Public Stigma of Prolonged Grief Disorder: An Experimental Replication and Extension

Prolonged grief disorder in bereaved parents: Exploring impacts and treatment pathways

Prolonged grief disorder (PGD) is characterized by intense and persistent grief that significantly impairs daily functioning. For bereaved parents, the loss of a child represents an unparalleled emotional challenge, placing them at heightened risk of developing PGD. This review traces the evolution of PGD from early conceptualization to current definitions in the International Classification of Diseases, 11^th revision, and Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision. Building on this historical foundation, the analysis examined the prevalence, risk factors, and diagnostic criteria of PGD in bereaved parents, with particular attention to sex differences, the nature of the loss, and the time elapsed since the child’s death. Furthermore, this review examines the multidimensional consequences of PGD on parents, including its emotional, physiological, and functional effects. Evidence-based treatments for PGD, such as psychotherapeutic approaches and emerging interventions, are also discussed. By synthesizing existing research, this review provides a comprehensive understanding of PGD among bereaved parents, highlights the unique challenges they face, and offers practical insights and recommendations for clinicians working with this population.

Prolonged grief reactions and help-seeking in bereaved adults during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted many care systems limiting bereaved peoples' ability to access social, community, and professional support. This study investigated help-seeking of people living with probable prolonged grief disorder (PGD) to identify challenges and facilitators of care, with the aim of informing bereavement practice and policy recommendations.

METHODS

Participants (N = 786; 96.3 % female, Mage = 54.51. SD = 11.64) who were 12 or more months post-bereavement completed an online survey indexing pandemic bereavement experiences, mental health and functional outcomes, and help-seeking experiences. Probable PGD was defined as a score ≥30 on the Prolonged Grief Scale 13-Revised (PG-13-R). Results were analyzed using univariate statistics for closed questions and content analysis for free-text responses.

RESULTS

Participants living with probable PGD (39.4 %) were more likely than others to: have sought help from professional or other structured grief supports (χ2(1) = 41.18, p < .001); have unmet bereavement needs (χ2(1) = 91.87, p < .001); and be living with significant functional impairment (t = -26.55, p < .001) and suicidal ideation (χ2(3) = 117.38, p < .001). Lack of provider availability and lack of relevant skills in working with grief and trauma were identified as challenges to care.

LIMITATIONS

The study used a convenience sample recruited online and so care is required before generalizing to less represented populations.

CONCLUSIONS

We identified both pandemic-specific and more general gaps within bereavement support systems. Our findings highlight a need to recognize care needs and elevate bereavement care within pandemic planning and health care systems more generally.

Prolonged Grief Symptoms Predict Social and Emotional Loneliness and Depression Symptoms

A minority of bereaved individuals develops severe, persistent, and disabling grief, termed "prolonged grief." The International Classification of Diseases, eleventh edition (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) include such grief reactions as prolonged grief disorder (PGD). Loneliness is often experienced by bereaved persons and can have severe health consequences. Preliminary research suggests that loneliness may perpetuate grief, but prolonged grief may also aggravate loneliness. Since existing empirical research provides limited information on temporal relationships between both constructs, we aimed to fill this gap in knowledge. Bereaved adults (88% female, mean age 54 years) filled in questionnaires assessing general, social, and emotional loneliness and prolonged grief and depression symptoms across two time points, 6 months apart. Cross-lagged panel model analyses showed that prolonged grief symptoms predicted more severe general, social, and emotional loneliness, as well as more depression symptoms. Loneliness did not predict prolonged grief symptoms and depression symptoms. Depression symptoms did not predict prolonged grief symptoms and loneliness. Additionally, latent change score analyses demonstrated that within person changes in prolonged grief symptoms and loneliness were related. Findings are inconsistent with the notion that loneliness causes prolonged grief and depression. Possibly, severe grief could lead to stigmatization, reduced social support, and feeling socially disconnected, perpetuating loneliness and depression symptoms.

Family Members Grieving the Loss of a Person to Incarceration: A Scoping Review

This scoping review examined grief related to the incarceration of a family member in order to establish a theoretical framework. A comprehensive search of PubMed, Social Sciences Citation Index, Embase, PsycInfo, Psychology & Behavioral Sciences, CINAHL, Cochrane Central Register of Controlled Trials & Cochrane Database of Systematic Reviews, PILOTS, and Psychiatry Online was conducted. We extracted data on sample characteristics, study design, purpose of the study, grief measure used, grief term and definition used, and key qualitative and quantitative findings. Twenty-five studies met inclusion criteria. Most studies used the terms 'ambiguous loss' (n = 15) and 'disenfranchised grief' (n = 12); however, grief terms and their definitions varied. The review identified 14 unique terms and more than 20 definitions. In several cases, the same term was defined and conceptualized differently between studies. This review also revealed shortcomings in existing theoretical frameworks for grief related to incarceration. Grief related to losing a family member to incarceration involves two distinct constructs: non-traditional losses and cascading losses. Non-traditional losses (measured on a continuum) capture elements of a loss to incarceration that are unique (compared to a loss via death) or may not be socially accepted, whereas cascading losses refers to the ongoing losses that one may experience related to the incarceration (e.g., loss of financial stability). This framework provides the field with consistent constructs and definitions that can be used to further advance research in incarceration-related grief and facilitates an improved ability to replicate findings between laboratories.

Is pregnancy loss (that) disenfranchised? Evidence from a vignette study

Background: Perceiving that society disregards grief after pregnancy loss (disenfranchised grief) elevates bereaved parents' psychological burden.Objective: In this research, we aimed to compare the disenfranchisement of pregnancy loss with four other loss types considering the bereaved's gender.Method: We collected data from Turkish participants (N = 1,280) using a 5 (loss type) x 2 (gender) between-subjects design with randomly assigned vignettes. Participants reported their expected grief and behavioural tendencies toward the bereaved. We conducted MANOVA and ANOVA analyses.Results: Results revealed that participants expected higher grief for pregnancy loss than two other disenfranchised grief types (former colleague's death, grandfather's diagnosis with Alzheimer's). Expected grief for pregnancy loss was higher than or similar to the level for the best friend's loss across examinations but lower than the level for the one-year-old child's loss. Behaviour tendencies were alike across vignettes, and their results did not paint a coherent picture. Findings did not differ by the bereaved's gender.Conclusion: Pregnancy loss might be less disenfranchised than bereaved parents perceive it, and parents' perceptions could be targeted in therapeutic interventions.

Comparing Public Perceptions of Child and Adult Grief Responses to Familial Incarceration

Children of incarcerated parents may grieve this loss, yet perceptions of their grief are understudied. Using vignettes varying by age (adult/child) and grief response (prolonged/resilient), we examined differences between perceptions of adults and children grieving parental incarceration. Participants rated grief response appropriateness, comfort providing support, and grief therapy recommendations for the grieving person in the vignette. Participants perceived resilience as more appropriate than prolonged grief [F (1, 224) = 9.02, p = .003, η2 = .04]. Age did not predict outcomes. Recommending grief therapy was higher for prolonged grief, yet 53% of participants with resilient vignettes recommended the person should seek grief therapy, which is concerning given possible iatrogenic effects. Thus, laypeople may have stigma toward individuals grieving parental incarceration, regardless of age.

Prolonged Grief Disorder, but Not Death From COVID-19, Elicits Public Stigma: A Vignette-Based Experiment

We investigated the effects of cause of death (COVID-19 with an underlying medical condition vs. without) and prolonged grief disorder status (PGD present or absent) on participants' reported public stigma towards the bereaved. Participants (N = 304, 66% women; Mage = 39.39 years) were randomly assigned to read one of four vignettes describing a bereaved man. Participants completed stigma measures assessing negative attributions, desired social distance, and emotional reactions. Participants reported significantly stronger stigmatizing responses towards an individual with PGD (vs. without PGD) across all stigma measures. There was no significant difference in stigma based on cause of death; however, stigma was reported regardless of cause of death. There was no significant interaction between cause of death and PGD on stigma. This study supports the robust finding of public stigma being reported toward an individual with PGD, suggesting these individuals are at risk of public stigma and not receiving adequate bereavement support.

The stigmatization of prolonged grief disorder and disenfranchised grief: A vignette-based experimental study

People with prolonged grief disorder (PGD) are at risk of public stigma, but research has yet to examine whether stigma is shaped by different types of relationship losses. In an experimental study, we asked participants (N = 306) to read three scenarios in which targets lost their romantic partner, child, or companion animal. Targets with PGD (vs. integrated grief) elicited more negative emotional reactions and attributions, and their experiences were perceived as less legitimate. Targets who lost their companion animal (vs. other relationship losses) were perceived as the most sensitive and their grief as the least legitimate, but they also elicited the lowest prosocial and fear reactions and were perceived as the warmest. Lastly, targets with PGD who lost their companion animal (vs. other relationship losses) elicited more negative emotional reactions and attributions, and their experiences were perceived as less legitimate. Implications and suggestions for future studies are discussed.

Public stigma toward prolonged grief and COVID-19 bereavement: A vignette-based experiment

We investigated the effects of cause of death and the presence of prolonged grief disorder (PGD) on eliciting public stigma toward the bereaved. Participants (N = 328, 76% female; Mage = 27.55 years) were randomly assigned to read one of four vignettes describing a bereaved man. Each vignette differed by his PGD status (PGD diagnosis or no PGD diagnosis) and his wife's cause of death (COVID-19 or brain hemorrhage). Participants completed public stigma measures assessing negative attributions, desired social distance, and emotional reactions. Bereavement with PGD (versus without PGD) elicited large and significantly stronger responses across all stigma measures. Both causes of death elicited public stigma. There was no interaction between cause of death and PGD on stigma. With increased PGD rates expected during the pandemic, the potential for public stigma and reduced social support for people bereaved via traumatic deaths and people with PGD requires mitigation.

Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies

Prolonged grief disorder has recently been added to the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders 5, Text Revision. This historical development is often presented as a linear process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. The present contribution provides an overview of work contradicting this dominant narrative. First, I show that the developmental history of prolonged grief disorder has been nonlinear and that this yields questions on generalizability and problems with measurement of the newest criteria sets. Second, I highlight an important gap in the validity evidence: the distinction of prolonged grief disorder from normal grief. Third, I discuss concerns relating to the societal effects of the inclusion of prolonged grief disorder in diagnostic handbooks, including the medicalization of grief, development and adverse effects of pharmacotherapy and stigmatization. A more realistic, balanced view on the history, validity and societal impact of prolonged grief disorder appears appropriate. I recommend stringent validation of assessment instruments for prolonged grief disorder, convergence of criteria-sets, closing gaps in validity evidence and developing strategies to mitigate the negative effects of grief diagnoses.

Perceptions of Crime Severity and Stigma Toward Family Members Grieving the Loss of a Person to Incarceration

Family members of incarcerated persons may experience grief related to the incarceration. We examined laypeople's perceptions of family members grieving the loss of an individual to incarceration. Participants (N = 1,095) were randomized to read vignettes that varied by grief trajectory (prolonged vs. resilient), race (Black vs. White vs. Latine), and crime type (violent vs. non-violent). Participants answered questions assessing grief response appropriateness, comfort providing support to the grieving person, beliefs that the grieving person should seek therapy, and how severe they believed the incarcerated person's crime was. Results indicated that prolonged grief trajectories and greater perceived crime severity were associated with decreased ratings of grief response appropriateness. Participants were more likely to endorse the need for therapy-seeking for individuals with prolonged grief (vs. resilience). Participants were less likely to recommend therapy for Black (vs. White) individuals, and women were more likely to recommend seeking therapy than men. The results suggest stigma might exist toward family members grieving the loss of individuals who committed crimes perceived to be more severe by laypeople, which could contribute to negative bereavement outcomes.

Perceptions of grief reactions in family members of incarcerated individuals: A vignette-based experiment

We examined perceptions of individuals grieving the loss of a family member to incarceration. Participants (N = 1095) were randomized to a vignette that varied by race-ethnicity, crime type, and grief trajectory to assess their perceptions. Results indicated: (1) participants perceived prolonged grief as less appropriate than resilience; (2) Black family members grieving someone who committed a violent crime as more appropriate compared to White family members; and (3) women endorsed both grief trajectories as more appropriate and indicated greater comfort supporting the family member. Lastly, participants indicated prolonged, White and Latinx grievers should seek therapy more than resilient or Black individuals.

Examining public stigma and expectations of grief following medical aid and dying in the US: A vignette-based experiment

Objectives

Families bereaved following Medical Aid in Dying (MAID)-related death express concerns about public stigma. As access to MAID expands, research examining MAID is needed, including understanding stigma toward family members. This study examines if stigmatization exists toward bereaved individuals whose family member utilized MAID at differing ages and assess if expectations of grief differ between bereaved individuals whose family member utilized MAID compared to bereaved individuals whose family member died of an illness.

Methods

This study utilized a randomized, between-groups, vignette-based experiment to test the effects of cause of death (MAID vs. illness-related death) and age (28, 38, 70, and 80 years) of the deceased on indicators of public stigma. Participants (N = 428) were recruited from mTURK (Mage = 42.54; SDage = 16.50).

Results

Analyses showed a statistically significant interaction between age and the mode of death (F(7, 400), p = 0.001, $\eta _{\rm p}^2$ = 0.06) and the main effect for age (F(5, 401), p = 0.004, $\eta _{\rm p}^2$ = 0.04) on expectations of grief, whereas emotional reactions and wanting social distance were not significant (p > 0.05). Participants expected more maladaptive grief among family members of 28- and 70-year-olds who died of illness compared to 28- or 38-year-olds who utilized MAID [28-year-old (M = 44.12, SD = 12.03) or 70-year-old (M = 44.32, SD = 10.29) illness-related death vs. 28-year-old (M = 39.3, SD = 11.56; p = 0.01) or 38-year-old (M = 38.71, SD = 11.56; p = 0.007) MAID-related death].

Significance of results

Findings suggest that direct stigma does not exist toward family members of individuals engaging in MAID. The American public may expect that family members of young individuals who utilize MAID are accepting of the death and expect them to experience fewer maladaptive grief symptoms. Future research should investigate differences in bereavement outcomes based on age of bereaved caregivers of individuals engaging in MAID.