Prolonged Grief Disorder Diagnostic Criteria-Helping Those With Maladaptive Grief Responses

Development of loneliness and social isolation after spousal loss: A systematic review of longitudinal studies on widowhood

BACKGROUND

Spousal loss is a stressful life event that is associated with loneliness and social isolation, both of which affect mental and physical health. The primary objective of this paper was to synthesize longitudinal studies that investigated loneliness and social isolation in widowhood.

METHODS

A systematic search of the literature was conducted using three electronic databases. 26 longitudinal studies published through June 2024 were included for further analysis. Participant characteristics, study design, and key findings were extracted.

RESULTS

Most studies were from the United States or Europe, included more widows than widowers, and assessed loneliness in older adults aged >60 years. Loneliness peaked directly following spousal death, but findings were inconsistent regarding the lasting effects of widowhood. Heterogeneity in the longitudinal trajectories of loneliness was noted, with studies showing linear increases, decreases, or curvilinear relationships over time. Several factors modified the relationship between widowhood and loneliness, including volunteerism, military experience, income, and age. Widowers consistently reported greater loneliness and worse social isolation when compared with widows. Few studies investigated social isolation specifically, but those that did found that social isolation may decrease in widowhood.

CONCLUSIONS

As the world grapples with a social pandemic of loneliness and social isolation, widowed adults may be uniquely affected. Few studies investigated the longitudinal trajectory of loneliness and especially social isolation in widowhood, and those that did found heterogenous results. Future work is needed to understand why some widowed adults are uniquely affected by feelings of loneliness and social isolation while others are not, and whether potentially modifiable factors that moderate or mediate this relationship could be leveraged by psychosocial interventions.

Amygdala-centered emotional processing in Prolonged Grief Disorder: Relationship with clinical symptomatology

BACKGROUND

Prolonged Grief Disorder 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 (61.5±8.9 years old) experiencing probable Prolonged Grief Disorder (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 fMRI scanning, and 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, compared to the integrated grief group (pcorr<0.05), which positively correlated with intrusive thoughts. Generalized psychophysiological interaction analysis revealed lower task-dependent functional connectivity between the right amygdala and posterior cingulate cortex/precuneus in PGD (pcorr<0.05), which negatively correlated with avoidance of loss reminders. Resting-state functional connectivity between the identified right amygdala and thalamus was higher in PGD (pcorr<0.05), which negatively correlated with loneliness.

CONCLUSIONS

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

Personalized fMRI tasks for grief severity in bereaved individuals: Emotional counting Stroop and grief elicitation protocols

Approximately 7-10% of people experiencing bereavement following a death develop prolonged grief disorder, a psychiatric disorder included in the DSM-5-TR. Prolonged grief disorder encompasses core symptoms of intense yearning/longing for and preoccupation with thoughts or memories of the deceased person experienced to a clinically significant degree for at least the last month, other key associated symptoms (e.g., avoidance, emotional pain), and the death must have occurred at least one year prior to diagnosis. Extant research has shown a relationship between activation in the reward pathway (e.g., nucleus accumbens) and grief severity. To date, functional MRI studies have primarily utilized the Emotional Counting Stroop task (ecStroop) and the Grief Elicitation task to explore these relationships. However, these prior studies are not without limitations, including small sample sizes and absence of a unified task protocol, hindering meaningful comparisons between studies. This protocol paper describes the ecStroop task and the Grief Elicitation task, which will be vital for facilitating multisite studies and enabling comparisons across studies. This will aid to advance the field by identifying neurophysiological measures that may, in the future, serve as potential biomarkers of prolonged grief disorder.

The Grief Debate, the DSM, and Clinical Practice

There has been an ongoing debate regarding grief, whether it may be at times pathological, and whether it is different from depression. This article addresses those questions by tracking the changing course of the Diagnostic and Statistical Manuals of Mental Disorders (DSMs) since DSM-III and by reviewing the debate concerning grief and depression. At the time when DSM-III was being prepared in the late 1970s (it was published in 1980), there was a concern that normal bereavement (or grief) was being diagnosed as major depression. To address this concern, the editors of DSM-III added a category of "uncomplicated bereavement." The fourth edition of the DSM (DSM-IV), published in 1994, then followed by a minor change. However, the editors of DSM-5 decided to eliminate the bereavement exclusion entirely. Their concern was simply whether the individual did or did not suffer from major depression. Since an individual might not warrant a diagnosis of major depression but might still be experiencing grief, the DSM discussion leads directly into the question of whether grief-later called prolonged grief disorder-and depression are separate conditions. Advocates for prolonged grief disorder maintained that grief is different from depression but that patients may present with a mix of grief and depressive symptoms that are clinically difficult to distinguish. Advocates of separate conditions have in fact developed an inventory of symptoms that identify prolonged grief disorder. However, inasmuch as a typical grief presentation will include depressive symptoms, the clinical challenge is to distinguish prolonged grief disorder and major depression, as well as to distinguish both from normal grief. Given the temporal limits of an average consultation, this article argues that making the required distinctions is an unrealistic expectation. Finally, researchers have developed specific treatment programs for prolonged grief disorder, but a conflict between the 2 primary researchers involved and the generalities in which the programs are phrased have led to the suggestion of a different approach to treatment that replaces generalities with a person-centered approach.

Risk factors for prolonged grief symptoms: A systematic review and meta-analysis

BACKGROUND

The diagnosis Prolonged Grief Disorder (PGD) has recently been included in ICD-11 and DSM-5-TR. To identify individuals who need help coping with grief, knowledge is needed about who is at risk of developing PGD. We, therefore, conducted a comprehensive systematic review and meta-analysis of the available literature on risk factors for prolonged grief symptoms (PGS).

METHODS

Based on a literature search in PsycInfo, PubMed, Web of Science, and CINAHL, we included the most frequently investigated risk factors in a meta-analysis. The effect size correlation was used as the standardized measure of the strength of the association between the risk factor and PGS.

RESULTS

Based on 120 studies of 61.580 participants published between 1989 and 2023, 19 risk factors were included in the meta-analysis. For the adjusted associations, the strongest associations with PGS were pre-loss grief symptoms (ESr = 0.39, 95%CI[0.24-0.53]) and depression (ESr = 0.30, 95%CI[0.13-0.44]). Small, but statistically significant associations were observed for unexpected death, violent/unnatural death, low educational level, low income, female gender, anxious attachment style, and death of a child or partner.

CONCLUSIONS

An updated overview of risk factors for PGS is presented, including their predictive strength. The results offer knowledge that can aid prevention and early identification of people at risk of PGD.

Reflections on a journey as sleep researcher and geriatric psychiatrist

After first recalling the origins of my interest in sleep and dreams at UVa (1969) and my MD thesis at Yale on sleep in mood disorders (1973), I will describe my service to the field of sleep disorders medicine, through various roles in the American Sleep Disorders Association, the Institute of Medicine, the National Institute of Mental Health, and the DSM-5 Task Force of the American Psychiatric Association. I will then present the broad themes of my contributions to psychiatric sleep research, focusing on the neurobiology of sleep as a dimension of the risk and protective architecture for depression in older adults, as a bridge to diagnostic and treatment issues in later-life depression, and to clinical and translational neuroscience addressing the intersections of sleep, aging, and mind/brain health. Throughout this narrative, I highlight many relationships with mentors and mentees. All of my scientific activity has been team-based, providing the social matrix for the physician-scientist I have become. This paper is part of the Living Legends in Sleep Research series, which is sponsored by Idorsia Pharmaceuticals and Jazz Pharmaceuticals.

Survey Study of a Hospital-Based Bereavement Program During COVID-19: Insights to Improve Support of the Bereaved

Background: The COVID-19 pandemic has highlighted that bereavement care is under-recognized with few hospitals offering universal bereavement services. Methods: One hundred sixty-nine bereaved individuals, whose loved ones died at our hospital during 2021 and 2022, completed a survey about their experience with the bereavement program. Results: Of respondents who recalled receiving bereavement outreach, 79% rated speaking to a team member soon after the death as having a positive impact on their bereavement, and 75% rated receiving a condolence call or note from the team positively. Feedback also identified opportunities for improvements in care: (1) importance of compassionate communication and connection with family members after a death; (2) more flexible hospital visitation policies; and (3) additional support for families during the end-of-life (EOL) period. Conclusions: The findings demonstrated that a hospital-based bereavement program can positively impact an individual's bereavement experience with a formal letter of condolence, psychoeducation information, and direct outreach from team members soon after death, being positively evaluated.

DSM-5-TR: Rationale, Process, and Overview of Changes

The DSM-5 text revision (DSM-5-TR) is the first published revision of the DSM-5 since its publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of the DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder on the basis of reviews of the literature over the past 10 years. In contrast to the DSM-IV-TR, in which updates were confined almost exclusively to the text, the DSM-5-TR includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of ICD-10-CM symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing "neuroleptic medications" with "antipsychotic medications or other dopamine receptor blocking agents" throughout the text and replacing "desired gender" with "experienced gender" in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.

Measuring Vulnerability in Grief: The Psychometric Properties of the Italian Adult Attitude to Grief Scale

Although experiences of loss and the consequent grief are natural in human life, some individuals may have difficulty managing these events, to the point of developing significant impairment in their functioning in important life areas. Given this, the present research aimed to explore the psychometric properties of the Italian version of the Adult Attitude to Grief scale (AAG) to facilitate research on adult vulnerability to grief among Italian-speaking populations. A sample of 367 participants (M_age = 30.44, SD = 11.21; 78% females) participated in this research. A back-translation procedure was implemented to develop the Italian AAG. Then, participants completed the Italian AAG alongside a battery of other self-report psychometric scales in order to assess aspects of the construct validity of the AAG: the Forty-Item Defense Style Questionnaire, the Impact of Event Scale-Revised, and the Beck Depression Inventory-II. A bifactor structure was found to have the best fit to the data, supporting the possibility of using both the general factor (i.e., vulnerability) and three dimensions (i.e., overwhelmed, controlled, and resilient). Unlike the original version, the control dimension emerged as a "protective" factor in the Italian population, together with the resilient factor. Furthermore, results provided satisfactory indications of internal consistency and construct validity. In conclusion, the Italian AAG was shown to be a valid, reliable, quick, and easy-to-use scale that can be used both for research and clinical practice in the Italian context.

Competitive Neurocognitive Processes Following Bereavement

Bereavement is a common human experience that often involves significant impacts on psychological, emotional and even cognitive functioning. Though various psychological theories have been proposed to conceptualize the grief process, our current understanding of the underlying neurocognitive mechanisms of grief is limited. The present paper proposes a neurocognitive model to understand phenomena in typical grief, which links loss-related reactions to underlying learning and executive processes. We posit that the competitive relationship between the basal ganglia (BG) and circuitry involving the medial temporal lobe (MTL) underlies common cognitive experiences in grief such as a sense of "brain fog." Due to the intense stressor of bereavement, we suggest that these two systems' usually flexible interactive relationship become imbalanced. The resulting temporary dominance of either the BG or the MTL system is then manifested in perceived cognitive changes. Understanding the underlying neurocognitive mechanism in grief could inform ways to best support bereaved individuals.

Prolonged Grief Disorder and the DSM: A History

ABSTRACT

In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.

Causes or Cures: What makes us think of attention issues as disorders?

Are attention issues disorders or not? Philosophers of medicine have tried to address this question by looking for properties that distinguish disorders from non-disorders. Such properties include deviation of a statistical norm, a loss of function or experienced suffering. However, attempts at such conceptual analysis have not led to a consensus on the necessary and sufficient conditions for the application of the concept of disorder. Recently, philosophers have proposed an experimental approach to investigate in which circumstances people think a specific concept is applicable. Here we present a quantitative vignette study investigating whether disorder attribution depends on the perceived cause and the perceived type of treatment for an attention problem. The results of our study indicate that the attribution of a disorder decreased when the attention problem was understood as caused by bullying (social environmental cause) or by an accident (non-social environmental cause) rather than a genetic cause. When prescribed a pill, attention problems were considered a disorder to a larger extent than when the child was prescribed an environmental treatment. Our study also suggests that whereas successful environmental treatments will not necessarily decrease the disorder attribution, successful pharmacological treatments will decrease the likelihood that a person is thought to still suffer from a disorder after receiving the treatment.

Grief, Loss and Bereavement. Understanding Concepts, Clinical Manifestations and Cultural Considerations at End of Life

The weight of grief is heavy on both patients with terminal illness, and their loved ones. We are now aware that grief is not limited to the time of death-grief reactions begin to occur at the time of diagnosis of terminal illness and evolve over time, impacting the patient and family unit in a variety of ways. Loss of what life "could have been" with better health, decline in physical functioning due to illness, and loss of identity and role within the family or community all play a part in the grieving process.

The Safety and Efficacy of Psychedelic-Assisted Therapies for Older Adults: Knowns and Unknowns

Psychedelics and related compounds have shown efficacy for the treatment of a variety of conditions that are prevalent among older adults, including mood disorders, the psychological distress associated with a serious medical illness, post-traumatic stress disorder (PTSD), and prolonged grief disorder. Psychedelics also have properties that could help provide therapeutic benefits for patients with dementing disorders, as well as promoting personal growth among healthy older adults. This article focuses on psilocybin, a classic psychedelic, and MDMA, a substituted amphetamine with properties similar to classic psychedelics. Both act on the 5HT_2A receptor. Psychedelics can be safely administered to healthy adults in controlled conditions. However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease. Very few older adults or patients with serious comorbidities have been included in clinical trials of psychedelics to date, raising the question of how generalizable study results are for the patients that most geropsychiatrists will be treating. Research on the neurophysiologic and mechanistic effects of psychedelics in older adults could also provide insights into the aging brain that could have clinical applications in the future. Given the potential of psychedelic compounds to benefit older adults, more research is needed to establish safety and efficacy among older adults, particularly those with multi-morbidity.

[Suicidology and Covid-19 Pandemic]

Seit über zwei Jahren ist die weltweite Bevölkerung der Pandemie mit dem SARS-CoV-2-Virus ausgesetzt. Die damit verbundene primäre Krankheitslast, also durch Infektionen, war und ist enorm. Sekundäre Belastungen ergaben sich durch Sorgen um die eigene und die Gesundheit enger Bezugspersonen, Trauerreaktionen im Falle des infektionsbedingten Verlustes von Angehörigen und all die gesellschaftlichen Einschränkungen im Rahmen der Pandemie-Bekämpfung. Der damit einhergehende Stress 1 resultierte – dies ist durch eine Vielzahl von Studien eindrucksvoll belegt – in einer Zunahme von psychischen Erkrankungen. So ist es zu einem deutlich verstärkten Auftreten von Depressions- und Angsterkrankungen gekommen, wobei bestimmte Bevölkerungsgruppen, wie z. B. alleinerziehende Mütter, einem besonderen Erkrankungsrisiko ausgesetzt waren (z. B. [2]). Bei Angehörigen von an Covid erkrankten Personen zeigt sich ein drastischer Anstieg von Traumafolgestörungen 3 und im Zuge der Einführung des ICD 11 mit der neuen Kategorie der prolongierten Trauerreaktion begrüßen einige Autoren diese neue diagnostische Entität gerade im Kontext der Corona-Erkrankung, weil es eben so viele Corona-Tote zu beklagen gab 4. Aber auch innerhalb der Gruppe von Personen, die an Corona erkrankten und dies einigermaßen überstanden haben, - und dies ist ja glücklicherweise die überwiegende Mehrzahl – zeigt sich noch nach einem Jahr eine deutlich erhöhte Menge von verschriebenen Psychopharmaka, im Vergleich zu einer Kontrollgruppe, als Beleg für fortbestehende psychische Symptome und eine womögliche ZNS-Beteiligung der Infektion (eine genaue Zuordnung innerhalb dieser Population zu dem als Postcovid-Syndrom bezeichneten Krankheitsbild muss noch erfolgen) 5.