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

Emotional vs. social loneliness and prolonged grief: a random-intercept cross-lagged panel model

Background: Bereavement following death, with loneliness as a prominent feature, can result in enduring stress and compromised health.Objective: Building on Weiss's ([1973]. Loneliness: The experience of emotional and social isolation. MIT Press) proposal of two distinct types of loneliness, this study investigated within-person associations between emotional loneliness (EL) and prolonged grief symptoms (PGS) (aim 1), as well as social loneliness (SL) and PGS (aim 2) over four years following spousal loss. Additionally, we examined the impact of gender, age, and education on the main factors.Methods: We used random-intercept cross-lagged panel modelling (RI-CLPM) to analyse self-reported data from 338 Danish spousal-bereaved adults (58% female; mean age = 72.1; range 65-81 years) on EL and SL (single-item questions) and PGS (Inventory of Complicated Grief, short version) at 6, 13, 18, and 48 months post-loss.Results: We found (1) within-person associations between EL and PGS; (2) no within-person associations between SL and PGS. In our model, PGS predicted EL over time, with no reciprocal effect. In contrast, PGS and SL were unrelated. Age did not link with EL, SL, or PGS. More years of education were associated with less EL and SL, but not with PGS. Gender influenced the association between SL and PGS.Conclusions: This study enhances our understanding of longitudinal, within-person associations between EL, SL, and PGS. Consistent with Weiss's (1973) relational theory of loneliness in widowhood, results highlight the unique role of EL. While replication is needed due to limitations like single-item measures and varying intervals, these findings emphasize EL's importance in widowhood and offer a basis for better understanding and addressing PGS. Monitoring the relationship between loneliness and grief may help healthcare providers offer timely, targeted interventions.

Prolonged grief disorder

Prolonged grief disorder is a mental health disorder recently included in diagnostic manuals worldwide. This Review presents published research evidence in strong support for the current conceptualisation of prolonged grief disorder: a diagnosable mental health condition with core symptoms of yearning, preoccupation, or both, which is associated with symptoms of emotional pain, identity disturbances, loss of meaning and purpose, and functional impairment. The public and academic discourse surrounding prolonged grief disorder has catalysed researchers to produce methodologically rigorous research evidence in support of this much-needed diagnosis. A coherent syndrome of prolonged grief disorder has a typical onset of 6 to 12 months after the death of a close person. Prolonged grief disorder is associated with various poor outcomes, including negative health outcomes (eg, high blood pressure), increased rates of suicidality, low life satisfaction, and increased service use. Psychotherapy is the main treatment for prolonged grief disorder. Theoretical models of the cause and maintenance of prolonged grief disorder are presently being refined through the rapidly increasing empirical literature. Awareness of prolonged grief disorder by general health practitioners, as well as mental health specialists, is key to appropriate early intervention.

Psilocybin-Assisted suppoRtive psychoTherapy IN the treatment of prolonged Grief (PARTING) trial: protocol for an open-label pilot trial for cancer-related bereavement

INTRODUCTION

Prolonged grief disorder (PGD) represents a substantial public health issue, especially in oncology settings where it affects up to 30% of bereaved carers. Current best-practice treatments are lengthy, and up to 50% of participants have persistent PGD. Building on encouraging recent research with psychedelic-assisted therapies, the Psilocybin-Assisted suppoRtive psychoTherapy IN the treatment of prolonged Grief (PARTING) trial is the first study to consider psilocybin-assisted psychotherapy as a potential treatment for prolonged grief.

METHODS AND ANALYSIS

PARTING is an open-label pilot trial of psilocybin-assisted psychotherapy for approximately 15 people with cancer-related PGD. It aims to investigate feasibility, safety, acceptability, participant experience and participant-reported therapeutic effects. Over a 5-week intervention period, participants will undergo three preparation sessions before receiving a psychoactive (25 mg) dose of psilocybin alongside non-directive supportive guidance, followed by four integration sessions. All sessions will be delivered by a psychologist and either a nurse or Indigenous Therapist. An artificial intelligence-assisted tool will be used to create an artwork of participants' psychedelic experience.Outcomes will be investigated over a 12-month follow-up period. Feasibility will be assessed through recruitment/retention rates and completion of follow-up assessments. Safety will be evaluated via adverse events over 12 months and the comparison of physiological measures (vital signs, biochemistry, haematology, ECG) recorded during screening and 1 day after the psilocybin dose. Qualitative thematic analysis of semistructured interviews with participants and trial therapists will assess acceptability and the therapeutic potential of the treatment. Diagnostic clinical interviews for PGD and quantitative participant-reported measures of therapeutic effects are also being collected. Participant-reported measures include grief severity, depression, anxiety, grief avoidance, psychological flexibility, connectedness, and quality of life.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from QIMR Berghofer Medical Research Institute Human Research Ethics Committee (P3801). Dissemination of results will occur via conference presentations, peer-reviewed publications and media.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12623000827639).

Can self-distancing benefit adjustment to bereavement? A multi-method investigation

Bereaved individuals experiencing prolonged grief often struggle to accept loss and manage emotional distress, making them a key focus of grief interventions. Self-distancing, where individuals process adverse events from an observer's perspective, may play a protective role in grief adaptation. This paper presents three studies examining self-distancing in grief adaptation. Study 1 surveyed bereaved adults (N = 207) and found self-distancing was significantly and negatively correlated with grief symptoms and rumination. Study 2 used a one-session perspective manipulation exercise and showed self-distancing significantly decreased negative emotions, while self-immersion (first-person) decreased positive emotions when recalling bereavement. Study 3 implemented a brief intervention where participants with elevated grief completed an expressive writing exercise using a self-distancing perspective (n = 16) or a self-immersion perspective (n = 15) for 15 min per day for three days. Results indicated that the two writing training tasks increased self-distancing and decreased grief symptoms, but only the self-distancing group reduced grief rumination. These findings highlight the protective role of self-distancing in grief adaptation. Low-intensity interventions, such as expressive writing from a self-distancing perspective, show promise in alleviating grief rumination and prolonged grief symptoms. These results highlight the potential of self-distancing as an accessible and effective strategy for managing prolonged grief, offering a valuable addition to existing grief interventions.

Perceptions of internal and external continuing bonds in bereaved individuals with and without prolonged grief disorder

This study aimed to compare individuals with and without a diagnosis of Prolonged Grief Disorder in terms of the intensity of internal and external continuing bonds, as well as the extent to which they interpret these bonds as comforting, socially acceptable, and an inseparable part of their self-identity. The sample consisted of 229 bereaved adults (PGD: N = 27; non-PGD: N = 202). Results indicated that the PGD group experienced internal and external bonds more intensely, reporting higher scores for interpreting them as an inseparable part of self-identity and lower scores for interpreting them as socially acceptable. While the PGD group found external bonds more comforting than the non-PGD group, no such difference was observed for internal bonds. These findings suggest that, when assessing whether continuing bonds are adaptive or maladaptive, it is crucial to consider not only their internal or external nature but also how they are interpreted.

Amygdala-Centered Emotional Processing in Prolonged Grief Disorder: Relationship With Clinical Symptomatology

BACKGROUND

Prolonged grief disorder (PGD) is a multidimensional condition with adverse health consequences. We hypothesized that enhanced negative emotional bias characterizes this disorder and underlies its key clinical symptoms.

METHODS

In a cross-sectional design, chronically grieving older adults (age 61.5 ± 8.9 years) experiencing probable PGD (n = 33) were compared with demographic- and time since loss-equated integrated (adaptive) grief participants (n = 38). To probe generalized negative affective reactivity, participants performed an emotional face-matching task during functional magnetic resonance imaging scanning and completed demographic and clinical assessments. Contrast maps (fearful + angry faces [-] shapes) were generated to determine group differences in brain activity within hypothesized affective and regulatory processing regions (amygdala, anterior insula, dorsal anterior cingulate, dorsolateral prefrontal cortex) and in exploratory whole-brain regression analyses.

RESULTS

The PGD group showed higher right amygdala activation to negative emotional stimuli than the integrated grief group (pcorrected < .05), which positively correlated with intrusive thoughts. Generalized psychophysiological interaction analysis revealed lower task-dependent functional connectivity (FC) between the right amygdala and posterior cingulate cortex/precuneus in PGD (pcorrected < .05), which negatively correlated with avoidance of loss reminders. Resting-state FC between the identified right amygdala and thalamus was higher in PGD (pcorrected < .05), which negatively correlated with loneliness.

CONCLUSIONS

Dysregulated amygdala-centric neural activity and FC during processing of negative affective stimuli and at rest appear to differentiate prolonged from integrated grief in older adults. Future investigations that use interventions to target amygdala-centric neural circuit abnormalities may provide new insights into the role of enhanced negative bias and related mechanisms that underlie PGD and support treatment efficacy.

Network analysis of prolonged grief disorder and anxiety symptoms among bereaved Chinese parents who lost their only child

Parents who have lost their only child and cannot or do not wish to adopt or have another child are labeled Shidu parents. Network analysis is used to examine symptom-level interactions in mental disorders. This study aimed to investigate the comorbidity network structure of prolonged grief disorder (PGD) and anxiety symptoms among Shidu parents and compare network differences between child loss from natural and unnatural causes. Key findings revealed that faintness, feeling afraid, panic, and meaninglessness are central symptoms, while meaninglessness, inability to trust others, and nightmares are bridge symptoms. The strongest connection in the PGD-anxiety network is between avoidance and shock, and the edge between meaninglessness and weakness strongly links the two communities. Shidu parents who experience unnatural loss have a stronger edge between inability to trust others and bitterness/anger. Highlighting these symptoms may help interventions address the comorbidities associated with PGD and anxiety among Shidu parents.

Factors associated with posttraumatic stress severity and treatment response in a retrospective, naturalistic sample of homicidally bereaved children and young people

Background: Research on the mental health of homicidally bereaved children and young people is scarce. Despite the importance of timely referral of those at risk of developing severe mental health problems, few convincing risk factors have been identified. The effectiveness of current treatment models is unclear.Objective: This study examined factors associated with posttraumatic stress (PTS)symptom severity and treatment response in a naturalistic sample of homicidally bereaved children and young people who received traumatic grief-focused cognitive behavioural therapy (TGF-CBT); and assessed whether PTS-symptoms decreased between the start and termination of treatment.Method: Data was used from 222 children and young people aged between 8 and 25, who had completed therapy by July 2017, and for whom either start - or end scores on PTS-symptoms, or both, were available. PTS-symptoms were measured with the Children's Revised Impact of Event Scale-8 (CRIES-8). We explored associations of personal and loss-related variables with baseline symptom levels and symptom reduction during treatment, using latent growth modelling.Results: PTS-symptoms decreased significantly from pre- to posttreatment and with a large effect size. Higher age was associated with early treatment discontinuation. Female sex was associated with higher baseline scores, and having lost a parent or sibling with lower baseline scores. Higher baseline scores were associated with larger symptom reduction during treatment.Conclusions: TGF-CBT shows promise in reducing PTS-symptoms following homicidal bereavement, regardless of the individual differences in personal or loss-related characteristics included in this study. However, it is important to recognize the uniqueness of children and young people confronted with homicidal loss, and to tailor treatment to their individual needs and developmental stage. More research on risk and protective factors for adverse mental health outcomes and response to treatment in children and young people bereaved by homicide is urgently needed.

Patterns and relationships of prolonged grief, post-traumatic stress, and depressive symptoms in Chinese shidu parents: Latent profile and network analyses

Parents who experience the trauma of losing an only child are called "shidu" parents in China. There are individual differences in post-loss outcomes.1,061 Chinese shidu parents were asked to complete questionnaires assessing prolonged grief, post-traumatic stress, and depressive symptoms. The mean age of the sample was 59.68 (SD = 7.52), with the average time since the loss was 9.46 years (SD = 7.05). Most participants were female (62.3%). The main cause of the loss was an unnatural case (52.7%). Latent profile analysis was used to identify similar symptom patterns. Network analysis was used to explore the relationships among symptoms within different subgroups. A two-profile model based on symptom severity identified a "low symptom severity" subgroup (n = 419) and a "high symptom severity" subgroup (n = 642). In the low symptom severity subgroup network, the most central symptoms were loss of interest, feeling numb, and meaninglessness. In the high symptom severity subgroup network, the most central symptoms were physiological cue reactivity, emotional pain, and feeling easily startled. Individual differences in the post-loss outcomes of Chinese shidu parents are reflected not only in symptom patterns but also in the relationships among symptoms.

A French-Language Web-Based Intervention Targeting Prolonged Grief Symptoms in People Who Are Bereaved and Separated: Randomized Controlled Trial

BACKGROUND

Losing a loved one, through death or separation, counts among the most stressful life events and is detrimental to health and well-being. About 15% of people show clinically significant difficulties coping with such an event. Web-based interventions (WBIs) are effective for a variety of mental health disorders, including prolonged grief. However, no validated WBI is available in French for treating prolonged grief symptoms.

OBJECTIVE

This study aimed to compare the efficacy and adherence rates of 2 WBIs for prolonged grief symptoms following the loss of a loved one through death or romantic separation.

METHODS

LIVIA 2.0 was developed relying on theoretical and empirical findings on bereavement processes and WBIs, and is compared with LIVIA 1, which has already demonstrated its efficacy. We conducted a randomized controlled trial and provided on-demand guidance to participants. Outcomes were assessed through web-based questionnaires before the intervention, after the intervention (12 weeks later), and at follow-up (24 weeks later). Primary outcomes were grief symptoms, depressive symptoms, and well-being. Secondary outcomes were anxiety symptoms, grief coping strategies, aspects related to self-identity, and program satisfaction.

RESULTS

In total, 62 participants were randomized (intent-to-treat [ITT] sample), 29 (47%) in LIVIA 2.0 (active arm) and 33 (53%) in LIVIA 1 (control arm). The dropout rate was 40% (37/62), and 10 participants were removed due to exclusion criteria, leading to a final per-protocol sample of 27 (44%) completers who differed from noncompleters only based on reporting fewer anxiety symptoms (t60=3.03; P=.004). Participants who are separated reported more grief symptoms (t60=2.22; P=.03) and attachment anxiety (t60=2.26; P=.03), compared to participants who are bereaved. There were pre-post within-group differences for both programs in the ITT sample, with significant reductions in grief (Cohen d=-0.90), depressive symptoms (Cohen d=-0.31), and centrality of the loss (Cohen d=-0.45). The same pattern was observed in the per-protocol sample, with the exception that anxiety symptoms also significantly diminished (Cohen d=-0.45). No difference was found in efficacy between the 2 programs (all P>.33). Participants (ITT sample) reported overall high levels of program satisfaction (mean 3.18, SD 0.54; over a maximum of 4). Effect stability was confirmed at the 6-month follow-up for all outcomes, with an improvement in self-concept clarity.

CONCLUSIONS

The 2 grief-related WBIs were effective in reducing grief, depressive and anxiety symptoms for participants who are bereaved or separated. The analyses did not reveal any pre-post between-group differences, suggesting that the innovations brought to LIVIA 2.0 did not significantly affect the outcome. However, caution is warranted with the interpretation of the results given the limited power of the sample, which only allows the detection of medium effect sizes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05219760; https://clinicaltrials.gov/study/NCT05219760.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/39026.

A role for event centrality in prolonged grief disorder

Having a traumatic or negative event at the centre of one's identity is associated with adverse psychological outcomes including post-traumatic stress, depression, and prolonged grief disorder (PGD). However, direct investigation of the role of centrality of a bereavement-event in the maintenance of PGD symptoms is scarce and has not compared immediate and long-term changes in event centrality nor examined the nature of the loss. Data from bereaved partners and adult children in The Aarhus Bereavement Study at four time points over 26 months post-loss were included in this study. Participants completed a PGD symptom measure and the Centrality of Events Scale (CES) on each occasion. Results suggest that bereaved partners had higher PGD and CES scores than bereaved adult children at all four post-bereavement time points. Regardless of relationship type, maintaining higher CES scores over time predicted PGD symptoms, over and above initial symptoms. Our findings suggest a risk factor for maintaining PGD symptoms is the continued centrality of the bereavement to ones' life story and autobiographical memory. This finding links the mechanisms for maintaining PGD symptoms to those involved in other disorders such as post-traumatic stress, with implications for theoretical models of prolonged grief as well as treatment.

Reflective functioning mediates the relationship between insecure adult attachment and the severity of prolonged grief symptoms

Background

This study aimed to investigate the mediation role of reflective functioning (i.e., certainty and uncertainty about mental states) in the relationship between insecure attachment (i.e., attachment avoidance and attachment anxiety ) and the severity of prolonged grief symptoms.

Methods

A cross-sectional study was conducted with 329 bereaved participants (51.7% females, mean age= 46.94 ± 14.62 years). Participants completed the Prolonged Grief Scale (PG-13), the Attachment Style Questionnaire (ASQ), and the Reflective Functioning Questionnaire (RFQ). Demographic and bereavement-related information were also collected.

Results

Certainty about mental states fully mediated the relationship between both the attachment avoidance and attachement anxiety and severity of prolonged grief symptoms.

Conclusions

The findings of this study indicate that reflective functioning impairment, specifically certainty about mental states of self and others, mediate the paths from insecure attachment to prolonged grief symptoms. This suggests that improving reflective functioning may contribute to the treatment bereaved individuals at risk of PGD.

Cluster analysis of prolonged grief, posttraumatic stress, and depression symptoms in bereaved asylum seekers and refugees

Background: Refugees and asylum seekers (ASRs) are frequently exposed to loss in addition to a variety of other stressors and often display high levels of various psychological symptoms.Objective: The study aimed to primarily determine clusters of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression symptoms in bereaved ASRs and secondly identify predictors of cluster membership. Sociodemographic  - and flight-related variables were investigated in exploratory analyses.Method: ASRs in Germany (N = 92) with interpersonal loss exposure, i.e. at least one missing or deceased relative or friend, were assessed with interview-based questionnaires for PGD, PTSD, and depressive symptoms. We used k-means cluster analysis to distinguish symptom profiles and logistic regression analyses to identify predictors of cluster membership.Results: We found a three-cluster-solution. The PGD-cluster (30%) was characterised predominantly by PGD symptoms, while the PGD/PTSD-cluster (32%) had high PGD and PTSD and moderate depressive symptoms. The resilient cluster (38%) showed low symptoms overall. insecure residence status predicted membership in the PGD and PGD/PTSD clusters relative to the resilient cluster, whilst higher attachment anxiety predicted membership in the PGD/PTSD cluster relative to the other clusters. Explorative analysis revealed duration of stay as a significant predictor.Conclusion: Findings can extend the current knowledge about different symptom profiles among bereaved ASRs in Europe. Insights to attachment  - and migration-related variables distinguishing between these profiles offer starting points for interventions.

From love to pain: is oxytocin the key to grief complications?

While most adults confronted with the death of a loved one manage to grieve, about 10-20% of individuals develop complicated grief, characterized by persistent distress and impaired social skills, or pathological grief, defined by the onset or decompensation of a psychiatric disorder. Little is known about the biological causes of these grief complications. Recent work suggests that oxytocin, a major neuroendocrine hormone regulating many neurocognitive mechanisms, may be involved in this process. Oxytocin is widely studied and well known for its impact on the mother-child bond and hormonal and brain systems related to attachment and social interactions. In this article, we propose a neurocognitive model of grief complications based on existing data on the role of oxytocin in interpersonal attachment and its impact on brain activity. We suggest that complicated grief is associated with dysfunctional cerebral oxytocinergic signaling and persistent hyperactivation of the nucleus accumbens. This mechanism is involved in limiting the reduction of interpersonal attachment to the deceased during acute phases and in searching for new interpersonal relationships during the recovery phase. We show how the exploration of cerebral oxytocinergic signaling would improve the understanding of physiological grief mechanisms in the general population and could allow the development of new therapeutic perspectives against the complications of grief.

Do insecure attachment styles predict prolonged grief symptoms? Significant null findings

Insecure attachment is proposed to be a risk factor in the development and persistence of severe grief. Although prior research demonstrates positive cross-sectional and longitudinal correlations between attachment styles and prolonged grief symptoms, controlled longitudinal analyses yield fewer convincing results. Therefore, we sought to further clarify the concurrent and longitudinal associations between these constructs. A sample of 225 bereaved Dutch adults (87% women; Mean age: 48.86 years) participated in a three-wave longitudinal survey including measures of attachment anxiety and attachment avoidance at baseline and prolonged grief symptoms at baseline and 6- and 12-month follow-up. Attachment anxiety and attachment avoidance were significantly positively correlated with prolonged grief symptoms at all time-points. However, multiple regressions, controlling for baseline symptoms, showed that attachment anxiety, attachment avoidance, and their interaction did not predict residual change in prolonged grief symptoms. These findings cast doubt on the proposed role of insecure attachment styles in prolonged grief.

A quasi-experimental trial of narrative reconstruction for prolonged grief disorder: Symptomatic improvement and enhanced memory integration

BACKGROUND

Prolonged grief disorder (PGD) was recently approved as a formal diagnosis in the DSM-5-TR. The implementation of bereavement interventions is frequently requested, but their effectiveness has been controversial. Narrative reconstruction (NR) is a time-limited integrative therapy, originally developed for the treatment of post-traumatic stress disorder (PTSD) and adapted for the treatment of PGD. NR consists of exposure to the loss memory, a detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved.

OBJECTIVES

In this study we evaluated the efficacy of NR for PGD.

METHOD

In this study, 33 participants with PGD were quasi-randomized-that is, assigned to an immediate (n = 20) or delayed (n = 13) 16-session NR intervention. PGD, intrusion, avoidance and depression symptoms, as well as levels of the loss memory integration, were assessed at pretreatment, post-treatment, and at a 3-month follow-up.

RESULTS

Mixed linear models showed significant intervention effects for PGD and intrusive symptomatology. Results also showed an increase in integration of the loss memory, and improvements remained stable for all outcomes at follow-up.

CONCLUSION

In this study we established NR as an effective intervention for PGD and call for further validation in future studies. Integrating this intervention into the routine care of people with PGD seems important and beneficial.

Grieving Parents' Meaning-Making Narration in Relation to Value Orientations: A Cross-Cultural Study

This study investigated the association between prolonged grief (PG) severity and meaning-making narration in a cross-cultural context, and specifically aimed to illustrate the role of value orientation in shaping the grieving process. 30 Chinese and 22 Swiss parents who lost their child were asked to narrate and appraise specific memories to reflect their self-evaluation of traditional and modern values. The self-reported Prolonged Grief Disorder Scale (ref ICD-11) assessed PG severity. Compared with the Swiss sample, the Chinese sample provided more elaborated memories, which was not associated with symptom severity. Both Chinese and Swiss bereaved parents with more severe PG provided more narratives of loss-related memories, particularly in response to modern values. They also provided more appraisals of negative meanings for self-defining memories, particularly in relation to their traditional values. These findings indicate that, despite cultural differences in narration tendency, PG severity in bereaved parents was associated with the maladaptive integration of autobiographical memories across different cultures, in relation to value orientations. A clinical implication is the potential value of facilitating narrations of grieving clients that center on value orientations to mitigate the hardship of the personal loss.

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.

A pull to be close: The differentiating effects of oxytocin and grief stimulus type on approach behavior in complicated grief

Theoretical models of complicated grief (CG) suggest that maladaptive motivational tendencies (e.g., perseverative proximity-seeking of the deceased; excessive avoidance of reminders) interfere with a person's ability to recover from their loved one's death. Due in part to conflicting evidence, little mechanistic understanding of how these behaviors develop in grief exists. We sought to (1) identify behavioral differences between CG and non-CG groups based on approach/avoidance bias for grief-, deceased-, and social-related stimuli, and (2) test the role of the neuropeptide oxytocin in shaping approach/avoidance bias. Widowed older adults with (n = 17) and without (n = 22) CG completed an approach/avoidance task measuring implicit bias for both personalized and non-specific grief-related stimuli (among other stimuli). In a double-blinded, randomized, counterbalanced design, each participant attended both an intranasal oxytocin session and a placebo session. Aims were to (1) identify differential effects of CG and stimulus type on implicit approach/avoidance bias [placebo session], and (2) investigate interactive effects of CG, stimulus type, and oxytocin vs. placebo on approach/avoidance bias [both sessions]. In the placebo session, participants in the non-CG group demonstrated an approach bias across all stimuli. Intranasal oxytocin had an overall slowing effect on the CG group's response times. Further, oxytocin decreased avoidance bias in response to photos of the deceased spouse in the CG group only. Findings support the hypothesis that oxytocin has a differential effect on motivational tendency in CG compared to non-CG, strengthening evidence for its role in CG. Findings also emphasize the need to consider differences in personalized vs. generic stimuli when designing grief-relevant tasks.

The Role of Emotion Regulation Difficulties and Intrusive and Deliberate Rumination in the Association Between Insecure Attachment and Prolonged Grief

This study investigated the role of emotion regulation difficulties and intrusive/deliberate rumination in the relationship between insecure attachment and prolonged grief symptoms. A total sample of 342 bereaved participants was included in the study. Both anxious and avoidant attachment styles were found to be associated with prolonged grief symptoms, with an avoidant attachment showing a stronger effect. Emotion regulation difficulties and rumination mediated the relationships between attachment styles and prolonged grief symptoms, supporting the proposed mediation model. The study identified specific mediating pathways for anxious and avoidant attachment styles. Additionally, female gender, higher age, unexpected death, and closeness of the relationship with the deceased were significant predictors of prolonged grief symptoms.

Factors Associated with Complicated Grief Following a Railway Tragedy

On July 6, 2013, a train with 72 crude oil tank cars derailed in the heart of Lac-Mégantic, a small municipality of 6,000 inhabitants located in Québec (Canada). This tragedy killed 47 people. Technological disasters are rarely studied in bereavement research, and train derailments even less. The goal of this article is to increase our understanding of the bereavement consequences of technological disasters. Specifically, we aim to identify the factors that lead to the experience complicated grief and distinguish from the protective factors. A representative population-based survey was conducted among 268 bereaved people, three and a half years after the train accident. Of these, 71 people (26.5%) experienced complicated grief. People with complicated grief (CG) differ significantly from those without CG in terms of psychological health, perception of physical health, alcohol use and medication, as well as social and professional relationships. Hierarchical logistic regression analysis identified four predictive factors for CG: level of exposure to the disaster, having a negative perception of the event, as well as having a paid job and low-income increase the risk of CG. The importance of having health and social practitioners pay attention to these factors of CG are discussed along with future directions for research.

The impact of continuing bonds following bereavement: A systematic review

Following bereavement, continuing bonds (CBs) include engaging with memories, illusions, sensory and quasi-sensory perceptions, hallucinations, communication, actions, and belief that evoke an inner relationship with the deceased. To date, the literature has been unable to confirm whether retaining, rather than relinquishing, bonds is helpful. A mixed studies systematic literature search explored how CBs affect grief. Studies on the effect or experience of CBs on adjustment following bereavement were eligible for inclusion. Six computerized databases were searched. A total of 79 of 319 screened studies were included. Three themes were derived from the thematic analysis: (1) comfort and distress, (2) ongoing bonds and relational identity, and (3) uncertainty, conceptualizing, and spirituality. Themes describe the role of CBs for the accommodation of the death story, transformation of the relationship, meaning reconstruction, identity processes, and affirmation of spiritual belief. Results shed light on the adaptive potentials for CBs.

An exploration of gender and prolonged grief symptoms using network analysis

BACKGROUND

Gender has been proposed as a potentially important predictor of bereavement outcomes. The majority of research in the field has explored this issue by examining gender differences in global grief severity. Findings have been mixed. In this study, we explore potential gender differences in grief using network analysis. This approach examines how individual symptoms relate to and reinforce each other, and so offers potential to shed light on novel aspects of grief expression across genders.

METHOD

Graphical lasso networks were constructed using self-report data from 839 spousally bereaved older participants (584 female, 255 male) collected at 2- and 11- months post-bereavement. Edge strength, node strength and global network strength were compared to identify similarities and differences between gender networks across time.

RESULTS

At both time points, the strongest connection for both genders was from yearning to pangs of grief. Yearning, pangs of grief, acceptance, bitterness and shock were prominent nodes at time 1. Numbness and meaninglessness emerged as prominent nodes at time 2. Males and females differed in the relative importance of shock at time 1, and the female network had greater overall strength than the male network at time 2.

CONCLUSIONS

This study identified many similarities and few differences in the relationships between prolonged grief symptoms for males and females. Findings suggest that future studies should examine alternate sources of variation in grief outcomes. Limitations are discussed.

Attachment patterns and autobiographical episodic memory functioning: A systemic review of adult studies to advance clinical psychological science

Patterns of insecure attachment are associated with psychopathology but the mechanisms involved remain poorly understood. Cognitive science proposes that attachment patterns are influenced by the autobiographical memory system and in turn influence its ongoing functioning. Disturbances in autobiographical memory represent cognitive risks for later emotional difficulties. We systemically reviewed 33 studies (in 28 articles) examining the association between attachment patterns and autobiographical episodic memory (AEM) in individuals from the age of 16 (i.e., from young to older adulthood). Attachment patterns were associated with key areas of AEM phenomenology, including intensity and arousal; detail, specificity, and vividness; coherence and fragmentation; and accuracy and latency. These associations appeared to be moderated by contextual and individual factors; mediated by emotional regulation and schema-based processing; linked to mental health outcomes. Attachment patterns may also influence the impact of certain AEM-based manipulations. We conclude by providing a critical discussion and a research agenda for bringing together attachment, memory, and emotion, with a view to promote mechanism-driven treatment innovation in clinical psychology.

Dwelling in prolonged grief: Resting state functional connectivity during oxytocin and placebo administration

Clinical theories of adaptation in bereavement highlight a need for flexible shifting between mental states. However, prolonged motivational salience of the deceased partner may be a complicating factor, particularly when coupled with perseverative thinking about the loss. We investigated how prolonged grief symptoms might relate to resting state functional brain network connectivity in a sample of older adults (n = 38) who experienced the death of a partner 6-36 months prior, and whether intranasal oxytocin (as a neuropeptide involved in pair-bonding) had differential effects in participants with higher prolonged grief symptoms. Higher scores on the Inventory of Complicated Grief (ICG) were associated with lower anticorrelation (i.e., higher functional connectivity) between the defaultretrosplenial - cingulo-operculardACC network pair. Intranasal oxytocin increased functional connectivity in the same defaultretrosplenial - cingulo-operculardACC circuit but ICG scores did not moderate effects of oxytocin, contrary to our prediction. Higher ICG scores were associated with longer dwell time in a dynamic functional connectivity state featuring positive correlations among default, frontoparietal, and cingulo-opercular networks, across both placebo and oxytocin sessions. Dwell time was not significantly affected by oxytocin, and higher prolonged grief symptoms were not associated with more variability in dynamic functional connectivity states over the scan. Results offer preliminary evidence that prolonged grief symptoms in older adults are associated with patterns of static and time-varying functional network connectivity and may specifically involve a default network-salience-related circuit that is sensitive to oxytocin.

The relationship between social acknowledgment and prolonged grief symptoms: a multiple mediation effect of beliefs about the goodness and controllability of grief-related emotions

Background: Social acknowledgment is a protective factor for survivors of trauma. However, the role of social acknowledgment in association with prolonged grief symptoms has not yet been established.Objectives: The current study aims to explore the relationship between social acknowledgment and prolonged grief via two beliefs foundational to how people think about grief-related emotions (1) goodness (i.e. whether emotions are desirable, useful, or unwanted and harmful), and (2) controllability (i.e. whether emotions are regulated according to our will or involuntary, arising of their own accord). These effects were explored in two different cultural samples of bereaved people.Methods: One hundred and fifty-four German-speaking and two hundred and sixty-two Chinese bereaved people who lost their loved ones completed questionnaires assessing social acknowledgment, beliefs about the goodness and controllability of grief-related emotions, and prolonged grief symptoms.Results: Correlation analyses showed that social acknowledgment was positively linked with stronger beliefs about the goodness and controllability of grief-related emotions and negatively related to prolonged grief symptoms. Beliefs about the goodness and controllability of grief-related emotions correlated negatively with prolonged grief symptoms. Multiple mediation analyses suggested that beliefs about the controllability and goodness of grief-related emotions mediated the link between social acknowledgment and prolonged grief symptoms. Cultural groups did not moderate the above model.Conclusion: Social acknowledgment may be related to bereavement adjustment consequences via the roles of beliefs about the goodness and controllability of grief-related emotions. These effects seem to be consistent cross-culturally.

Group-based compassion-focused therapy for prolonged grief symptoms in adults - Results from a randomized controlled trial

Prolonged grief disorder is a debilitating condition, which affects approximately one out of ten who lose a loved one. While existing meta-analyses have synthesized evidence regarding the overall effect of psychological interventions for pathological grief across different types of psychotherapy, it remains clinically relevant to explore whether specific types of psychological interventions are efficacious in the treatment of grief. The present study investigated the efficacy of group-based Compassion-Focused Therapy (CFT) for adults who had lost a spouse or a parent, and who reported clinically relevant levels of prolonged grief symptoms (PGS) at 11 months post-loss. A total of 82 participants were randomized to the CFT group (n = 42) or the waitlist control (n = 40). Time × group interactions showed no statistically significant effects of the intervention on the primary outcome PGS at post-intervention or 6-month follow-up. Likewise, no statistically significant effects were found for any of the secondary outcomes or process variables, with the exception of posttraumatic stress symptoms and self-reassurance. Taken together, in the present study group-based CFT did not emerge as an efficacious treatment for PGS. Possible explanations include that CFT may not target core maintaining processes in PGS and that the group-based, 8-week operationalization of CFT may be less than optimal.

Desired attachment and breakup distress relate to automatic approach of the ex-partner

BACKGROUND AND OBJECTIVES

Romantic relationship breakups can lead to severe emotional disturbances including major depression. Anxious attachment and desired attachment with the ex-partner are hypothesized to elicit repetitive thought about the breakup and the former partner and attempts to reunite with (i.e. approach) the ex-partner, which fuel breakup distress. Since prior research on this topic has mostly used survey methodology, the study aim was to examine the relations between above-mentioned variables employing a behavioral measure of approach of the ex-partner.

METHODS

Automatic approach-avoidance tendencies toward the former partner were assessed with an Approach Avoidance Task (AAT). Sixty-two students (76% female) moved a manikin towards or away from stimuli pictures (ex-partner, matched stranger, landscape) as fast as possible based on the stimulus frame color (blue, yellow). Participants also completed questionnaires assessing anxious attachment, desired attachment, repetitive thought about the breakup (rumination) and the ex-partner (yearning), and breakup distress (prolonged grief symptoms).

RESULTS

Anxious attachment related positively to rumination and breakup distress. Desired attachment related positively to yearning, automatic approach bias toward the ex-partner, and breakup distress. Both anxious and desired attachment, rumination, yearning, and approach bias related positively to breakup distress.

LIMITATIONS

The use of a student sample may limit generalizability. A correlational design precludes causal conclusions.

CONCLUSIONS

Together with prior work, results suggests anxious attachment hampers psychological adaptation to a breakup by increasing the use of ruminative coping. Desire to retain an attachment bond with the ex-partner, expressed in yearning and approach of the ex-partner, may also worsen breakup distress.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Distinct Psychological Characteristics Predict Resilience and Recovery Throughout Widowhood

The dual-process model proposes that early and later bereavement involves different types of stressors and adaptation processes (Stroebe & Schut, 1999, 2010). It is thus possible that different factors facilitate adaptation during the early months versus subsequent years following widowhood. Elevated depressive symptoms, though prevalent after widowhood, may indicate problematic adaptation, as they are associated with poor long-term physical and mental health outcomes. We predicted that neutral death acceptance would be associated with less increase in depression during early widowhood (when confronted with loss-oriented stressors), whereas perceived control would predict depressive symptom decline during later widowhood (when adapting to controllable restoration-oriented stressors). Older adults (N = 265) reported on neutral death acceptance, perceived control, and depression before widowhood and on depression 0.5, 1.5, and 4.0 years after the death of their spouse. Bilinear spline growth modeling revealed that, on average, depressive symptoms increased from before to 0.5 years after spouse death and fell from 0.5 to 4.0 years after spouse death. Neutral death acceptance predicted a smaller increase in depression from before to 0.5 years after spouse death, as well as a smaller subsequent decrease in depression from 0.5 to 4.0 years after spouse death. Perceived control predicted a larger decrease in depression from 0.5 to 4.0 years after spouse death. Neutral death acceptance and perceived control had unique associations with resilience and recovery throughout early and later widowhood. These variables may be fruitful targets in interventions for depression throughout the full course of widowhood.

Supporting People having Lost a Close Person by Bereavement or Separation: Study Protocol of a Randomized Controlled Trial Comparing Two French-Language Internet Interventions (Preprint)

Background

Internet-based interventions (IBIs) are as efficient as face-to-face psychotherapy for a variety of mental health disorders, including complicated grief. Most evidence stems from guided IBIs. However, recent research indicates that the benefit of guidance is lower in more interactive IBIs. As such, providing guidance only to people requiring it (guidance on demand) appears a cost-effective solution. This is particularly important to develop given the recent rise in grief symptoms in the context of the COVID-19 pandemic. This paper presents the protocol of a randomized controlled trial comparing the efficacy and adherence rate of 2 IBIs for grief-related symptoms after the loss a close one following death or romantic separation, using a guidance on demand framework. LIVIA 2.0 was developed based on theoretical and empirical findings on grief processes and IBIs, and it will be compared to LIVIA 1 that has already demonstrated its efficacy.

Objective

Our main hypotheses are that LIVIA 1 (control condition) and LIVIA 2.0 (experimental condition) increase participants’ well-being and decrease their distress at posttest and at follow-up, that LIVIA 2.0 is more efficient than LIVIA 1 for all outcomes, and that LIVIA 2.0 has less dropouts than LIVIA 1.

Methods

Outcomes will be assessed at pretest, posttest (12 weeks later), and follow-up (24 weeks later). We will recruit 234 participants through a variety of means, including social media and contacts with the press. Primary outcomes are grief symptoms, depressive symptoms, and eudemonic well-being. Secondary outcomes are anxiety symptoms, grief coping strategies, aspects related to self-identity reorganization, and program satisfaction. LIVIA 2.0 participants will additionally undergo a weekly mood and grief symptom monitoring, allowing us to explore the short-term efficacy of the sessions.

Results

The creation and development of the content of LIVIA 2.0 was completed during the first phase of the project. Participant recruitment will begin in May 2022 and will last until January 2023.

Conclusions

This study will emphasize the relevance of the innovations included in LIVIA 2.0 regarding the efficacy and dropout rate of IBIs for grief symptoms and will allow investigations on how these changes impact the demand for guidance. In the current postpandemic times, developing and assessing IBIs targeting grief symptoms are particularly critical given the rise in grief-related symptoms.

Trial Registration

clinicaltrials.gov NCT05219760; https://tinyurl.com/3dzztjts

International Registered Report Identifier (IRRID)

PRR1-10.2196/39026

Psychometric Characteristics of the Oxford Grief Memory Characteristics Scale and Its Relationship With Symptoms of ICD-11 and DSM-5-TR Prolonged Grief Disorder

Difficulties with loss-related memories are hypothesised to be an important feature of severe and enduring grief reactions according to clinical and theoretical models. However, to date, there are no self-report instruments that capture the different aspects of memory relevant to grieving and adaptation after bereavement over time. The Oxford Grief-Memory characteristics scale (OG-M) was developed using interviews with bereaved individuals and was subject to exploratory and confirmatory factor analyses in a community sample (N = 676). Results indicated the scale was unidimensional and demonstrated excellent psychometric properties. The impact of memory characteristics on symptoms of Prolonged Grief Disorder (PGD) according to both ICD-11 and DSM-5-TR criteria were investigated using cross-lagged structural equation modelling in a three-wave longitudinal sample (N = 275) at baseline and 6 and 12 months later. Results indicated that loss-related memory characteristics predicted future symptoms of PGD after controlling for autoregressions, and concurrent associations between symptoms and memory characteristics. Cross-lagged associations between memory characteristics and symptoms were significant in the first 6 months of follow-up. After that, memory characteristics predicted future symptoms, but not the other way round. Theoretical and clinical utility of the scale and its features are discussed.

How we continue bonds with deceased persons: The proximity-seeking behavior scale

Continuing bonds is a multifaceted process, encompassing perceptions, beliefs, illusions and hallucinations, and overt behaviors. We developed the Proximity-Seeking Behavior Scale (PSBS) to assess overt behavior to continue bonds with the deceased person. We had 694 bereaved adults complete an online survey. Exploratory and confirmatory factor analyses yielded a one-factor model for PSBS items. PSBS reliability was good. PSBS scores correlated positively with rumination and yearning, feeling connected to the deceased person, and prolonged grief and depression symptoms. The PSBS appears a reliable and valid instrument to assess proximity-seeking behaviors.

Grieving as a form of learning: Insights from neuroscience applied to grief and loss

Recent grief research suggests that the influential cognitive stress theory should be updated with evidence from cognitive neuroscience. Combining human and animal neuroscience with attachment theory, we propose that semantic knowledge of the everlasting nature of the attachment figure and episodic, autobiographical memories of the death are in conflict, perhaps explaining the duration of grieving and generating predictions about complications in prolonged grief disorder (PGD). Our gone-but-also-everlasting model emphasizes that grieving may be a form of learning, requiring time and experiential feedback. Difficulties before loss, such as spousal dependency or pre-existing hippocampal volume, can prolong learning and predict PGD. Complications such as avoidance, rumination, and stress-induced hippocampal atrophy may also develop after loss and create functional or structural mechanisms predicting PGD.

Caregivers' Self-Compassion and Bereaved Children's Adjustment: Testing Caregivers' Mental Health and Parenting as Mediators

Objectives

Self-compassion, which involves mindfulness, self-kindness, and common humanity, has been found to be related to individuals' mental health. Few studies have examined caregivers' self-compassion in relation to parenting behaviors and child adjustment in addition to its relation to their own mental health. In the current study we examined caregivers' self-compassion as a protective factor related to parentally bereaved children's internalizing and externalizing problems and further tested whether these relations were mediated by caregivers' mental health (complicated grief and psychological distress) and parenting.

Methods

The sample consisted of 74 caregivers (female = 78.4%) who participated in a larger study designed for bereaved families. At T1 (baseline) and T2 (20 weeks later), caregivers completed measures on demographic information, self-compassion, complicated grief, parental warmth, and consistent discipline, as well as child internalizing and externalizing problems.

Results

Findings supported that caregivers' self-compassion was prospectively related to decreased internalizing and externalizing problems in bereaved children. Mediation analyses showed that the effect of self-compassion on externalizing problems was mediated by parental warmth and by consistent discipline. In addition, caregivers' self-compassion was prospectively associated with decreased complicated grief and psychological distress of the caregiver.

Conclusions

These findings add to the knowledge on the benefits of self-compassion for bereaved families and suggest that caregivers' self-compassion intervention may be a leveraging point to protect both bereaved caregivers from complicated grief and distress but also to strengthen parenting which leads to bereaved children's adjustment.

The Network Structure of ICD-11 Disorders Specifically Associated with Stress: Adjustment Disorder, Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Complex Posttraumatic Stress Disorder

INTRODUCTION

The ICD-11 includes a new grouping for "disorders specifically associated with stress" that contains revised descriptions of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) and new diagnoses in the form of complex PTSD (CPTSD) and prolonged grief disorder (PGD). These disorders are similar in that they each require a life event for the diagnosis; however, they have not yet been assessed together for validity within the same sample. We set out to test the distinctiveness of the four main ICD-11 stress disorders using a network analysis approach.

METHODS

A population-based, cross-sectional design. A nationally representative sample of adults from the Republic of Ireland aged 18 years and older (N = 1,020) completed standardized measures of PTSD, CPTSD, AjD, and PGD. A network analysis was conducted at the symptom level. Outcome measures included the International Trauma Questionnaire, the Inventory of Complicated Grief, and the International Adjustment Disorder Questionnaire.

RESULTS

Consistent with the taxonomic structure of the ICD-11, our results showed that although the four conditions clustered independently at the disorder level, the specific symptoms of PTSD, CPTSD, PGD, and AjD clustered together very strongly but more strongly than with symptoms of the other disorders. The majority (61%) of the variation in each symptom could be explained by its neighboring symptoms. The strongest transdiagnostically connecting symptom was "startle response."

DISCUSSION/CONCLUSION

Mental health professionals caring for people who have experienced a range of stressors and traumatic life events can be confident in diagnosing these conditions that have clear diagnostic boundaries. Interventions addressing stress-associated disorders should be based on diagnostic assessment to ensure close fit between symptoms and treatment.

Change in avoidance and negative grief-related cognitions mediates treatment outcome in older adults with prolonged grief disorder

Objective: The present study investigated the role of the two theoretically derived mediators in the treatment of Prolonged Grief Disorder (PGD). Mediators were changes in avoidance and maladaptive cognitions. An additional hypothesis tested whether these candidate mediators are specific to CBT-based Complicated Grief Treatment (CGT) compared to Interpersonal Therapy (IPT). Method: We performed secondary analyses with assessment completers (n = 131) from a randomized-controlled trial with older adults with PGD. Patients received 16 sessions of CGT or IPT. Outcomes were treatment response and reductions in grief symptoms and grief-related related impairment. Results: Reductions in avoidance between baseline and week 16 mediated reductions in grief symptoms and grief-related impairment. Reductions in maladaptive grief-related cognitions over the same period mediated treatment response, reductions in grief symptoms and grief-related impairment. There were no significant treatment-mediator interactions. We could not establish that mediators changed before the outcomes. Conclusion: Results are consistent with theoretical models of PGD, including the CGT treatment model. Despite different therapeutic procedures, we found no significant interaction effect, but CGT produced larger effects. Future research needs to establish a timeline of change through the use of multiple measurements of mediators and outcomes.Trial registration: ClinicalTrials.gov identifier: NCT01244295.

Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected. Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.

It's not who you lose, it's who you are: Identity and symptom trajectory in prolonged grief

The death of a loved one has been associated with a range of emotional and cognitive impacts, with up to 10% of the bereaved population experiencing a prolonged grief reaction. Direct investigation of the role of self-identity in the maintenance of grief symptoms is limited and has not discriminated between relationship type. This longitudinal study investigated the differences in grief symptoms over time depending on relationship to the deceased person (partner or adult child), as well as the association between long-term grief symptoms and identity, attachment, and cognitive interdependence. Data from bereaved partners and adult children in The Aarhus Bereavement Study at two- and 18-months post-bereavement were included in this study. They completed questionnaires measuring their grief symptoms at both time points, a measure of attachment at Time 1, and measures of the interdependence of their pre- and post-loss identity with the deceased, their cognitive interdependence, and everyday memory retrieval failures at Time 4. Compared with adult children, bereaved partners experienced more intense grief symptoms at both time points. Regression analysis identified that over and above immediate grief symptoms, key predictors of prolonged grief symptoms were a merged post-bereavement identity with the deceased, younger age, and everyday memory retrieval difficulties. Relationship type and pre-bereavement identity contributed to initial but not prolonged grief symptoms. We discuss these findings in terms of the role of interdependence in prolonged grief.

The causal systems approach to prolonged grief: Recent developments and future directions

The network theory of prolonged grief posits that causal interactions among symptoms of prolonged grief play a significant role in their coherence and persistence as a syndrome. Drawing on recent developments in the broader network approach to psychopathology, we argue that advancing our understanding of the causal system that gives rise to prolonged grief will require that we (a) strengthen our assessment of each component of the grief syndrome, (b) investigate intra-individual relationships among grief components as they evolve over time within individuals, (c) incorporate biological and social components into network studies of grief, and (d) generate formal theories that posit precisely how these biological, psychological, and social components interact with one another to give rise to prolonged grief disorder.

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

The Typical Beliefs Questionnaire (TBQ) assesses common grief-related cognitions, which demonstrated satisfactory psychometric properties in a treatment-seeking sample with prolonged grief disorder (PGD). Chinese shidu parents (bereaved parents over the age of 49 who have lost their only child) are at a high risk of PGD. The current study aimed to examine psychometric properties of the Chinese version of the TBQ (TBQ-C) in a community sample of shidu parents with and without PGD, to compare this to the original validation clinical sample in the United States bereaved of any close relationship and to consider its use as a clinical tool. We examined the rate of positive endorsement, factor structure, internal consistency and validity of the TBQ-C in 310 community-based shidu parents (including 102 who met the criteria for PGD). Results showed that the rate of positive endorsement for each item ranged from 7.2% to 48.6% among non-PGD participants and from 20.6% to 92.2% among PGD participants. Confirmatory factor analysis indicated that the original five-factor structure fit both the non-PGD and PGD shidu parents. The TBQ-C showed acceptable internal consistency and satisfactory convergent and concurrent validity in both groups. It had good discriminant validity and can be helpful in distinguishing shidu parents with and without PGD. The TBQ-C can be used to investigate common grief-related beliefs that may be problematic for both shidu parents with and without PGD.

The role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief

Few studies examine the relationship of grief with interrelated and broad concepts. In this study, the role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief was investigated with individuals (N = 254) who have lost a close person in the last 5 years. Mediation and moderated mediation analyses revealed that individuals with early maladaptive schemas may experience more complicated grief symptoms through the effect of early maladaptive schemas. For individuals with self-sacrifice schema, difficulties in the grief process were regulated by moderate to high levels of sense of coherence.

The centrality of a loss-event: Patterns, correlates, and predictive value

BACKGROUND AND OBJECTIVES

Evidence shows that the centrality of a loss-event maintains emotional distress following loss. Aims of the current study were to examine (i) if subgroups of bereaved people can be distinguished based on their endorsement of different manifestations of loss-centrality, (ii) if subgroup membership was associated with socio-demographic and loss-related variables, and (iii) the linkage of subgroup membership with symptom-levels of prolonged grief (PG), posttraumatic stress (PTS), and depression assessed concurrently and 6 months later.

METHODS

Three-hundred ninety-eight bereaved people completed the 7-item Centrality of Event Scale, with their loss as anchor-event and completed symptom-measures concurrently and 6 months later. Latent profile analysis (LPA) was used to identity profiles of loss-centrality.

RESULTS

LPA revealed a three-profile solution representing low, average, and high centrality classes, respectively. The death of a partner and younger age increased the likelihood of membership of classes evidencing stronger centrality. Membership of the low centrality class was associated with lower concurrent PG, PTS, and depression; membership of the high centrality class predicted elevated PG 6 months later, beyond baseline PG.

CONCLUSIONS

Subgroups of loss-centrality were distinguished by increasing endorsement of all (rather than some) manifestations of loss-centrality. Clinical implications are discussed.

Prolonged grief and posttraumatic stress disorder following the loss of a significant other: An investigation of cognitive and behavioural differences

BACKGROUND

Cognitive behavioural correlates to bereavement-related mental health problems such a Prolonged Grief Disorder (PGD) and Posttraumatic Stress Disorder (PTSD) are of theoretical and clinical importance.

METHODS

Individuals bereaved at least six months (N = 647) completed measures of loss-related cognitions and behaviours (i.e., loss-related memory characteristics, negative appraisals, coping strategies, grief resilience, and perceived social disconnection) and measures of PGD and PTSD symptoms. Individuals were assigned to one of four groups depending on probable clinical diagnoses (No-PGD/PTSD, PTSD, PGD, PGD+PTSD).

RESULTS

Results indicated that higher loss-related memory characteristics and lower grief resilience increased the likelihood of a clinical problem. The PGD and PGD+PTSD groups reported significantly higher loss-related memory characteristics and appraisals compared to the PTSD group. Social disconnection increased the likelihood of comorbid PGD+PTSD in comparison to any other group.

CONCLUSIONS

Results indicate cognitive differences between loss-related cognitions, memory characteristics and coping strategies between PGD and PTSD, and points to distinct cognitive correlates to psychopathology following loss.

Risk and resilience factors associated with traumatic loss-related PTSD in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

PURPOSE

Sudden death of a loved one is the most prevalent potentially traumatic event worldwide, yet little is known about risk and resilience factors associated with traumatic loss-related posttraumatic stress disorder (PTSD).

METHODS

Data from a nationally representative sample of U.S. military veterans were analyzed to identify sociodemographic, military, health and psychosocial correlates of traumatic loss-related PTSD.

RESULTS

Loneliness, somatic symptoms, and attachment style were the strongest correlates of PTSD symptom severity and positive screens for traumatic loss-related PTSD.

CONCLUSION

Loneliness, somatic symptoms, and attachment style may represent therapeutic targets to help mitigate traumatic loss-related PTSD in U.S. veterans.

Narrative reconstruction therapy for prolonged grief disorder - a pilot study

Background: Prolonged grief disorder (PGD) is a chronic and disabling condition that affects approximately 10% of non-traumatically bereaved people. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD), is a time-limited integrative therapy consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved. Objective: This pilot study examined the efficacy of NR therapy in reducing symptoms in bereaved people diagnosed with PGD. Method: Ten PGD patients participated in the study and were treated with 16 weekly sessions of NR. PGD, PTSD, and depression symptoms, as well as levels of loss integration, were assessed at pre-treatment, post-treatment, and at a 3-month follow-up. Results: Following NR, participants showed significant reductions in PGD, depression, and PTSD symptoms, and elevated levels of trauma integration. Symptoms showed further improvement at the three-month follow-up. Conclusions: These findings provide preliminary evidence for the feasibility and efficacy of NR in treating PGD. Narrative reconstruction therapy requires further evaluation in randomized controlled trials.