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

The relationship between perceived stress and prolonged grief disorder among Chinese Shidu parents: effects of anxiety and social support

BACKGROUND

Shidu parents refer to the couple who have lost their only child and have not given birth or adopted another child in China. The number of Shidu parents is increasing annually. The aim of this research was to examine the mediating role of anxiety and the moderating role of social support between perceived stress and prolonged grief disorder (PGD) among Chinese Shidu parents.

METHODS

A cross-sectional study was carried out with 505 participants who completed a questionnaire including the Prolonged Grief Questionnair-3 (PG-13), the Perceived Stress Scale-10 (PSS-10), the Self-Rating Anxiety Scale (SAS) and the Duke-UNC Functional Social Support Questionnaire (FSSQ). SPSS PROCESS macro was employed to examine the mediating role of anxiety and the moderating role of social support.

RESULTS

The mediation analysis showed anxiety partially mediated the link between perceived stress and PGD, and the proportion of mediation of anxiety was 39.22%. The moderated mediation analysis revealed the second stage of mediating effects of anxiety on the link between perceived stress and PGD was moderated by social support. Specifically, compared with Shidu parents with higher social support, the association between anxiety and PGD was closer for those with lower social support.

CONCLUSIONS

The moderated mediation model can broaden our understanding of how and when perceived stress, anxiety and social support work together to affect PGD. The interventions aimed at improving mental health of Chinese Shidu parents need to work on reducing stress and enhancing social support.

Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

Following traumatic loss, defined as the death of a loved one due to unexpected or violent circumstances, adults may experience a myriad of grief-related problems. Given the addition of Prolonged Grief Disorders into the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition, Text-Revision and influx of unexpected deaths due to the global Coronavirus pandemic, there is heightened interest in the measurement of grief-related processes. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify measures of grief used in studies of adults who experienced traumatic loss. Searches yielded 164 studies that used 31 unique measures of grief-related constructs. The most commonly used instrument was the Inventory of Complicated Grief-Revised. Half of the measures assessed constructs beyond diagnosable pathological grief responses. Given the wide variation and adaptations of measures reviewed, we recommend greater testing and uniformity of measurement across the field. Future research is needed to adapt and/or design measures to evaluate new criteria for Prolonged Grief Disorder.

Psychopathology in a treatment-seeking sample of homicidally bereaved individuals: Latent class analysis

BACKGROUND

Violently bereaved individuals are at increased risk of developing severe and comorbid disorders. Comorbidity may increase psychiatric symptom severity and suicide risk and decrease psychosocial functioning compared with having one disorder. We aimed to identify subgroups of individuals with similar symptom patterns, describe prevalence rates and overall levels of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) per class, and explore associations between class membership and personal and homicide related variables.

METHODS

We investigated the comorbidity of symptoms of PGD, PTSD, MDD, and GAD in a sample of 923 treatment-seeking homicidally bereaved individuals by deploying latent class analysis.

RESULTS

Three subgroups were identified: (i) a moderate distress, low depression class (12.4%), (ii) a high distress, moderate depression class (42.7%), and (iii) a high distress and high depression class (45.0%). Prevalence rates and total scores of the questionnaires followed the pattern of iii ≥ ii ≥ i (ps ≤ .001). Being female and having experienced prior life stress distinguished between all classes (ps ≤ .05).

LIMITATIONS

The data-driven analytic approach and reliance on self-reported routine outcome monitoring data limit the generalizability and validity of the study. Strengths include the large sample size and the inclusion of four measures in a treatment-seeking, violently bereaved sample.

CONCLUSIONS

Classes were most clearly distinguishable based on symptom severity, indicating high comorbidity following bereavement by homicide. This argues for an integrated treatment that targets different complaints simultaneously rather than successively.

Psychometric properties of the German version of the Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ)

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ) was developed to measure depressive and anxious avoidance behaviors, which, according to cognitive-behavioral models, are supposed to play an important role in the development and maintenance of prolonged grief. The present study aimed to develop a German version of the DAAPGQ and evaluate its psychometric properties and validity within a representative sample of the German general population (N = 2531). The German-language DAAPGQ was developed using a forward-backward translation procedure. Then, a subsample of individuals who reported having lost a significant other (N = 1371) of a representative sample was assessed with the German DAAPGQ, along with information on sociodemographic characteristics, prolonged grief symptom severity (PG-13), general anxiety (GAD-2) and depression (PHQ-2). The factor structure of the DAAPGQ was evaluated using confirmatory factor analyses, reliability by calculating internal consistency on subscale level and convergent validity by correlations between DAAPQG subscale sores with PG-13, GAD-2 and PHQ-2 sum scores. As expected, a two-factor model with correlated latent variables showed good fit to the data, replicating findings from the original version. Internal consistency was high for both subscales (Cronbach’s α .86 and .95, respectively). Convergent validity was established by theoretically expected and statistically significant positive correlations of DAAPGQ subscales with symptom severity of prolonged grief, depression, and anxiety and negative correlations with time since loss. Furthermore, the addition of depressive and anxious avoidance significantly improved the prediction of prolonged grief symptom severity over sociodemographic and loss-related information. In sum, our results suggest that the German-language DAAPGQ is a reliable and valid measure of depressive and anxious avoidance and a useful tool to improve our knowledge on the role of avoidance in prolonged grief. We also provide descriptive data to improve the applicability of the DAAPGQ for individual diagnostics.

A Biopsychosocial Approach to Grief, Depression, and the Role of Emotional Regulation

According to the field of affective neuroscience, grief has been identified as one of the seven primary emotions necessary for human survival. However, maladaptive grief could cause significant impairment in an individual's life, leading to psychopathologies such as major depressive disorder. Research on grief has shifted to a biopsychosocial approach, leaving behind outdated models-such as the Kübler-Ross theory-that have shown poor consistency. The field of psychoneuroimmunology has identified adverse life events such as social loss as being associated with major depressive disorder, and inflammatory processes in chronic health conditions. Likewise, scientists in the field of affective neuroscience have theorized that prolonged and sustained activation of the grief neurological pathway can cause a cascade of neurotransmitters that inhibits the reward-seeking system, causing symptoms of depression. The objective of this review is to highlight findings on the grief process using a biopsychosocial approach to explore grief's impact on psychopathophysiology.

Evidence on the Conceptual Distinctness of Normal Grief From Depression

Abstract. Background: The distinctness of grief from depression has been the subject of a long scholarly debate, even influencing definitions of diagnostic criteria. Aims: This study aims at clarifying the issue by a multifaceted analysis of data from a large German sample. Method: A community sample of 406 bereaved persons answered the Wuerzburg Grief Inventory (WGI), a multidimensional grief questionnaire designed to measure normal grief in the German language, and the General Depression Scale – Short Version (GDS-S), a self-report depression scale. Data were analyzed by factor analysis to identify structural (dis-)similarities of the constructs, and analysis of variance (ANOVA) to identify the influence of the factors relationship to the deceased, type of death, and time since loss on grief measures and depression scores. Results: Factor analysis clustered items referring to grief-related impairments and depression into one factor, items referring to other dimensions of grief on separate factors, however. Relationship to the deceased influenced the grief measures impairments and nearness to the deceased, but not depression scores if controlled for impairments. Type of death showed specific effects on grief scores, but not on depression scores. Time since loss influenced grief scores, but not depression scores. Limitations: The analysis is based on a self-selected community sample of grieving persons, self-report measures, and in part, on cross-sectional data. Conclusion: Factor analysis and objective data show a clear distinction of dimensions of grief and depression. The human experience of grief contains a sense of nearness to the lost person, feelings of guilt, and positive aspects of the loss experience in addition to components resembling depression.

Prolonged grief and depression: A latent class analysis

Recent trends in grief research have been exploring how symptoms of prolonged grief disorder (PGD) and depression co-occur in bereaved individuals using Latent Class Analysis (LCA). However, the PGD criteria have kept undergoing changes and the newest DSM-5 PGD criteria have not been captured in these studies. Also, previous LCA-grief studies have been conducted in Western cultures, focusing more on bereaved adult populations. In this study, we applied LCA on a non-Western sample of bereaved young and middle-aged adults to examine whether the consistently observed 3 latent classes will emerge. We explored if the socio-demographic, loss-related factors, religiousness, spirituality, and continuing bond to the deceased, differentiated the latent classes. We confirmed the 3 latent classes comprising the Resilient class (20.6%), the predominantly PGD class (44.7%), and the combined PGD and Depression class (34.7%). Age, time elapsed since the loss, continuing bond and relationship with the deceased as well as spiritual beliefs were the differential predictors of class membership. This study increases our conceptual and clinical understanding of the predictability of PGD symptomology outcome, according to the newest DSM-5 criteria following bereavement in a non-Western sample. In addition to the continuing bond which was the strongest correlate, attention should be paid to important sociocultural frameworks in grief management.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

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

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

The latent nature of prolonged grief - A taxometric analysis: Results from a representative population sample

Individuals suffering from prolonged grief disorder (PGD) show severe grief reactions after the death of a significant other, even beyond a period of grieving that is within a person's cultural and religious context. In addition to this core element, PGD can manifest in various ways. Symptoms may include persistent preoccupation, intense emotional pain, or impairment in important life domains. The symptoms, furthermore, have to be of culturally or religiously inappropriate extent or severity, taking into account different norms of grieving. PGD is discussed as a distinct diagnostic category in the revision of the International Classification of Diseases (ICD-11). Nosology of PGD has been highly debated surrounding the suggested inclusion in the DSM-5, which had been declined due to insufficient evidence. This paper addresses the latent nature of PGD. Using a short form of the Inventory of Complicated Grief-Revised (ICG-R), we applied three popular taxometric methods: MAXEIG, MAMBAC and L-Mode. Data stemmed from a subsample of N = 1445 bereaved individuals that participated in a large representative German population survey (N = 2520). The analysis strongly indicated a dimensional latent structure of PGD. Implications of the conceptualization of PGD on a continuum are discussed, regarding measurement, diagnosis, etiology and future research.

Day patient treatment for traumatic grief: preliminary evaluation of a one-year treatment programme for patients with multiple and traumatic losses

Background: Bereaved individuals who have lost a loved one under traumatic circumstances can develop symptoms of Persistent Complex Bereavement Disorder (PCBD) and/or Posttraumatic Stress Disorder (PTSD). This is particularly common in refugees, as they frequently have been confronted with multiple traumatic losses. For patients with severe PTSD and traumatic grief a treatment programme was developed, embedding individual traumatic grief focused therapy in a group-based multidisciplinary day patient treatment programme. The day patient treatment comprised a weekly five-hour programme consisting of three phases with a duration of four months each. Objective: To evaluate the feasibility and potential effectiveness of the treatment programme. Method: Data were analyzed from 16 participants treated between October 2013 and March 2014. PTSD severity and PTSD/PCBD diagnoses were measured during the initial and final phases of treatment using the Clinician-Administered PTSD Scale for DSM-IV (CAPS) and the Traumatic Grief Inventory Self Report (TGI-SR). One clinical case is presented in more detail. Treatment attendance was also registered and therapist satisfaction was evaluated in a focus group. Results: Thirteen patients (81%) completed the treatment. Each day of the treatment programme was attended by a mean of 76% of the participants. In the focus group, therapists noted symptom reduction in their patients and they therefore regarded Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) as an effective therapy for their patients. During treatment, significant decreases in PTSD severity as well as diagnosable PTSD and PCBD were observed. Conclusions: Results support the feasibility and potential effectiveness of the day patient treatment programme for traumatic grief. The programme appears to be particularly suitable for refugees with severe PTSD and PCBD psychopathology, who may not benefit enough from usual care.

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.

The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults

Few epidemiological studies have investigated prolonged grief disorder (PGD) in the general population of Asian countries, including China. The aim of this study was to explore the rates and risks of PGD, and the association between PGD, post-traumatic stress disorder (PTSD), depression and anxiety in bereaved Chinese adults. The PG-13, PTSD Checklist-Civilian Version (PCL-C), Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS) were administered to 445 subjects. Prevalence within the general population of China was 1.8% (i.e., 8/445). Among the eight subjects who met the PGD diagnosis, 75%, 87.5% and 75% scored above the cut-off point on the PCL-C, SDS and SAS, respectively, although a portion remained free from comorbidity. ANOVA, correlation analysis and stepwise multiple regression analysis demonstrated that kinship to deceased, age of the deceased, religion belief and cause of death were predictive of prolonged grief. A small proportion of bereaved persons may exhibit PGD. There is a substantial but far from complete overlap between PGD and the other three diagnoses. Bereaved parents and the widowed have high risk of PGD. These findings highlight the need for prevention, diagnosis and treatment for PGD patients.

Prolonged grief disorder and depression in a German community sample

The aims of this study were to examine rates and risk factors for prolonged grief and to investigate the association between prolonged grief and depression. The authors interviewed a heterogeneous bereaved sample of 61 Germans, 6 of whom had prolonged grief and depression, respectively. The 2 syndromes were strongly linked to one another. Risk factors for prolonged grief were being a woman and having high levels of religious beliefs and low levels of satisfaction with one's religious beliefs, emotional closeness to the deceased, and unanticipated loss. Symptoms of prolonged grief may endure years post-loss and often overlap with depression.

Mourning Sickness: The Politicizations of Grief

In this paper, I propose that the politicization of grief falls into 3 categories of what I have termed different types of Mourning Sickness. In Mourning Sickness Type I, the politicization of grief functions to discipline the individual mourner's body into a productive, functioning, and contributing member of a capitalistic society. Moreover, I argue that the individualist ethos that pathologizes grief neuters the rage that can come with mourning and turns the gaze away from social injustices such as poverty, imprisonment, and opportunity gaps that are caused by state neglect. In Mourning Sickness Type II, I suggest that the politicization of grief is about consciously manipulating individual and collective grief in the service of nationalism and military power. The manipulation of grief on this level includes the explicit links made between loss and grief and justification for war, aggression, and violence, but also includes the distinctions made between whose lives are deemed grievable and whose lives are considered worthless and unmournable. Both Mourning Sickness Types I and II are of the pathological variety urgently requiring academic and public critique. In the last type of Mourning Sickness, I suggest that grief is also politicized when it is activated as a motivator toward a social justice agenda that includes peace, reconciliation, nonviolence, and positive social change on behalf of individuals, communities, and nations.