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

Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement

This study examined associations of Prospective IU and Inhibitory IU with symptom-levels of Prolonged Grief Disorder (PGD), Posttraumatic Stress-Disorder (PTSD), and depression in a sample of bereaved individuals. Specifically, 265 bereaved individuals completed measures of IU, PGD, PTSD, and depression in the first year after the death of a loved one; 134 participants again completed symptom-measures six months later. Cross-sectional analyses showed that Inhibitory IU (but not Prospective IU) was positively associated with symptom-levels of PTSD and depression (but not PGD), even when controlling for neuroticism, worry, and rumination. Prospective analyses showed that Prospective IU (but not Inhibitory IU) at baseline, predicted PGD severity six months later (but not PTSD or depression at follow-up) while controlling for baseline symptom-levels. The findings support the notion that IU is a vulnerability factor for different emotional problems, including those developing after the death of a loved one. Clinical implications of these findings are discussed.

Psychometric Properties of the Grief Cognitions Questionnaire for Children (GCQ-C)

Negative thinking is seen as an important mediating factor in the development of prolonged grief disorder (PGD), a syndrome encompassing debilitating symptoms of grief. No measure of specific grief related cognitions is available yet. Based on an adult measure of negative thinking in adults we developed a questionnaire for children, the Grief Cognitions Questionnaire for Children (GCQ-C). This study investigated several psychometric properties of the GCQ-C. Both reliability and validity were investigated in this study, in which hundred fifty-one children and adolescents (aged 8-18 years) participated. Findings showed that items of the GCQ-C represented one underlying dimension. Furthermore, the internal consistency and temporal stability were found to be adequate. Third, the findings supported the concurrent validity (e.g., significant positive correlations with self-report indices of PGD, depression and posttraumatic stress disorder), convergent and divergent validity of the GCQ-C. This study provides further evidence for the importance of negative thinking in PGD in children and adolescents.

Cognitive behavioural therapy for psychopathology in relatives of missing persons: study protocol for a pilot randomised controlled trial

BACKGROUND

It is hypothesized that the grieving process of relatives of missing persons is complicated by having to deal with uncertainty about the fate of their loved one. We developed a cognitive behavioural therapy (CBT) with mindfulness that focuses on dealing with this uncertainty. In this article, we elucidate the rationale of a pilot randomised controlled trial (RCT) for testing the feasibility and potential effectiveness of this CBT for reducing symptoms of psychopathology in relatives of missing persons.

METHODS

A pilot RCT comparing participants of the CBT condition (n = 15) with waiting list controls (n = 15) will be executed. Individuals suffering from psychopathology related to the long-term disappearance of a loved one are eligible to participate. The treatment consists of eight individual sessions. Questionnaires tapping psychological constructs will be administered before, during, and after the treatment. The feasibility of the treatment will be evaluated using descriptive statistics (e.g., attrition rate). The primary analysis consists of a within-group analysis of changes in mean scores of persistent complex bereavement disorder from baseline to immediately post-treatment and follow-up (12 and 24 weeks post-treatment).

DISCUSSION

A significant number of people experience the disappearance of a loved one. Surprisingly, an RCT to evaluate a treatment for psychopathology among relatives of missing persons has never been conducted. Knowledge about treatment effects is needed to improve treatment options for those in need of help. The strengths of this study are the development of a tailored treatment for relatives of missing persons and the use of a pilot design before exposing a large sample to a treatment that has yet to be evaluated. Future research could benefit from the results of this study.

TRIAL REGISTRATION

NTR4732 (The Netherlands National Trial Register (NTR)).

Assessment of Emotional Experience and Emotional Recognition in Complicated Grief

There is substantial evidence of bias in the processing of emotion in people with complicated grief (CG). Previous studies have tended to assess the expression of emotion in CG, but other aspects of emotion (mainly emotion recognition, and the subjective aspects of emotion) have not been addressed, despite their importance for practicing clinicians. A quasi-experimental design with two matched groups (Complicated Grief, N = 24 and Non-Complicated Grief, N = 20) was carried out. The Facial Expression of Emotion Test (emotion recognition), a set of pictures from the International Affective Picture System (subjective experience of emotion) and the Symptom Checklist 90 Revised (psychopathology) were employed. The CG group showed lower scores on the dimension of valence for specific conditions on the IAPS, related to the subjective experience of emotion. In addition, they presented higher values of psychopathology. In contrast, statistically significant results were not found for the recognition of emotion. In conclusion, from a neuropsychological point of view, the subjective aspects of emotion and psychopathology seem central in explaining the experience of those with CG. These results are clinically significant for psychotherapists and psychoanalysts working in the field of grief and loss.

The push and pull of grief: Approach and avoidance in bereavement

BACKGROUND AND OBJECTIVES

Prolonged Grief (PG) is recognized as a post-bereavement syndrome that is associated with significant impairment. Although approach and avoidance tendencies have both been hypothesized to play key roles in maintaining PG symptoms, understanding of these relationships has been limited by a reliance on self-report methodology. This study applies an experimental paradigm to simultaneously investigate the relationship between PG severity and approach-avoidance behavioral tendencies.

METHODS

Fifty-five bereaved individuals with and without PG completed a behavioral measure of approach and avoidance responding in which they pulled or pushed a joystick in response to grief-related, positive, negative and neutral images that appeared on a computer screen. Concurrent visual feedback created the illusion that the images were either approaching or receding from the participant. Half of the participants also received a prime designed to activate their grief prior to the task.

RESULTS

Irrespective of prime condition, PG participants pulled grief-related images more quickly than they pushed them. This difference was not observed in response to non-grief related images. Non PG participants showed no difference in their reaction times to grief-stimuli.

LIMITATIONS

This study was undertaken in a nonclinical setting and the majority of participants had lost a loved one due to chronic illness. Future research with treatment-seeking populations and sudden loss will be needed to explore the generalizability of the findings.

CONCLUSIONS

The findings from this study provide preliminary evidence supporting models of PG that integrate approach and avoidance tendencies.

Anxious and depressive avoidance behavior in post-loss psychopathology: a longitudinal study

BACKGROUND

Avoidance behavior is a central component of cognitive behavioral theories of bereavement-related psychopathology. Yet, its role is still not well understood. This study examined associations of anxious and depressive avoidance behaviors with concurrently and prospectively assessed symptom-levels of prolonged grief disorder (PGD), depression, and posttraumatic stress disorder (PTSD).

DESIGN AND METHODS

Two hundred and ninety-one individuals, confronted with loss maximally three years earlier, completed self-report measures of anxious and depressive avoidance and emotional distress and again completed distress measures one year later.

RESULTS

Anxious and depressive avoidance were concurrently associated with symptom-levels of PGD, depression, and PTSD, even when controlling for the shared variance between both forms of avoidance and relevant socio-demographic and loss-related variables. Prospective analyses showed that baseline anxious avoidance predicted increased symptom-levels of PGD, depression, and PTSD one year later, among participants who were in their first year of bereavement but not among those who were beyond this first year. Baseline depressive avoidance was significantly associated with elevated PTSD one year later, irrespective of time since loss.

CONCLUSIONS

Both anxious and depressive avoidance are associated with different indices of poor long-term adjustment following loss. However, anxious avoidance seems primarily detrimental in the first year of bereavement.

Common therapeutic factors in bereavement groups

Group therapy remains a popular treatment format for individuals experiencing bereavement. Although many innovative group treatments for grief are being developed, common therapeutic factors can also contribute to outcomes. The author integrates research on group therapy processes and treatment for grief, and examines evidence regarding group therapeutic factors that may influence bereavement group outcomes. Specifically, research on therapeutic factors related to sharing and support, interpersonal learning, and meaning-making is highlighted where it has relevance to bereavement groups. Potential research examining the interactions of these processes, their effects on group functioning and outcomes, and the moderators of these effects are discussed.

Cognition in Adult Bereavement: Preliminary Findings From Five Hospice Bereavement Focus Groups

Grief is an experience of both common and unique responses (Hooyman & Kramer, 2006). Grief affects people in various ways including emotionally, cognitively, socially, physically, and spiritually (Corr, 2007; Doka, 2014). Little has been published on the cognitive domain of loss affecting attention, and concentration of bereaved adults. This qualitative study explored these effects among adults in one hospice bereavement program in Central Texas. Five focus groups included facilitated bereavement topical conversations resulting in descriptions of memory, concentration, and attention deficits after loss. These results suggested that participation in bereavement programming may normalize the experience facilitating cognitive task accomplishment. Referrals for bereavement care may be appropriate in order to facilitate equilibrium in individual's lives following a significant death.

Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG): toward integrated treatment of symptoms related to traumatic loss

BACKGROUND

Traumatic events such as disasters, accidents, war, or criminal violence are often accompanied by the loss of loved ones, and may then give rise to traumatic grief. Traumatic grief refers to a clinical diagnosis of persistent complex bereavement disorder (PCBD) with comorbid (symptoms of) posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD) following confrontation with a traumatic loss. Trauma survivors, who are frequently from different cultural backgrounds, have often experienced multiple losses and ambiguous loss (missing family members or friends). Current evidence-based treatments for PTSD do not focus on traumatic grief.

OBJECTIVE

To develop a treatment for traumatic grief combining treatment interventions for PTSD and PCBD that may accommodate cultural aspects of grief.

METHOD

To provide a rationale for treatment, we propose a cognitive stress model of traumatic grief. Based on this model and on existing evidence-based treatments for PTSD and complicated grief, we developed Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) for the treatment of patients with traumatic grief. The treatment is presented along with a case vignette.

RESULTS

Processes contributing to traumatic grief include inadequately integrating the memory of the traumatic loss, negative appraisal of the traumatic loss, sensitivity to matching triggers and new stressors, and attempting to avoid distress. BEP-TG targets these processes. The BEP-TG protocol consists of five parts with proven effectiveness in the treatment of PCBD, PTSD, and MDD: information and motivation, grief-focused exposure, memorabilia and writing assignments, finding meaning and activation, and a farewell ritual.

CONCLUSION

Tailored to fit the needs of trauma survivors, BEP-TG can be used to address traumatic grief symptoms related to multiple losses and ambiguous loss, as well as cultural aspects of bereavement through its different components.

Evaluation of the CHUMS Child Bereavement Group: A Pilot Study Examining Statistical and Clinical Change

This article describes the largest evaluation of a UK child bereavement service to date. Change was assessed using conventional statistical tests as well as clinical significance methodology. Consistent with the fact that the intervention was offered on a universal, preventative basis, bereaved young people experienced a statistically significant, small to medium-sized decrease in symptoms over time. This change was equivalent across child age and gender. Type of bereavement had a slight impact on change when rated by parents. Potential clinical implications are highlighted, and various limitations are discussed that we hope to address using an experimental design in future research.

Network analysis of persistent complex bereavement disorder in conjugally bereaved adults

Persistent complex bereavement disorder (PCBD) is a bereavement-specific syndrome characterized by prolonged and impairing grief. Most research on this syndrome rests on the traditional latent variable model, whereby symptoms reflect an underlying entity. The network (or causal system) approach offers an alternative framework for understanding PCBD that does not suffer from limitations inherent in the latent entity approach. The network approach to psychopathology conceptualizes the relation between symptoms and disorder as mereological, not reflective. That is, symptoms do not reflect an inferred, unobservable category or dimension, but rather are themselves constitutive of the disorder. Accordingly, we propose that PCBD constitutes a causal system of mutually reinforcing symptoms that arise following the death of a loved one and settle into a pathological equilibrium. In this study, we used data from the Changing Lives of Older Couples database to identify symptoms central to PCBD, to distinguish the PCBD network from an overlapping but distinct network of depression symptoms, and to examine how previously identified risk factors may contribute to the maintenance or development of PCBD. Together, these findings provide an important first step toward understanding the nature and etiology of the PCBD network.