BEREAVEMENT BY TRAUMATIC MEANS: THE COMPLEX SYNERGY OF TRAUMA AND GRIEF

Traumatic and complicated grief among children: one or two constructs?

The purpose of this study was to examine the concepts of traumatic and complicated grief among children. Some authors seemingly use the concepts interchangeably, whereas others make a distinction between the two. A sample of 240 mainly parentally bereaved children were administered the Extended Grief Inventory (EGI). Two confirmatory factor analyses were run to examine the EGI factor structure and to determine whether traumatic and complicated grief are one or two concepts. Goodness-of-fit tests for the two models was considered acceptable for both models, however, the two-factor model was a better fit. Multiple regression analyses found that children's age, gender, and ethnicity were important predictors of traumatic grief but only gender was a predictor of complicated grief. Violent death was a predictor of complicated grief in an unadjusted regression analysis.

Early outreach to survivors of the shootings in Norway on the 22nd of July 2011

BACKGROUND

Under-treatment and unmet needs among survivors have been documented years after terror attacks. Improved early and proactive outreach strategies, including targeted interventions for individuals in need, are required. After the terrorist attacks in Norway on 22 July 2011, a national, proactive outreach strategy was developed and implemented to help those who were directly affected.

OBJECTIVES

THE AIMS OF THIS STUDY WERE THREEFOLD: (1) to investigate whether the survivors at the island of Utøya had received proactive outreach from the municipalities, (2) to examine the relationships between received health services and the survivors' level of exposure and post-trauma health problems, and (3) to explore the level of unmet needs among survivors 5 months post-terror.

METHODS

Three hundred and twenty five survivors (M age=19.4, SD=4.6, 47.1% females, response rate 66%) of the 2011 massacre on Utøya Island, Norway, were interviewed face-to-face 4-5 months post-terror. The survivors were asked if they had received proactive outreach from their municipality, and what type of health services they had received. Survivors' level of peri-trauma exposure, loss and injury, posttraumatic stress reactions, symptoms of anxiety and depression, somatic health problems, and sick leave, were assessed.

RESULTS

Most participants (87%) reported that they had received early and proactive outreach, and most (84%) had a contact person. In addition a majority of the survivors has received support from their general practitioner (63%), or other municipal help services (66%). Specialized mental health services by psychiatrists or psychologists had been provided to 73.1% of the survivors. Survivors who had been referred to specialized mental health services reported higher levels of exposure to trauma, posttraumatic stress reactions, depression and anxiety, and somatic health problems, compared to non-receivers of such services. Forty-three survivors (14%) reported unmet needs for services.

CONCLUSION

In accordance with the national strategy, the vast majority of the participants in this study had received an early and proactive outreach and targeted responses from specialized mental health services had been provided to survivors in need of more extensive help. However, an important minority of the participants had not been reached as planned. The knowledge from this study may guide professionals and decision makers in planning for future disasters and improve the levels of care.

Sudden death of father or sibling in early childhood increases risk for psychotic disorder

OBJECTIVE

To determine if exposure to a severe, acute stressor during early development is associated with an increased incidence of schizophrenia and bipolar disorder compared to exposure to a chronic stressor.

DESIGN

We identified all those born in Helsinki between 1960 and 1990 whose father or sibling died between their conception and 5-years-of-age through linking two national registers: the Finnish Population Register and the Cause of Death Register. The reason for the death was also extracted from the Cause of Death Register. A third register, the Finnish Hospital Discharge Register, was used to determine psychiatric outcomes in adulthood.

SAMPLE

11,855 individuals whose father or sibling had died before they were 5-years-old. In total, 129 individuals had an ICD 8, 9 or 10 diagnosis of schizophrenia and 165 had a diagnosis of bipolar disorder. 6136 individuals had a father or sibling who died from a sudden, external cause (e.g. accident or suicide) and 5719 individuals had father or sibling who died from a non-external, illness-associated cause.

RESULTS

Sudden loss of a father or sibling led to a significantly greater risk of developing bipolar disorder or schizophrenia in adulthood compared to loss of a father or sibling from illness. These associations are independent of sex, parental history of psychiatric illness, age at exposure to loss and age at follow-up.

CONCLUSION

Our findings are in keeping with accumulating evidence which indicates that exposure to stress during early development can increase the risk of psychotic illness among those exposed.

Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia

BACKGROUND

During the Khmer Rouge (KR) regime from 1975 to 1979 millions of Cambodians were confronted with the death or murder of family members. The long-term psychological consequences of these traumatic losses have not yet been investigated. The purpose of this study was to determine the rate and potential predictors of prolonged grief disorder (PGD) in survivors of the KR regime.

METHOD

The Inventory of Complicated Grief-Revised (ICG-R) was administered in a sample of N=775 Cambodians in face-to-face interviews who had lost at least one family member during the KR regime. Symptoms of PTSD were assessed with the PTSD Checklist-Civilian Version and symptoms of depression and anxiety with the Hopkins Symptom Checklist-25.

RESULTS

The prevalence of PGD in the sample was 14.3%. PGD was moderately associated with symptoms of depression, anxiety and PTSD. The loss of a spouse, a child, or a parent was associated with higher symptom severity of PGD than was the loss of a sibling or distant relatives. PGD was predicted by the relationship to the deceased and symptoms of depression and PTSD.

LIMITATIONS

Limitations of the study include the non-random sampling recruitment. The ICG-R has not been validated for use in Cambodia.

CONCLUSIONS

The vast majority of Cambodians lost family members during the KR regime. Even three decades later, PGD was prevalent in a substantial proportion of the present sample and related to other psychiatric disorders. The results underline the importance of examining PGD in studies of war-related psychological impairment.

The witnessing of disenfranchised grief: reliability and validity

BACKGROUND AND PURPOSE

To examine the psychometric properties of a newly designed instrument: Witnessing of Disenfranchised Grief (WDG).

METHODS

The 22-item questionnaire was administered to a community-based sample of convenience (N = 201). Each subject reported having experienced a loss by death or miscarriage. There was no stipulation regarding the timing of the loss.

RESULTS

The tool was found to be one dimensional with factor loadings of 0.40-0.78, inter-item correlation ranging from p < .01 to p < .05, and a Cronbach's alpha of 0.91. A loss that was viewed as witnessed resulted in decreased manifestation of some grief symptoms.

CONCLUSIONS

The WDG is a measure of the degree to which one who grieves perceives their loss to be witnessed.

A nationwide random sampling survey of potential complicated grief in Japan

To investigate the prevalence of significant loss, potential complicated grief (CG), and its contributing factors, we conducted a nationwide random sampling survey of Japanese adults aged 18 or older (N = 1,343) using a self-rating Japanese-language version of the Complicated Grief Brief Screen. Among them, 37.0% experienced their most significant loss by expected non-violent death, 17.9% by unexpected non-violent death, and 5.5% by violent death. The mean length of time since the loss was 11.9 years (SD = 11.6). The percentage of individuals with potential CG (5 or higher score on the scale) was 2.5% among those who experienced significant loss. The individuals with potential CG showed lower mental health scores than those without. Through regression analysis, we found the significant effects of gender difference, time since the loss, and the interaction of the mode of death, gender of the bereaved, and the kinship relationship to the deceased on the CG score. Women who had lost a child by sudden or violent death showed significantly higher CG scores, but men did not. By comparison, those (particularly men) who had lost a partner by expected or sudden nonviolent death showed significantly higher CG scores. The implications of the findings are discussed.

Associations between prolonged grief disorder, depression, posttraumatic stress disorder, and anxiety in Rwandan genocide survivors

A number of studies have demonstrated that symptoms of prolonged grief disorder (PGD) represent a symptom cluster distinct from bereavement-related depression, anxiety, and posttraumatic stress disorder (PTSD). The aim of the present study was to confirm and extend these findings using the most recent criteria defining PGD. The authors interviewed a total of 400 orphaned or widowed survivors of the Rwandan genocide. The syndromes were strongly linked to each other with a high comorbidity. Principal axis factoring resulted in the emergence of 4 different factors. The symptoms of depression, along with the cognitive, emotional, and behavioral symptoms of PGD, loaded on the first factor, symptoms of anxiety on the second factor, symptoms of PTSD on the third factor, and the separation distress symptoms of PGD on the fourth factor. This indicates that the concept of PGD includes symptoms that are conceptually related to depression. However, the symptom cluster of separation distress presents a grief-specific dimension that may surface unrelated to depressive symptoms.

Emerging interventions for PTSD: future directions for clinical care and research

Efficacious therapeutic approaches for treating Posttraumatic Stress Disorder (PTSD) are needed given the significant psychosocial and physical impairment associated with the disorder (e.g., Hidalgo and Davidson, 2000; Jaycox and Foa, 1999; Stein et al., 2000). Although variations of cognitive behavioral therapy (CBT) effectively treat PTSD, non-response rates and dropout rates remain relatively high (Bradley et al., 2005; Schottenbauer et al., 2008). Thus, treatment outcome research is needed to improve the effectiveness of existing protocols, particularly within specific populations, develop new approaches for treating individuals who cannot access or do not benefit from traditional treatments, and evaluate the types of treatment that may be effective for particular individuals. The present review provides an overview of emerging treatment approaches for PTSD that attempt to address these remaining issues in the treatment outcome literature. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

ATTEND: toward a mindfulness-based bereavement care model

Few, if any, mindfulness-based bereavement care models exist. The ATTEND (attunement, trust, touch, egalitarianism, nuance, and death education) model is an interdisciplinary paradigm for providers, including physicians, social workers, therapists, nursing staff and others. Using a case example to enhance the breadth and depth of understanding, this article focuses on attunement as a means to moderate the negative effects of traumatic bereavement, support the framework for posttraumatic growth in the bereaved, improve psychological outcomes for providers, and set the stage for the other aspects of the ATTEND model.

Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: a review of the literature among highly exposed populations

The September 11, 2001 (9/11), terrorist attacks were unprecedented in their magnitude and aftermath. In the wake of the attacks, researchers reported a wide range of mental and physical health outcomes, with posttraumatic stress disorder (PTSD) the one most commonly studied. In this review, we aim to assess the evidence about PTSD among highly exposed populations in the first 10 years after the 9/11 attacks. We performed a systematic review. Eligible studies included original reports based on the full Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.; American Psychiatric Association, 2000) criteria of PTSD among highly exposed populations such as those living or working within close proximity to the World Trade Center (WTC) and the Pentagon in New York City and Washington, DC, respectively, and first responders, including rescue, cleaning, and recovery workers. The large body of research conducted after the 9/11 attacks in the past decade suggests that the burden of PTSD among persons with high exposure to 9/11 was substantial. PTSD that was 9/11-related was associated with a wide range of correlates, including sociodemographic and background factors, event exposure characteristics, loss of life of significant others, and social support factors. Few studies used longitudinal study design or clinical assessments, and no studies reported findings beyond six years post-9/11, thus hindering documentation of the long-term course of confirmed PTSD. Future directions for research are discussed.

The “Trauma Signature:” Understanding the Psychological Consequences of the 2010 Haiti Earthquake

The 2010 Haiti earthquake was one of the most catastrophic episodes in history, leaving 5% of the nation’s population killed or injured, and 19% internally displaced. The distinctive combination of earthquake hazards and vulnerabilities, extreme loss of life, and paralyzing damage to infrastructure, predicts population-wide psychological distress, debilitating psychopathology, and pervasive traumatic grief. However, mental health was not referenced in the national recovery plan. The limited MHPSS services provided in the first eight months generally lacked coordination and empirical basis.

There is a need to customize and coordinate disaster mental health assessments, interventions, and prevention efforts around the novel stressors and consequences of each traumatic event. An analysis of the key features of the 2010 Haiti earthquake was conducted, defining its “Trauma Signature” based on a synthesis of early disaster situation reports to identify the unique assortment of risk factors for post-disaster mental health consequences. This assessment suggests that multiple psychological risk factors were prominent features of the earthquake in Haiti. For rapid-onset disasters, Trauma Signature (TSIG) analysis can be performed during the post-impact/pre-deployment phase to target the MHPSS response in a manner that is evidence-based and tailored to the event-specific exposures and experiences of disaster survivors. Formalization of tools to perform TSIG analysis is needed to enhance the timeliness and accuracy of these assessments and to extend this approach to human-generated disasters and humanitarian crises.

Prolonged grief among traumatically bereaved relatives exposed and not exposed to a tsunami

Numerous studies on the mental health consequences of traumatic exposure to a disaster compare those exposed to those not exposed. Relatively few focus on the effect of the death of a close relative caused by the disaster-suffering a traumatic bereavement. This study compared the impact on 345 participants who lost a close relative in the 2004 Indian Ocean tsunami, but who were themselves not present, to 141 who not only lost a relative, but also were themselves exposed to the tsunami. The focus was on psychological distress assessed during the second year after the sudden bereavement. Findings were that exposure to the tsunami was associated with prolonged grief (B = 3.81) and posttraumatic stress reactions (B = 6.65), and doubled the risk for impaired mental health. Loss of children increased the risk for psychological distress (prolonged grief: B = 6.92; The Impact of Event Scale-Revised: B = 6.10; General Health Questionnaire-12: OR = 2.34). Women had a higher frequency of prolonged grief. For men, loss of children presented a higher risk for prolonged grief in relation to other types of bereavement (B = 6.36 vs. loss of partner). Further long-term follow-up could deepen the understanding of how recovery after traumatic loss is facilitated.

Operation Iraqi Freedom/Operation Enduring Freedom: exploring wartime death and bereavement

Military deaths are often sudden, unanticipated, traumatic, and/or violent in nature and involve the death of a young adult. More than 5,500 service members have died as a result of their service in the wars in Afghanistan (2001) and Iraq (2003) in combat- or non-combat- related incidences. As the death toll continues to rise, service members and their families struggle with the visible and invisible wounds of war. This article explores wartime death, trauma, and bereavement experienced by those survivors affected by service members who have died as a result of their military service in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). It recognizes the circumstantial and cultural factors of the death as well as the grief and trauma experiences of survivors. Resources and suggested interventions of support are highlighted.

Silenced voices: hearing the stories of parents bereaved through the suicide death of a young adult child

The current paper reports findings from a qualitative research project that aimed to explore parents' experiences following the suicide death of their young adult child. Twenty-two Australian parents told of the suicide death of their son or daughter during the data collection period (2003 to late 2004). One narrative theme drawn from the interview data is reported here: the way in which suicide-bereaved parents feel unable to talk about their child's life and death, their experience of suicide and their resultant bereavement. Parents reported being silenced by others and silencing themselves in relation to talking about their bereavement. Parents' private stories are used to explain the difficulties they faced given the contemporary social and cultural context of grief and suicide. Then follows an examination of the impact these difficulties had on their ongoing grief narrative and availability of social support. Implications for health and social care intervention are presented to assist in better preparing support workers in their interactions with parents bereaved in this manner.

Predictors of complicated grief after a natural disaster: a population study two years after the 2004 South-East Asian tsunami

The authors examined predictors of complicated grief (CG) in Norwegians 2 years after bereavement in the 2004 South-East Asian tsunami. A cross-sectional postal survey retrospectively covering disaster experiences and assessing CG according to the Inventory of Complicated Grief yielded 130 respondents (35 directly disaster-exposed and 95 not directly exposed), with 47.7% screening CG positive. They identified positive associations between CG and being female, losing a child or spouse, and time to death confirmation, and negative associations with previous losses, being employed, and receiving social support. Direct exposure did not increase CG risk. Support service providers should be aware of this high prevalence of severe, persistent grief.

The effect of traumatic bereavement on tsunami-exposed survivors

Fourteen months after the 2004 tsunami, mental health outcome was assessed in 187 bereaved relatives, 308 bereaved friends, and in 3,020 nonbereaved Swedish survivors. Of the bereaved relatives, 41% reported posttraumatic stress reactions and 62% reported impaired general mental health. Having been caught or chased by the tsunami in combination with bereavement was associated with increased posttraumatic stress reactions. Complicated grief reactions among relatives were almost as frequent as posttraumatic stress reactions. The highest levels of psychological distress were found among those who had lost children. Traumatic bereavement, in combination with exposure to life danger, is probably a risk factor for mental health sequelae after a natural disaster.

The Mental Health Consequences of Disaster-Related Loss: Findings from Primary Care One Year After the 9/11 Terrorist Attacks

This study examines the long-term psychiatric consequences, pain interference in daily activities, work loss, and functional impairment associated with 9/11-related loss among low-income, minority primary care patients in New York City. A systematic sample of 929 adult patients completed a survey that included a sociodemographic questionnaire, the PTSD Checklist, the PRIME-MD Patient Health Questionnaire, and the Medical Outcomes Study Short Form-12 (SF-12). Approximately one-quarter of the sample reported knowing someone who was killed in the attacks of 9/11, and these patients were sociodemographically similar to the rest of the sample. Compared to patients who had not experienced 9/11-related loss, patients who experienced loss were roughly twice as likely (OR = 1.97, 95%; CI = 1.40, 2.77) to screen positive for at least one mental disorder, including major depressive disorder (MDD; 29.2%), generalized anxiety disorder (GAD; 19.4%), and posttraumatic stress disorder (PTSD; 17.1%). After controlling for pre-9/11 trauma, 9/11-related loss was significantly related to extreme pain interference, work loss, and functional impairment. The results suggest that disaster-related mental health care in this clinical population should emphasize evidence-based treatments for mood and anxiety disorders.

Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks

A Web-based survey of adults who experienced loss during the September 11, 2001, terrorist attacks was conducted to examine the prevalence and correlates of complicated grief (CG) 2.5-3.5 years after the attacks. Forty-three percent of a study group of 704 bereaved adults across the United States screened positive for CG. In multivariate analyses, CG was associated with female gender, loss of a child, death of deceased at the World Trade Center, and live exposure to coverage of the attacks on television. Posttraumatic stress disorder, major depression, anxiety, suicidal ideation, and increase in post-9/11 smoking were common among participants with CG. A majority of the participants with CG reported receiving grief counseling and psychiatric medication after 9/11. Clinical and policy implications are discussed.