and role confusion were linked with reduced psychological QoL, trust difficulties were linked with reduced social QoL, and bitterness was linked with reduced environmental QoL. These results are consistent with models that highlight the importance of self-identity and loss of meaning in PGD. By elucidating pathways of dysfunction, these findings offer clinical implications that may help to improve outcomes for persons with PGD.

Symptomatology following loss and trauma: Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample

BACKGROUND

Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population.

METHOD

In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables.

RESULTS

Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life.

CONCLUSIONS

PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.

Cognitive predictors of grief trajectories in the first months of loss: A latent growth mixture model

Objective: The identification of modifiable cognitive antecedents of trajectories of grief is of clinical and theoretical interest. Method: The study gathered 3-wave data on 275 bereaved adults in the first 12–18 months postloss (T1 = 0–6 months, T2 = 6–12 months, T3 = 12–18 months). Participants completed measures of grief severity, cognitive factors (loss-related memory characteristics, negative appraisals, unhelpful coping strategies, and grief resilience), as well as measures of interpersonal individual differences (attachment and dependency). Latent growth mixture modeling was used to identify classes of grief trajectories. Predictors of class membership were identified using multinomial logistic regression and multigroup structural equation modeling. Results: Four latent classes were identified: 3 high grief classes (Stable, Low Adaptation, and High Adaptation) and a low grief class (Low Grief). When considered separately, variance in all four cognitive factors predicted membership of the high grief classes. When considered together, membership of the high grief classes was predicted by higher mean scores on memory characteristics. More negative appraisals predicted low or no adaptation from high grief severity. Losing a child also predicted membership to the stable class. Fast adaptation of high grief was predicted by a pattern of high memory characteristics but low engagement with unhelpful coping strategies. Conclusions: The findings have implications for clinical practice and point to early cognitive predictors of adaptation patterns in grief. Findings are consistent with cognitive models highlighting the importance of characteristics of memory, negative appraisals, and unhelpful coping strategies in the adaptation to highly negative life events.

The study identifies a number of modifiable cognitive predictors that are linked to grief severity and maintenance in the first months of loss. Targeting these cognitive predictors in the first 6 months of loss may prove helpful in facilitating grief adaptation.

Posttraumatic Symptoms and Change of Complicated Grief among Bereaved Families of the Sewol Ferry Disaster: One Year Follow-up Study

BACKGROUND

The objective of this study was to determine whether severity and severity change of coexisting psychiatric symptoms might affect change of complicated grief (CG) regarding the Sewol ferry disaster.

METHODS

Data from a cross-sectional survey were obtained 18 months (Time 1) and 30 months (Time 2) after the disaster. We ascertained sociodemographic variables and variables obtained from self-reporting questionnaires (i.e., CG, depression, anxiety, post-traumatic stress disorder [PTSD], insomnia, embitterment, and suicidal risk) among 56 bereaved family members.

RESULTS

Severity of other psychiatric symptoms at Time 1 had no effect on change of CG at Time 2. However, changes in severity of PTSD over a year affected change of CG.

CONCLUSION

It is important to evaluate changes in severity of PTSD and its treatment during management of CG, especially when it involves bereaved families experiencing a traumatic accident.

Toward a Better Understanding of Psychological Symptoms in People Confronted With the Disappearance of a Loved One: A Systematic Review

OBJECTIVE

The disappearance of a loved one is claimed to be the most stressful type of loss. The present review explores the empirical evidence relating to this claim. Specifically, it summarizes studies exploring the prevalence and correlates of psychological symptoms in relatives of missing persons as well as studies comparing levels of psychopathology in relatives of the disappeared and the deceased.

METHOD

Two independent reviewers performed a systematic search in PsychINFO, Web of Science, and Medline, which resulted in 15 studies meeting predefined inclusion criteria. Eligible studies included quantitative peer-reviewed articles and dissertations that assessed psychopathology in relatives of missing person.

RESULTS

All reviewed studies were focused on disappearances due to war or state terrorism. Prevalence rates of psychopathology were mainly described in terms of post-traumatic stress disorder and depression and varied considerably among the studies. Number of experienced traumatic events and kinship to the missing person were identified as correlates of psychopathology. Comparative studies showed that psychopathology levels did not differ between relatives of missing and deceased persons.

CONCLUSIONS

The small number of studies and the heterogeneity of the studies limit the understanding of psychopathology in those left behind. More knowledge about psychopathology postdisappearance could be gained by expanding the focus of research beyond disappearances due to war or state terrorism.

An investigation of approach behaviour in Prolonged Grief

Prolonged Grief (PG) is recognized as a potentially debilitating post-bereavement syndrome. Theoretical models of PG highlight the importance of both approach and avoidance behaviours in maintaining the syndrome. Research to date has focussed primarily on investigating avoidance in response to loss reminders. Comparatively few studies have indexed approach behaviours in PG. We use a quasi-experimental paradigm to simultaneously examine approach and avoidance behaviours to reminders of the deceased. Fifty-five bereaved individuals with and without PG responded to stimuli showing the deceased's name, an attachment figure's name, a neutral name, or a letter string, by pulling or pushing a joystick according to a whether the stimuli was a word or not. Concurrent visual feedback created the illusion that the images were either approaching or receding from the participant. Participants with PG were quicker to pull than push the three name stimuli, with quicker pulling of the deceased and attachment name than the neutral name. Non-PG participants responded more quickly to the attachment name but evidenced no relative approach or avoidance of any stimuli. Findings provide behavioural evidence about approach behaviour in PG, and are discussed with references to models that recognise the role of yearning for the deceased in PG.

An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation

OBJECTIVE

To determine the preliminary feasibility, acceptability, and effects of Meaning-Centered Grief Therapy (MCGT) for parents who lost a child to cancer.

METHOD

Parents who lost a child to cancer and who were between six months and six years after loss and reporting elevated levels of prolonged grief were enrolled in open trials of MCGT, a manualized, one-on-one cognitive-behavioral-existential intervention that used psychoeducation, experiential exercises, and structured discussion to explore themes related to meaning, identity, purpose, and legacy. Parents completed 16 weekly sessions, 60-90 minutes in length, either in person or through videoconferencing. Parents were administered measures of prolonged grief disorder symptoms, meaning in life, and other assessments of psychological adjustment preintervention, mid-intervention, postintervention, and at three months postintervention. Descriptive data from both the in-person and videoconferencing open trial were pooled.ResultEight of 11 (72%) enrolled parents started the MCGT intervention, and six of eight (75%) participants completed all 16 sessions. Participants provided positive feedback about MCGT. Results showed postintervention longitudinal improvements in prolonged grief (d = 1.70), sense of meaning (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continuing bonds with their child (d = 1.26), posttraumatic growth (ds = 0.29-1.33), positive affect (d = 0.99), and various health-related quality of life domains (d = 0.46-0.71). Most treatment gains were either maintained or increased at the three-month follow-up assessment.Significance of resultsOverall, preliminary data suggest that this 16-session, manualized cognitive-behavioral-existential intervention is feasible, acceptable, and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child to cancer. Future research should examine MCGT with a larger sample in a randomized controlled trial.

Symptoms of prolonged grief and posttraumatic stress following loss: A latent class analysis

OBJECTIVE

Individuals vary in how they respond to bereavement. Those who experience poor bereavement outcomes often report symptoms from more than one diagnostic category. This study sought to identify groups of individuals who share similar patterns of prolonged grief disorder and posttraumatic stress disorder symptoms to determine whether these profiles are differentially related to negative appraisals thought to contribute to prolonged grief disorder and posttraumatic stress disorder symptomatology.

METHODS

Participants were 185 bereaved adults. Latent class analysis was used to identify subgroups of individuals who showed similar patterns of co-occurrence of prolonged grief disorder and posttraumatic stress disorder symptoms. Multinomial regression was used to examine the extent to which appraisal domains and sociodemographic and loss factors predicted class membership.

RESULTS

Latent class analysis revealed three classes of participants: a low symptom group, a high prolonged grief disorder symptom group, and a high prolonged grief disorder and posttraumatic stress disorder symptom group. Membership of the prolonged grief disorder group and prolonged grief disorder and posttraumatic stress disorder group was predicted by higher mean negative self-related appraisals. Demographic and loss-related factors did not predict group membership.

CONCLUSION

These findings have implications for understanding co-occurrence of prolonged grief disorder and posttraumatic stress disorder symptoms following bereavement. Findings are consistent with theoretical models highlighting the importance of negative self-related beliefs in prolonged grief disorder.

Circulating levels of oxytocin may be elevated in complicated grief: a pilot study

Complicated grief (CG) is a debilitating syndrome characterized by persisting and intense distress and impairment after the death of a loved one. The biological mechanisms associated with this syndrome remain unclear but may involve neurobiological pathways implicated in the stress response and attachment systems. The neuropeptide oxytocin has been implicated in attachment and social behaviour, and loss of social bonds has been associated with disruptions in oxytocin signalling. Furthermore, prior research has reported associations between circulating oxytocin and other mental illnesses, including depression. The present pilot study aimed to examine plasma levels of oxytocin in bereaved adults with primary CG (n = 47) compared to age- and sex-matched bereaved individuals with primary Major Depressive Disorder (MDD) (n = 46), and bereaved individuals without any mental disorder (n = 46). In unadjusted analyses comparing groups according to primary diagnosis, oxytocin levels were significantly higher for primary CG compared to primary MDD (p = 0.013), but not compared to bereaved controls (p = 0.069). In adjusted regression models, having a primary or probable (Inventory of Complicated Grief ≥ 30) diagnosis of CG was associated with significantly higher oxytocin levels (p = 0.001). While additional research is needed, findings from our pilot study provide preliminary support for recent conceptualizations of CG implicating a role for oxytocin and the attachment system. Importantly, these findings contribute to the limited current knowledge about possible biological correlates of CG.

A systematic review and meta-analysis of correlates of prolonged grief disorder in adults exposed to violent loss

Background: Violent loss (i.e. loss through homicide, suicide, or accident) is associated with high levels of prolonged grief disorder (PGD). Objective: The current meta-analysis aims at identifying correlates of PGD in adults exposed to violent loss. Method: We conducted a systematic literature search in PsycINFO, PsycARTICLES, PubMed, Web of Science, and Scopus. We used the Pearson correlation coefficient r as an effect size measure and a random effects model was applied to calculate effect sizes. Results: Thirty-seven eligible studies published between 2003 and 2017 (N = 5911) revealed 29 potential correlates. Most studies used a cross-sectional design. Analyses revealed large significant effect sizes for comorbid psychopathology (r = .50-.59), suicidality (r = .41, 95% confidence interval [CI] [.30; .52]), and rumination (r = .42, 95% CI [.31; .52]), while medium effect sizes were found for exposure to traumatic events and factors concerning the relationship to the deceased. Small effect sizes emerged for sociodemographic characteristics, multiple loss, physical symptoms, and religious beliefs. Ten variables did not show a significant association with PGD. Heterogeneity and a small number of studies assessing certain correlates were observed. Conclusions: The associations with psychological disorders may indicate shared mechanisms of psychopathology. Moreover, we recommend that clinicians carefully assess suicidal ideation among individuals with PGD who have been exposed to violent loss. Further research is warranted using longitudinal study designs with large sample sizes to understand the relevance of these factors for the development of PGD.

Negative-pressure wound therapy versus standard dressings for adults with an open lower limb fracture: the WOLLF RCT

BACKGROUND

Open fractures of the lower limb occur when a broken bone penetrates the skin and is exposed to the outside environment. These are life-changing injuries. The risk of deep infection may be as high as 27%. The type of dressing applied after surgical debridement could potentially reduce the risk of infection in the open-fracture wound.

OBJECTIVES

To assess the disability, rate of deep infection, quality of life and resource use in patients with severe open fracture of the lower limb treated with negative-pressure wound therapy (NPWT) versus standard wound management after the first surgical debridement of the wound.

DESIGN

A pragmatic, multicentre randomised controlled trial.

SETTING

Twenty-four specialist trauma hospitals in the UK Major Trauma Network.

PARTICIPANTS

A total of 460 patients aged ≥ 16 years with a severe open fracture of the lower limb were recruited from July 2012 through to December 2015. Patients were excluded if they presented more than 72 hours after their injury or were unable to complete questionnaires.

INTERVENTIONS

Negative-pressure wound therapy (n = 226) where an 'open-cell' solid foam or gauze was placed over the surface of the wound and connected to a suction pump which created a partial vacuum over the dressing versus standard dressings not involving negative pressure (n = 234).

MAIN OUTCOME MEASURES

Disability Rating Index (DRI) - a score of 0 (no disability) to 100 (completely disabled) at 12 months was the primary outcome measure, with a minimal clinically important difference of 8 points. The secondary outcomes were deep infection, quality of life and resource use collected at 3, 6, 9 and 12 months post randomisaton.

RESULTS

There was no evidence of a difference in the patients' DRI at 12 months. The mean DRI in the NPWT group was 45.5 points [standard deviation (SD) 28.0 points] versus 42.4 points (SD 24.2 points) in the standard dressing group, giving a difference of -3.9 points (95% confidence interval -8.9 to 1.2 points) in favour of standard dressings (p = 0.132). There was no difference in HRQoL and no difference in the number of surgical site infections or other complications at any point in the 12 months after surgery. NPWT did not reduce the cost of treatment and it was associated with a low probability of cost-effectiveness.

LIMITATIONS

Owing to the emergency nature of the interventions, we anticipated that some patients who were randomised into the trial would subsequently be unable or unwilling to take part. Such post-randomisation withdrawal of patients could have posed a risk to the external validity of the trial. However, the great majority of these patients (85%) were found to be ineligible after randomisation. Therefore, we can be confident that the patients who took part were representative of the population with severe open fractures of the lower limb.

CONCLUSIONS

Contrary to the existing literature and current clinical guidelines, NPWT dressings do not provide a clinical or an economic benefit for patients with an open fracture of the lower limb.

FUTURE WORK

Future work should investigate alternative strategies to reduce the incidence of infection and improve outcomes for patients with an open fracture of the lower limb. Two specific areas of potentially great benefit are (1) the use of topical antibiotic preparations in the open-fracture wound and (2) the role of orthopaedic implants with antimicrobial coatings when fixing the associated fracture.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33756652 and UKCRN Portfolio ID 11783.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 73. See the NIHR Journals Library website for further project information.

Mind and mourning: The primacy of "we" in complicated grief

Standard models of complicated grief rely on a self-other divided mind that reflects the physical separateness of individuals. In these models, grief persists for those mourners who cannot reorganize self-and-other mental representations or adapt to identity changes after loss. However, advances in cognitive science indicate that relationships are often processed via distributed social-cognitive coding whereby individuals together form a psychologically extended common mind. I propose a novel "we" hypothesis in which shared representations, rather than self-other distinctions, shape the mind for a subgroup of mourners with complicated grief. Recognition of "we-experiences" in mourning can enhance grief theory, research, and practice.

Prolonged grief and attachment security: A latent class analysis

The death of a loved one has been associated with a wide range of mental health outcomes. Attachment theory is one of the primary paradigms for understanding bereavement outcome, yet there is comparatively little examination of the relationship between attachment style and bereavement responses. In this study we use Latent Class Analysis to identify subgroups of bereaved individuals based on patterns of prolonged grief (PG) and major depression symptom co-occurrence in 285 bereaved individuals. We then explored the relationship between these subgroups and attachment anxiety and avoidance. Three new subgroups of individuals were identified: one showing high levels of PGD and depression (PGD/depression), one showing high depression (Depression), and one showing few symptoms (Low). Attachment anxiety significantly differentiated between the three groups; the highest levels of attachment anxiety predicted membership of the PGD/depression group, the lowest levels, membership of the Low group. Attachment avoidance was predictive of greater depressive symptoms, with higher levels of attachment avoidance differentiating the two symptom groups (PGD/depression and depression) from the Low symptom group. These findings underscore the relevance of insecure attachment style to the current understanding of PGD.

Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: a network analysis

BACKGROUND

Complicated and persistent grief reactions afflict approximately 10% of bereaved individuals and are associated with severe disruptions of functioning. These maladaptive patterns were defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as persistent complex bereavement disorder (PCBD), but its criteria remain debated. The condition has been studied using network analysis, showing potential for an improved understanding of PCBD. However, previous studies were limited to self-report and primarily originated from a single archival dataset. To overcome these limitations, we collected structured clinical interview data from a community sample of newly conjugally bereaved individuals (N = 305).

METHODS

Gaussian graphical models (GGM) were estimated from PCBD symptoms diagnosed at 3, 14, and 25 months after the loss. A directed acyclic graph (DAG) was generated from initial PCBD symptoms, and comorbidity networks with DSM-5 symptoms of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) were analyzed 1 year post-loss.

RESULTS

In the GGM, symptoms from the social/identity PCBD symptoms cluster (i.e. role confusion, meaninglessness, and loneliness) tended to be central in the network at all assessments. In the DAG, yearning activated a cascade of PCBD symptoms, suggesting how symptoms lead into psychopathological configurations. In the comorbidity networks, PCBD and depressive symptoms formed separate communities, while PTSD symptoms divided in heterogeneous clusters.

CONCLUSIONS

The network approach offered insights regarding the core symptoms of PCBD and the role of persistent yearnings. Findings are discussed regarding both clinical and theoretical implications that will serve as a step toward a more integrated understanding of PCBD.

Are shame and self-esteem risk factors in prolonged grief after death of a spouse?

Although many single factors of prolonged grief have been identified in the literature, a comprehensive understanding of predictors is still lacking. This article argues that shame and low self-esteem, present risk factors in prolonged grief after spousal loss, based on a review of correlational studies. Using a practitioner-scientist approach, a developmental model of shame as a core factor in prolonged grief is proposed, outlining the progression from childhood relational trauma, to insecure attachment, shame, self-esteem contingent on spousal approval to eventual prolonged grief.

Differences in meanings made according to prolonged grief symptomatology

This study investigated differences in specific meanings made following bereavement, according to participants' prolonged grief symptomatology. A survey of 580 bereaved adults (M_age = 61.6 years, 70.7% female) showed 13 meanings predicted symptomatology, with the largest differences between the two lower symptomatology groups and the high symptomatology group; the latter was more likely to report no meaning. The results provide further support for empirically distinct groups within the bereaved population, not only in terms of symptoms, etiology, outcomes, courses, and treatment responses, but also in their meanings made, and may assist in advancing meaning reconstruction interventions.

Cognitive therapy and eye movement desensitization and reprocessing for reducing psychopathology among disaster-bereaved individuals: study protocol for a randomized controlled trial

Background: Confrontation with a traumatic (e.g. disaster-related) loss is a risk factor for the development of psychopathology, including symptoms of prolonged grief (PG), posttraumatic stress (PTS), and depression. Although interventions have been developed for reducing post-loss psychopathology, more research into the effectiveness of treatment is needed to improve care for bereaved persons. Cognitive therapy (CT) and eye movement desensitization and reprocessing (EMDR) have been shown to be effective in trauma-exposed populations. We hypothesize that CT and EMDR are also effective in reducing symptoms among people exposed to traumatic loss. Objective: In this article we describe the rationale of a randomized controlled trial (RCT) to examine (1) treatment effects of CT and EMDR for reducing PG, PTS, and depression among traumatically bereaved people, and (2) the associations between improvements in PG, PTS, and depression symptoms on the one hand and tentative mechanisms of change, including a sense of unrealness, negative cognitions, avoidance behaviour, and intrusive memories, on the other hand. Method: A two-armed (intervention versus waiting list controls) RCT will be conducted. Participants will be asked to fill in questionnaires prior to treatment, during treatment, and one, 12, and 24 weeks post-treatment. Potential participants are people who have lost one or multiple significant other(s) in the Ukrainian plane disaster in 2014 with clinically significant levels of self-rated PG, PTS, and/or depression. Multiple regression, including analysis of covariance, and multilevel regression analyses will be used. Discussion: There is a need for treatment for psychopathology following traumatic loss. Strengths of this study are the development of a treatment that targets grief and trauma-related complaints and the examination of potential mechanisms of change in CT and EMDR. Bereaved people, clinicians, and researchers could benefit from the results of this study.

Psychological Mindedness and Psychotherapy Process in Short-Term Group Therapy

Psychological mindedness is regarded as an important patient characteristic that can influence the course of psychotherapy. The purpose of this study was to investigate the relationship between patients' capacity for psychological mindedness and aspects of the group psychotherapy process as experienced and rated by therapists and other group members. Participants were 110 patients who completed two forms of short-term group therapy for the treatment of complicated grief. Psychological mindedness was assessed at pretreatment by external raters using a video-interview procedure. Group therapists assessed patients' therapeutic work and therapeutic alliance following each group therapy session. Therapists and other group members rated each patient's expression of emotion and provided appraisals of their cohesion to each patient throughout the course of therapy. Psychological mindedness was found to be positively associated with several group process variables as rated by the therapist and other group members.

Tracking Deceased-Related Thinking with Neural Pattern Decoding of a Cortical-Basal Ganglia Circuit

BACKGROUND

Deceased-related thinking is central to grieving and potentially critical to processing of the loss. Self-report measurements might fail to capture important elements of deceased-related thinking and processing. Here, we used a machine learning approach applied to fMRI - known as neural decoding - to develop a measure of ongoing deceased-related processing.

METHODS

23 subjects grieving the loss of a first-degree relative, spouse or partner within 14 months underwent two fMRI tasks. They first viewed pictures and stories related to the deceased, a living control and a demographic control figure while providing ongoing valence and arousal ratings. Second, they performed a 10-minute Sustained Attention to Response Task (SART) with thought probes every 25-35 seconds to identify deceased, living and self-related thoughts.

RESULTS

A conjunction analysis, controlling for valence/arousal, identified neural clusters in basal ganglia, orbital prefrontal cortex and insula associated with both types of deceased-related stimuli vs. the two control conditions in the first task. This pattern was applied to fMRI data collected during the SART, and discriminated deceased-related but not living or self-related thoughts, independently of grief-severity and time since loss. Deceased-related thoughts on the SART correlated with self-reported avoidance. The neural model predicted avoidance over and above deceased-related thoughts.

CONCLUSIONS

A neural pattern trained to identify mental representations of the deceased tracked deceased-related thinking during a sustained attention task and also predicted subject-level avoidance. This approach provides a new imaging tool to be used as an index of processing the deceased for future studies of complicated grief.

Networks of loss: Relationships among symptoms of prolonged grief following spousal and parental loss

The death of a loved one can trigger a range of emotional, behavioral, motivational and cognitive reactions collectively labeled as "grief." There has been a recent resurgence of empirical interest in grief reactions, and there is now a general consensus that 7%-10% of bereaved individuals experience intense and chronic reactions termed Prolonged Grief (PG). However, there is ongoing debate about how best to conceptualize the construct. Recent studies have advanced this debate by applying a network, or causal systems approach. Whereas traditional views of psychopathology posit symptoms of disorders reflect the independent actions of latent entities, the network approach argues that the symptoms themselves interact to give rise to the disorder. A network conceptualization offers novel approaches to studying the mechanisms that contribute to PG. To date, however, research has focused only on spousal loss and only used a single archival data set. Therefore, in this paper we apply network analysis to examine relationships among PG symptoms in samples of individuals bereaved by loss of a spouse (Study 1, N = 193) and a parent (Study 2, N = 180). Participants completed the PG-13 and a measure of depression. A comparison test suggested the networks produced from each sample were not reliably different. The strongest link in both networks was between yearning and emotional pain. Meaninglessness was relatively central, whereas avoidance was peripheral in both networks. Findings are discussed with reference to theoretical models and the potential benefits a network approach may hold for understanding relationships between symptoms of PG. (PsycINFO Database Record

Complicated grief after suicide bereavement and other causes of death

The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.

Self-Identity After Bereavement: Reduced Self-Clarity and Loss-Centrality in Emotional Problems After the Death of a Loved One

There is evidence that both the centrality of a loss-event as well as reduced self-concept clarity are involved in emotional problems after the death of a loved one. One issue that is still unexplored is the relative importance of these two concepts in predicting bereavement outcome. The current study examined the degree to which both concepts contribute to emotional distress after loss, both concurrently and longitudinally. Data were available from 124 individuals, all bereaved within the previous half year, who completed measures of prolonged grief, posttraumatic stress, and depression at inclusion into the study and again 6 months later. Loss-centrality and self-unclarity were associated with all three outcome measures, in cross-sectional analyses. Longitudinal analyses indicated that loss-centrality predicted symptom levels of prolonged grief, self-unclarity predicted symptom levels of depression, and both loss-centrality and self-unclarity were associated with posttraumatic stress 6 months after baseline. Implications of these findings are discussed.

Short-Term Group Therapy for Complicated Grief: The Relationship Between Patients' In-Session Reflection and Outcome

OBJECTIVE

The objective of the present study was to examine the nature of patients' work in two types of short-term group psychotherapy. The study sought to investigate the relationship between patients' psychodynamic work versus supportive work in group psychotherapy and treatment outcome at termination and at 6-month follow-up. Psychodynamic work refers to reflection regarding intrapsychic motivations, defenses, and relational patterns, and supportive work refers to practical problem solving.

METHOD

Participants were 110 patients who completed two forms of group therapy for complicated grief: interpretive therapy and supportive therapy. Two types of patients' in-session activity-psychodynamic work and supportive work-were rated by group therapists in both treatments. Pre-post and follow-up outcome domains included general symptoms, grief symptoms, and life dissatisfaction/severity of target objectives.

RESULTS

There was no significant difference in the nature of patients' therapeutic work between interpretive and supportive groups. Psychodynamic work was associated with pre-post improvement in grief symptoms. Psychodynamic work was also associated with further improvement in grief symptoms at 6-month follow-up, along with improvement in broader symptom domains. Supportive work was not associated with any pre-post or follow-up benefit.

CONCLUSION

The findings provide evidence that psychodynamic work-focused on the development of insight and self-reflection-in group psychotherapy can contribute to further benefit after the completion of treatment. This finding cut across two approaches to short-term group therapy for complicated grief, suggesting that it may reflect a general curative mechanism of group treatments.

Symptoms of prolonged grief, post-traumatic stress, and depression after loss in a Dutch community sample: A latent class analysis

Mental health problems following loss can manifest as heterogeneous symptomatology that may include symptoms of Prolonged Grief Disorder (PGD), Post-Traumatic Stress Disorder (PTSD), and Major Depressive Disorder (MDD). However, the co-occurrence of symptoms of these three disorders is still only partially explored. The aims of this study were to identify subgroups (i.e., classes) in a Dutch sample of bereaved individuals, based on severity and/or co-occurrence of symptoms and to identify predictors for these subgroups, taking into account all three disorders. Using data from 496 participants who filled in questionnaires assessing PGD, PTSD and MDD, we conducted latent class analyses to identify different symptom classes. Predictors of these classes were identified using one-way ANOVA, Chi Square tests and multinomial regression analysis. We found three different classes: a resilient class, a PGD class and a combined PGD/PTSD class. Violent cause of death, loss of a child, and loss of a partner were associated with membership of the combined PGD/PTSD class. This study increases our understanding of the predictability of symptomology outcome following bereavement. This is a first step towards designing assessment and intervention methods, specifically directed towards subgroups of individuals sharing characteristic symptomatology.

Predictors of treatment response for cognitive behaviour therapy for prolonged grief disorder

Background: Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive behaviour therapy (CBT) has been shown to effectively treat PGD, there is a need to identify predictors of treatment non-response. Methods: PGD patients (N = 80) were randomly allocated to receive 10 weekly two-hour group CBT sessions and (a) four individual sessions of exposure therapy or (b) CBT without exposure. PGD was assessed by self-report measures at baseline, post-treatment (N = 61), and six-months (N = 56) after treatment. Results: Post-treatment assessments indicated that greater reduction in grief severity relative to pretreatment levels was associated with being in the CBT/Exposure condition, and lower baseline levels of self-blame and avoidance. At follow-up, greater grief symptom reduction was associated with being in the CBT/Exposure condition and lower levels of avoidance. Conclusions: These patterns suggest that strategies that target excessive self-blame and avoidance during treatment may enhance response to grief-focused cognitive behaviour therapy.

Grief rumination mediates the association between self-compassion and psychopathology in relatives of missing persons

Background: The disappearance of a loved one is a unique type of loss, also termed 'ambiguous loss', which may heighten the risk for developing prolonged grief (PG), depression, and posttraumatic stress (PTS) symptoms. Little is known about protective and risk factors for psychopathology among relatives of missing persons. A potential protective factor is self-compassion, referring to openness toward and acceptance of one's own pain, failures, and inadequacies. One could reason that self-compassion is associated with lower levels of emotional distress following ambiguous loss, because it might serve as a buffer for getting entangled in ruminative thinking about the causes and consequences of the disappearance ('grief rumination'). Objective: In a sample of relatives of missing persons we aimed to examine (1) the prediction that greater self-compassion is related to lower symptom-levels of PG, depression, and PTS and (2) to what extent these associations are mediated by grief rumination. Method: Dutch and Belgian relatives of long-term missing persons (N = 137) completed self-report measures tapping self-compassion, grief rumination, PG, depression, and PTS. Mediation analyses were conducted. Results: Self-compassion was significantly, negatively, and moderately associated with PG, depression, and PTS levels. Grief rumination significantly mediated the associations of higher levels of self-compassion with lower levels of PG (a*b = -0.11), depression (a*b = -0.07), and PTS (a*b = -0.11). Specifically, 50%, 32%, and 32% of the effect of self-compassion on PG, depression, and PTS levels, respectively, was accounted for by grief rumination. Conclusions: Findings suggest that people with more self-compassion experience less severe psychopathology, in part because these people are less strongly inclined to engage in ruminative thinking related to the disappearance. Strengthening a self-compassionate attitude using, for instance, mindfulness-based interventions may therefore be a useful intervention to reduce emotional distress associated with the disappearance of a loved one.

Normal grief and its correlates in Lubumbashi, an urban city in the Democratic Republic of Congo

Introduction

Grief is a universal experience faced at one time or another by most people during their lives. Response to grief and bereavement losses can lead to psychiatric disorders such as mood disorders, post traumatic responses, insomnia loss of appetite, anxiety, and depression. The aim of our study is to value in our community the physical and psychological complications of a normal grief.

Methods

We conducted a cross-sectional study from March 2012 to September 2012 in Lubumbashi, Democratic Republic of Congo. Two questionnaires, the Hamilton Anxiety Scale and the Beck Depression Inventory scale were used as screening tool. A snow ball sampling method was performed and the questionnaires were administered only to those who consented to participate in the study.

Results

A total of 78 subjects were included in the study of which 87.2% were aged between 14-50 years old. The majority of the subjects were female 65.4%, and about a quarter (28%) was unemployed. The main correlates of the grief reported in the present study were being treated as witchcraft or accused to be responsible of a death (68%), being rejected by family and not being allowed to inherit (32%). Being homeless was reported in 26%. The main psychological symptoms reported were psychological distress after 1 year (65%) and related physical health problems after the death (72%). Depression and mild anxiety were the most reported disorders, with respectively 92.3% and 74.4% of the subjects.

Conclusion

Grief in Lubumbashi is associated with a large number of psychological, social and health problems. Health problems such as gastric is, high blood pressure were often reported. Being accused of witchcraft remains the main social impact. Depression and anxiety were the most psychological problem associated with grief.

Features of Prolonged Grief Symptoms in Chinese and Swiss Bereaved Parents

This study investigates clinical expressions of prolonged grief in samples of 32 Chinese and 33 Swiss bereaved parents, according to the proposed International Classification of Diseases, 11th Revision model of prolonged grief disorder (PGD). Sex differences and predictors (cultural attitudes, sense of coherence, and posttraumatic growth) of PGD were analyzed. In result, after controlling for sociodemographic and loss-related sample differences, both samples showed similar PGD symptom profiles, with Swiss parents exhibiting more severe grief-related preoccupation and Chinese parents exhibiting some accessory symptoms and functional impairment to a greater extent. Multivariate analyses revealed for the Chinese sample primary predictions of PGD by life satisfaction, general health and one's world view (social cynicism) and for the Swiss sample by female sex, sense of coherence, and life satisfaction. The findings substantiate the basic appropriateness of the International Classification of Diseases, 11th Revision PGD in distinct cultural groups and may contribute to a better understanding of grief expression and its potential predictors across different cultures.

Treatment for complicated grief: state of the science and ways forward

PURPOSE OF REVIEW

There is increasing recognition that a minority of bereaved persons experiences persistent and disabling grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment research within a cognitive behavioral treatment framework, and establish a novel and systematic research agenda for complicated grief treatment.

RECENT FINDINGS

Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to definitions of complicated grief may threaten generalizability and clinical application of research findings. Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in targeting complicated grief. However, little is known about what, how, and for whom treatment works best.

SUMMARY

In light of these findings, we recommend systematic investigation of: what works best in complicated grief treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling studies; how it works, by conducting investigations on therapeutic theories and examining mediators of therapeutic change; and for whom it works, by examining potential moderators of treatment effects.