Grief-related beliefs in shidu parents with and without prolonged grief disorder: Psychometric properties of a Chinese version of the Typical Beliefs Questionnaire

Living with grief and thriving after loss: a qualitative study of Chinese parents whose only child has died

Introduction: Chinese bereaved parents over the age of 49 who have lost their only child are known as shidu parents. This study aimed to explore their symptoms of prolonged grief disorder (PGD) and post-traumatic growth (PTG).Methods: Shidu parents who experienced the loss of their only child at least six months prior and had no biological or adopted children at the time of the study were recruited. Eleven shidu parents participated in individual interviews conducted in Mandarin via WeChat video or voice calls. The interview guide was developed by the first researcher and refined through discussions with doctoral students and a professor specializing in bereavement. Reflexive thematic analysis was used to analyse the data from the semi-structured interviews.Results: The interviewees (3 men and 8 women) were aged between 53 and 72 years, and the time since their child's loss ranged from 2.25 to 24 years. Four themes of PGD symptoms were identified: Separation distress, Cognitive, emotional, and behavioural symptoms, Somatic responses and Changes in grief responses. Subtheme of 'feelings of inferiority or shame' and 'somatic responses' were prominent among this group, potentially representing culturally relevant grief reactions. They also experienced genuine PTG that helped them adapt to life without the child: changes in self-perception, changes in interpersonal relationships, and a changed philosophy of life. The subtheme of 'living for self' emerged as a potentially unique PTG among shidu parents.Conclusion: Shidu parents share some important similarities with bereaved individuals across cultures, but also exhibit some unique characteristics. Considering their persistent intense grief, regular screening for grief severity, physical issues, and suicidal ideation is essential. Culturally sensitive interventions that acknowledge and validate their sense of inferiority or shame may be beneficial. Additionally, fostering PTG may support shidu parents in coping with their loss and adapting to life.

Atrophy in the supramarginal gyrus associated with impaired cognitive inhibition in grieving Chinese Shidu parents

Background: The loss of an only child, known as Shidu in China, is a profoundly distressing experience, often leading to Prolonged Grief Disorder (PGD). Despite its impact, the structural brain alterations associated with PGD, potentially influencing cognitive impairments in Shidu parents, remain understudied.Objective: This study aims to identify brain structural abnormalities related to prolonged grief and their relation with cognitive inhibition in Shidu parents.Methods: The study included 40 Shidu parents and 42 non-bereaved participants. Prolonged grief was evaluated using the Prolonged Grief Questionnaire (PG-13). We employed voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) to assess brain structural alterations and their correlation with cognitive inhibition, as measured by Stroop interference scores.Results: Findings suggest that greater prolonged grief intensity correlates with reduced grey matter volume in the right amygdala and the left supramarginal gyrus (SMG). Additionally, enhanced amygdala-to-whole-brain structural connectivity showed a marginal association with prolonged grief, particularly with emotional-related symptoms. Furthermore, a decrease in SMG volume was found to mediate the relation between prolonged grief and Stroop Time Inference (TI) score, indicating an indirect effect of prolonged grief on cognitive inhibition.Conclusions: The study provides insight into the neural correlates of prolonged grief in Shidu parents, highlighting the SMG's role in cognitive inhibition. These findings emphasise the need for comprehensive grief interventions to address the complex cognitive and emotional challenges faced by this unique bereaved population.

A case report to understand the use of an evidence-based approach of prolonged grief therapy in Chinese culture

Prolonged grief disorder (PGD) is a new diagnosis that may cause significant functional impairment. Prolonged grief therapy (PGT) is a manualized 16-session intervention, whose efficacy has been demonstrated in studies primarily from Western cultures. The current report aimed to present a case to illustrate the use of PGT in Chinese culture. The client was a bereaved adult suffering from PGD after the death of her mother ten years ago. Additionally, she lost her father three months ago. Questionnaires were completed before and after treatment. In-depth interview was conducted at a 3-month follow-up. The client's scores for grief, functional impairment, grief-related beliefs and avoidance, depression and insomnia all decreased substantially after treatment. The follow-up feedbacks indicated that the beneficial effects of PGT persisted in the client's life. This case report provides preliminary evidence that bereaved people in China could benefit greatly from PGT, with minimal cultural adaptation.

Prevalence of prolonged grief disorder and its symptoms among bereaved individuals in China: a systematic review and meta-analysis

BACKGROUND

The prevalence of prolonged grief disorder (PGD) and its symptoms among the bereaved population in China vary considerably.

AIMS

This meta-analysis aims to estimate the prevalence of PGD and its symptoms among bereaved individuals in China.

METHODS

We conducted a literature search in major Chinese and English databases from their inception to 4 October 2023, for cross-sectional studies on the prevalence of PGD or its symptoms in bereaved Chinese individuals. The risk of bias of the included studies and certainty of the evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data ('JBI checklist') and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE), respectively. The 'metaprop' package in R V.4.1.2 was used to synthesise the prevalence.

RESULTS

A total of 28 studies involving 10 994 bereaved individuals were included in the analysis, with JBI checklist scores between 3 and 7. The combined prevalence (95% confidence interval) of PGD and its symptoms was 8.9% (4.2% to 17.6%) and 32.4% (18.2% to 50.8%), respectively. PGD and its symptoms were most prevalent among those who had lost their only child (22.7%) and those bereaved by earthquakes (80.4%), respectively. The GRADE system assigned a very low certainty level to the evidence for the pooled prevalence of PGD and its symptoms.

CONCLUSIONS

The pooled prevalence of PGD and its symptoms indicate a potential high need for grief counselling services among bereaved individuals in China. This need is particularly pronounced in those who have lost their only child and those bereaved due to earthquakes. Further methodologically rigorous studies are needed to provide more accurate prevalence estimates.

PROSPERO REGISTRATION NUMBER

CRD42023432553.

Latent class analysis of grief-related beliefs among recently bereaved adults

Grief-related beliefs play an important role in bereavement adjustment. This study aimed to investigate the patterns and correlates of grief-related beliefs among recently bereaved adults (n = 311). Latent class analysis results suggested three meaningful grief belief classes could be identified: the High grief belief class (24.1%), Predominantly counterfactual thoughts class (42.4%), and Low belief class (33.4%). Members in the High grief belief class reported the highest levels of grief symptoms, depression and PTSD symptoms, loneliness, and functional impairment. Compared with the Low belief class, unmarried people, people in poor health, individuals who lost parents, partners, or children, and those who experienced violent or unexpected death were more likely to belong to the High grief belief class. Findings of this study support the importance of examining grief-related cognitions in research and clinical practice, especially counterfactual thoughts about the death, which may need to be specifically screened and targeted in treatment.

Prevalence of prolonged grief disorder and its symptoms in Chinese parents who lost their only child: A systematic review and meta-analysis

BACKGROUND

Parents who lost their only child and cannot have a second child ("Shidu") have been a large population in China. Prolonged grief disorder (PGD) in Shidu parents is of clinical and public health concern but the reported PGD prevalence varies widely. To facilitate the planning of grief counseling services, this meta-analysis estimated prevalence of PGD and its symptoms and identified subgroups at elevated risk for PGD.

METHODS

We searched English and Chinese literature databases to identify cross-sectional surveys reporting prevalence of PGD or PGD symptoms in Chinese Shidu parents. The Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data ("JBI") was used to assess risk of bias of included studies.

RESULTS

Seven studies with a total of 2,794 Shidu parents were included and their JBI scores ranged from five to eight. The pooled prevalence of PGD and PGD symptoms was 20.9% and 75.0%, respectively. Greater risk of PGD was observed in mothers [vs. fathers, OR (odds ratio) = 1.89, P = 0.001] and in parents with religious beliefs (vs. without religious beliefs, OR = 1.65, P = 0.040). More severe PGD symptoms were presented in parents whose only child died from accidents [vs. illness, MD (mean difference) = 3.99, P < 0.001]. Deceased children of PGD parents were older than those of non-PGD parents (MD = 1.64, P = 0.035) and PGD parents had a shorter duration since the loss than non-PGD parents (MD = -3.26, P = 0.013).

CONCLUSIONS

PGD is prevalent among Shidu parents. Grief counseling services for Shidu parents would be more effective if they target those who are mothers and have religious beliefs and those whose children died from accidents, lost children are older, and loss occurs more recently.