Toward a Better Understanding of Psychological Symptoms in People Confronted With the Disappearance of a Loved One: A Systematic Review

Prevalence and correlates of positive and negative psychological effects of bereavement due to COVID-19: A systematic review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic was associated with an increase in mortality rates globally. Given the high numbers of deaths and the potentially traumatic characteristics of COVID-19 deaths, it was expected that grief-related distress would be higher in COVID-19 bereaved (compared to non-COVID-19 bereaved) people. This systematic review investigates the empirical evidence regarding this claim. More specifically, this review summarizes studies up to December 2024, evaluating the prevalence and correlates of positive and negative psychological effects of COVID-19 bereavement.

METHODS

Systematic searches were conducted in PsychInfo, Web of Science, and Medline by two independent reviewers. Eligible studies included quantitative research in peer-reviewed articles reporting on positive and/or negative psychological outcomes, using validated measures, in COVID-19 bereaved adults. The primary outcome was prolonged grief symptoms (PG).

RESULTS

We identified 9918 articles, whereof 28 studies met the inclusion criteria. Rates of psychological outcomes were primarily reported in terms of (early) PG, depression, posttraumatic stress, anxiety, and pandemic grief, and varied widely between studies (e.g., PG rates ranged between 30 % and 87 %). No studies reported on positive psychological outcomes. Closer kinship to the deceased, death unexpectedness, and COVID-19 stressors were identified as correlates of increased psychopathology.

CONCLUSIONS

Due to the small number and heterogeneity of studies, knowledge about psychological effects of COVID-19 bereavement is limited. This review offers a synthesis of research evidence to inform clinicians, policy makers, public health professionals, and future research concerned with psychological effects of COVID-19 bereavement.

Collective ambiguous loss after mass hostage-taking in war: exploring public mental health outcomes and resilience

Objective: Collective ambiguous loss can arise in communities facing the unresolved absence or presence of loved ones, marked by uncertainty and confusion. This study examines the impact of such loss on the general public in Israel after 251 individuals were taken hostage by Hamas on October 7 2023.Method: A diverse sample of 740 participants (ages 18-85, 58.2% women) took part in a comprehensive survey from December 2023 to January 2024. The survey measured boundary ambiguity (BA), separation distress related to disappearance (Ambiguous Loss Inventory Plus - ALI + - SD), general psychological distress (Mini-DASS), and personal resilience factors: ambiguity tolerance (Need for Closure Scale-Revised, NCSR) and psychological flexibility (PF).Results: Public stances indicated that 85% of respondents had moderate to very low confidence in the hostages' return, coupled with high endorsement of psychological engagement indicators such as emotional pain, intrusive thoughts, and survivor guilt. Those acquainted with a hostage (12%) showed no differences in stances or ALI + -SD and Mini-DASS levels, except for higher BA and greater engagement in demonstrations activities for their return. SEM analysis showed that ALI + -SD mediated the relationship between BA and Mini-DASS (high BA related to high general distress). In this model, BA and ALI + -SD explained over half of the variation in general psychological distress (R2 = 53%). A second model revealed serial mediation by BA and ALI + -SD in the relationship between NCSR and Mini-DASS, with lower ambiguity tolerance related to increased general distress. However, no such mediation was observed in the relationship between PF and Mini-DASS, and overall, the effect of personal resilience on general distress was relatively small.Conclusions: Mass hostage-taking substantially impacts society's mental health, extending beyond personal acquaintance with a hostage. The findings underscore the need to shift focus from personal resilience to community-based policies and therapeutic approaches to effectively address communal ambiguous loss amid collective trauma.

The Ambiguous Loss Inventory Plus (ALI+): Introduction of a Measure of Psychological Reactions to the Disappearance of a Loved One

BACKGROUND

The disappearance of a significant person is an ambiguous loss due to the persistent uncertainty about the whereabouts of the person. Measures specifically capturing the psychological consequences of ambiguous loss are lacking. Therefore, this study aimed to develop the Ambiguous Loss Inventory Plus (ALI+) and evaluated its suitability for use with relatives of missing persons.

METHODS

ALI+ items were generated based on established measures for prolonged grief symptoms and literature on psychological responses to ambiguous loss. Eight relatives of missing persons (three refugees, five non-refugees) and seven international experts on ambiguous loss rated all items in terms of understandability and relevance on a scale from 1 (not at all) to 5 (very well).

RESULTS

On average, the comprehensibility of the items was rated as high (all items ≥ 3.7). Likewise, all items were rated as relevant for the assessment of common responses to the disappearance of a loved one. Only minor changes were made to the wording of the items based on the experts' feedback.

CONCLUSIONS

These descriptive results indicate that the ALI+ seems to cover the intended concept, thus showing promising face and content validity. However, further psychometric evaluations of the ALI+ are needed.

Locked in grief: a qualitative study of grief among family members of missing persons in southern Sri Lanka

INTRODUCTION

The psychological and social issues experienced by family members of missing persons are different from normal grief following the death of a loved one. The term "Ambiguous loss" describes this psychological phenomenon. Ambiguous loss acts as a barrier to adjusting to grief, leading to symptoms of depression and intra and interpersonal relational conflicts. An in-depth phenomenological understanding of this subjective experience is important.

METHOD

A qualitative study was conducted among close family members of persons who had gone missing during the civil conflict and the 2004 tsunami in southern Sri Lanka following formal ethical approval from an university ethics review committee. Purposive and snowballing sampling methods were used to recruit the participants. Theoretical sample saturation was achieved with 24 family members of missing persons. Responders were mothers, fathers, wives, husbands, and siblings of missing individuals. In-depth interviews were recorded with the help of a semi-structured guide, after informed consent. The recordings were transcribed and coded by three independent investigators. The investigators through consensus arrived at the phenomenological themes and grounded them through reflexivity. The triangulation process involved cross-checking observational notes made by the interviewers and consulting the interviewees.

RESULTS

We interviewed 24 first degree relatives of missing individuals. Twenty-one of the interviewees were unsure about the fate of the missing individual, while three of them believed the missing individual to be dead. Of the 24 missing individuals, 20 were males and 18 had gone missing in civil conflicts and 6 in the Indian Ocean Tsunami. Six predominant phenomenological themes were identified. Those were lack of closure, hope, guilt, helplessness, perpetual suffering, and an emotional vacuum. These phenomenological experiences are highlighted by the interviewees through a range of utterances that hold profound cultural, social and emotional significance of unresolved and vacillating grief.

CONCLUSION

The highlighted phenomenology of grief in surviving family members of those who go missing following traumatic events demands a response from health and social services in every country that experiences disaster. The surviving loved one is 'locked in grief' indefinitely and future research on evidence-based interventions to overcome this predicament is warranted.

Using Ground Penetrating Radar and Resistivity Methods to Locate Unmarked Graves: A Review

The location of unmarked graves in forensic and archaeological investigations is legally and culturally important. In a forensic context, locating covert burials of missing persons can provide closure to the family, as well as facilitating the successful prosecution of the individual(s) responsible. Archaeologically, burials provide an important source of information about health, diet, physical anthropology, and culture. Despite the importance of these features, the location of unmarked graves with conventional archaeological and forensic techniques, such as excavation, is difficult and expensive. As a result, geophysical techniques have been widely applied to the location of unmarked graves as they are non-invasive, cost and time effective, and avoid the unnecessary disturbance of human remains. This article brings together the literature on ground penetrating radar (GPR), and two resistivity methods, electrical resistivity tomography (ERT) and fixed probe resistivity (FPR), on their ability to locate burials and reviews their use in forensic and archaeological investigations. This paper aims to provide law enforcement personnel, archaeologists, geophysicists, and interested academics with an overview of how these techniques work, how they have been previously applied to grave detection, and the strengths and weakness of these methods.

The Ravages of Enforced Disappearance: A Psychoanalytic Perspective of Traumatic Events and Encrypted Mourning

In the context of violence and enforced disappearance in Mexico, the concept of mourning is recontextualized from a psychoanalytic perspective. Two themes of the psychoanalytic theory of mourning are considered: 1) the impossibility to confirm the death of the missing person and 2) the availability and purpose of symbolic resources (rites, community activities). The private and public aspects of mourning are reviewed in relation to the afflictions of the relatives of the missing. Without a body to mourn, the rites that are performed around the disappeared have a different function than funeral rites. Nuanced by repetition, these rites attempt to work through the traumatic loss. The role of search groups in working through the pain of loss is also explored. The notions of intrapsychic crypt and endocryptic identification are reviewed, to better understand the encrypted mourning -the particular state of prolonged grief- endured by the relatives of the disappeared.

Narrating ambiguous loss: Deficiencies in narrative processing and negative appraisal of consequences

OBJECTIVE

To compare narrative coping with physical and psychological ambiguous loss (AL) and definite loss in terms of distancing (vs. narrative immersion), meaning-making, and subjective biographical consequences.

METHODS

Thirty adults who had lost a parent to death, to going missing, or to Alzheimer disease (N = 90, 67 females; mean age 36.73 years, SD = 7.27; mean time since loss 9.0 years) narrated two loss-related and three control memories.

RESULTS

Individuals with AL were not more immersed in the loss experience, but less successful in finding meaning and in evaluating the loss and its consequences positively compared to those with a definite loss. These group differences were not due to differences in depression, posttraumatic stress disorder, and protracted grief.

CONCLUSIONS

Ambiguity of loss renders meaning-making and coherently narrating loss more difficult, leading to more negative affect, suggesting interventions that help narrating loss coherently in a self-accepting way.

Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress

Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.

The Grief of Relatives of Missing Migrants and Supportive Interventions: A Narrative Review

This review aims to determine the impact of the disappearance of migrants on their family members, to identify their grief management needs, and to describe interventions carried out to date, exploring reports on the grief of relatives of people who disappear in any context. A search of the literature retrieved 24 publications. It was found that the disappearance produced an impact at individual, family, and community level. The primary requisite of relatives was knowledge of the location of their loved one, besides the need for emotional, social, and economic support and recognition of their suffering. There have been few reports of family support interventions, although recommendations have been proposed for their design and implementation. The relatives of migrants are especially vulnerable due to geographic, political, and legal obstacles. The impact of the disappearance and the need for support were found to be highly varied. Further research and interventions on this issue are required.

The Endless Grief in Waiting: A Qualitative Study of the Relationship between Ambiguous Loss and Anticipatory Mourning amongst the Relatives of Missing Persons in Italy

This article presents the results of a qualitative study aiming to consider the relationship between ambiguous loss and anticipatory mourning amongst relatives of missing people in Italy. Eight people participated in the research, narrating their experiences of losing a beloved person (one found alive, three found dead, and four still missing). Findings suggest the presence of a particular form of ambiguous loss, characterised by traits typical of both prolonged and traumatic grief. These findings describe how families are faced with an emotional vortex related to a never-ending wait, and how the mourning is solved only when the missing person is found dead or alive. The discovery of a corpse is traumatic but it allows mourners to fully recognise their grief. When a person is found, it changes the relationship in a positive way. When neither of these events happen, mourners have two different kinds of reactions: they experience either a prolonged grief or a drive to solve their suffering by helping other people (post-traumatic growth). In this study, it is highlighted how a community can be useful or detrimental in this process, and the importance of psychological and social support to prevent significant clinical outcomes is stressed.

The experience of sudden loss of a colleague or neighbor following the MH17 plane crash in the Ukraine: a qualitative interview study

Background

The literature on loss and traumatic grief after disasters provides findings on the impact of losing a partner, child or close friend on partners, parents and friends. However, little attention has been given to the broader everyday social environment of deceased persons. The present study constitutes a qualitative exploration of the impact on colleagues and neighbors following the MH17 airplane disaster in the Ukraine, July 2014.

Methods

Eighteen structured interviews were conducted with eleven colleagues and seven neighbors. The interviews focused on the relation(−ship) with the victim, on the disaster, the first days and weeks hereafter, and the status one and a half years after the crash.

Results

Especially for colleagues and neighbors with an intensive, long-lasting relation and ties based on friendship and trust, the impact of the sudden death was large. The MH17 disaster was considered a special event, different from, for instance, an “ordinary” accident. It was actively covered by the media and a recurrent conversation topic in meetings with other people. In the workplace, employers and less involved colleagues show empathy for a limited period of time, but grief has an expiration date – a moment where it gets more difficult to others or influences productivity. The appreciation for rituals in the workplace or in the neighborhood varies.

Conclusions

The interviews indicate a “hierarchy of bereavement”. People are not part of the typical inner circle, but feel “affected” and experience little social recognition and acknowledgment, particularly in the longer term. As such, colleagues and neighbors may experience loneliness and/or isolation. Generally, there is no need to consult a practitioner, despite the experience of health complaints such as intrusive dreaming and lack of sleep.

Cognitive behavioural therapy and mindfulness for relatives of missing persons: a pilot study

Objectives

Relatives of long-term missing persons need to deal with uncertainties related to the disappearance. These uncertainties may give rise to ruminative thinking about the causes and consequences of the loss. Focusing on tolerating uncertainties in treatment of relatives of missing persons might foster recovery. Adding mindfulness to cognitive behavioural therapy might serve this aim. The feasibility and potential effectiveness of cognitive behavioural therapy with mindfulness were evaluated in a pilot study. We aimed to detect changes in symptom levels and mindfulness from pre-treatment to 1 week, 12 weeks, and 24 weeks post-treatment.

Method

Dutch adults who experienced the disappearance of a significant other more than 3 months earlier and scored above clinical thresholds for psychological distress were eligible to participate. Participants were recruited from January 2015 to July 2016. Participants in the immediate treatment group started treatment after 1 week after randomization, whereas waiting list controls started the treatment after 12 weeks of waiting. Data from self-report measures as well as clinical diagnostic interviews (tapping persistent complex bereavement disorder, major depressive disorder, and posttraumatic stress disorder) were gathered among 17 relatives of missing persons with elevated symptom levels.

Results

The response rate (31.7%) was low, and dropout rate (47.1%) high. Cognitive behavioural therapy with mindfulness coincided with changes in psychopathology levels (Hedges’ g 0.35–1.09) and mindfulness (Hedges’ g − 0.10–0.41). Participants completing the treatment were satisfied with treatment quality and reported high treatment compliance.

Conclusions

Because of the limited research about effective treatments for relatives of missing persons and promising results of small and/or uncontrolled trials examining the effect of mindfulness-based treatment to target grief-related complaints, it seems valuable to continue investigating the effects of cognitive behavioural therapy with mindfulness on reducing post-loss psychopathology in future research. However, in order to increase the feasibility of future trials among relatives of missing persons, we recommend collaborating internationally and/or extending duration of recruitment phase, to maximize the sample size.

Trial registration

The Netherlands National Trial Register, NTR4732.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0472-z) contains supplementary material, which is available to authorized users.

Complicated grief and post-traumatic stress symptom profiles in bereaved earthquake survivors: a latent class analysis

Background: Studies on mental health following disasters have primarily focused on post-traumatic stress disorder (PTSD), yet severe, enduring, and disabling grief [i.e. complicated grief (CG)] also appears relevant. Objective: The present study examines symptom profiles of PTSD and CG among bereaved Sichuan earthquake survivors 1 year after the disaster. Method: Self-report measures of demographic, disaster, and loss-related characteristics and symptoms of PTSD and CG were administered among 803 survivors (63% women; mean age = 46.7 years). Latent class analysis (LCA) was performed to identify subgroups of people with different PTSD and CG symptom profiles. Results: The LCA demonstrated that a five-class solution yielded the best fit, consisting of a CG class with low PTSD and high CG (N = 208), a combined class with high PTSD and high CG (N = 205), a class with low PTSD and partial CG (N = 145), a class with partial PTSD and CG (N = 136), and a resilient class with low PTSD and CG (N = 108). Being a woman (vs man), losing a child or spouse (vs other), being injured (vs non-injured), and/or having a missing family member (vs non-missing) predicted membership of the CG class compared to other classes. Conclusions: CG appears to be a unique consequence of disasters involving many casualties. Disaster survivors should be screened for CG and provided with appropriate psychological treatment.

I've changed, but I'm not less happy: Interview study among nonclinical relatives of long-term missing persons

Twenty-three nonclinical relatives of long-term missing persons were interviewed. Patterns of functioning over time were studied retrospectively by instructing participants to draw a graph that best described their pattern. Patterns most frequently drawn were a recovery and resilient/stable pattern. Participants were also asked to select 5 out of 15 cards referring to coping strategies, which they considered most helpful in dealing with the disappearance. Acceptance, emotional social support, mental disengagement, and venting emotions were most frequently chosen. This study provided some indication of coping strategies that could be strengthened in treatment for those in need of support.

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.

Grief rumination mediates the association between self-compassion and psychopathology in relatives of missing persons

Background: The disappearance of a loved one is a unique type of loss, also termed 'ambiguous loss', which may heighten the risk for developing prolonged grief (PG), depression, and posttraumatic stress (PTS) symptoms. Little is known about protective and risk factors for psychopathology among relatives of missing persons. A potential protective factor is self-compassion, referring to openness toward and acceptance of one's own pain, failures, and inadequacies. One could reason that self-compassion is associated with lower levels of emotional distress following ambiguous loss, because it might serve as a buffer for getting entangled in ruminative thinking about the causes and consequences of the disappearance ('grief rumination'). Objective: In a sample of relatives of missing persons we aimed to examine (1) the prediction that greater self-compassion is related to lower symptom-levels of PG, depression, and PTS and (2) to what extent these associations are mediated by grief rumination. Method: Dutch and Belgian relatives of long-term missing persons (N = 137) completed self-report measures tapping self-compassion, grief rumination, PG, depression, and PTS. Mediation analyses were conducted. Results: Self-compassion was significantly, negatively, and moderately associated with PG, depression, and PTS levels. Grief rumination significantly mediated the associations of higher levels of self-compassion with lower levels of PG (a*b = -0.11), depression (a*b = -0.07), and PTS (a*b = -0.11). Specifically, 50%, 32%, and 32% of the effect of self-compassion on PG, depression, and PTS levels, respectively, was accounted for by grief rumination. Conclusions: Findings suggest that people with more self-compassion experience less severe psychopathology, in part because these people are less strongly inclined to engage in ruminative thinking related to the disappearance. Strengthening a self-compassionate attitude using, for instance, mindfulness-based interventions may therefore be a useful intervention to reduce emotional distress associated with the disappearance of a loved one.