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Kuo JC, Chan W, Leon-Novelo L, Lairson DR, Brown A, Fujimoto K. Latent classification model for censored longitudinal binary outcome. Stat Med 2024. [PMID: 38951953 DOI: 10.1002/sim.10156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/23/2024] [Accepted: 06/10/2024] [Indexed: 07/03/2024]
Abstract
Latent classification model is a class of statistical methods for identifying unobserved class membership among the study samples using some observed data. In this study, we proposed a latent classification model that takes a censored longitudinal binary outcome variable and uses its changing pattern over time to predict individuals' latent class membership. Assuming the time-dependent outcome variables follow a continuous-time Markov chain, the proposed method has two primary goals: (1) estimate the distribution of the latent classes and predict individuals' class membership, and (2) estimate the class-specific transition rates and rate ratios. To assess the model's performance, we conducted a simulation study and verified that our algorithm produces accurate model estimates (ie, small bias) with reasonable confidence intervals (ie, achieving approximately 95% coverage probability). Furthermore, we compared our model to four other existing latent class models and demonstrated that our approach yields higher prediction accuracies for latent classes. We applied our proposed method to analyze the COVID-19 data in Houston, Texas, US collected between January first 2021 and December 31st 2021. Early reports on the COVID-19 pandemic showed that the severity of a SARS-CoV-2 infection tends to vary greatly by cases. We found that while demographic characteristics explain some of the differences in individuals' experience with COVID-19, some unaccounted-for latent variables were associated with the disease.
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Affiliation(s)
- Jacky C Kuo
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Wenyaw Chan
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Luis Leon-Novelo
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David R Lairson
- Department of Management, Policy and Community Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Armand Brown
- Bureau of Epidemiology, Houston Health Department, Houston, Texas, USA
| | - Kayo Fujimoto
- Department of Health Promotion and Behaviroal Sciences, University of Texas Health Science Center at Houston, Houston, Texas, USA
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2
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Bağcaz A, Kılıç C. Differential correlates of prolonged grief and depression after bereavement in a population-based sample. J Trauma Stress 2024; 37:231-242. [PMID: 38129914 DOI: 10.1002/jts.22998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 12/23/2023]
Abstract
Bereavement can lead to prolonged grief disorder (PGD) as well as episodes of major depression. Studies on the prevalence of PGD and its differences from postbereavement depression have not been conclusive. This study compared the correlates of depression and prolonged grief (PG) symptoms in a population-based random sample (N = 535) using the Beck Depression Inventory, Inventory of Complicated Grief-Revised, Anxiety Sensitivity Index (ASI), and Adult Separation Anxiety Questionnaire (ASAQ). Correlates of PG and depressive symptoms were examined using linear regression in 328 bereaved respondents. The prevalence of probable PGD based on PGD-2009 criteria was 3.0% among bereaved respondents and 1.9% in the total sample. PG was related to bereavement-related features including sex of the deceased, β = - .110, p = .026; time since loss, β = - .179, p = .001; the number of lifetime losses experienced, β = .157, p = .016; and perceived closeness with the deceased, β = .214, p < .001. Only lower income of the bereaved predicted depression, β = - .139, p = .018. In women, but not in men, the loss of a male family member (i.e., brother or son) was a significant predictor of PG symptoms, β = - .180, p = .006. The results confirm the qualitative distinction between depression and PG in a nonclinical sample and show that PG is mainly related to the intrinsic and extrinsic characteristics of the deceased or of death, whereas depression relates only to the characteristics of the bereaved person.
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Affiliation(s)
- Arda Bağcaz
- Department of Psychiatry, Başkent University Faculty of Medicine, Ankara, Turkey
- Stress Assessment and Research Center, Hacettepe University, Ankara, Turkey
| | - Cengiz Kılıç
- Department of Psychiatry, Hacettepe University Faculty of Medicine, Ankara, Turkey
- Stress Assessment and Research Center, Hacettepe University, Ankara, Turkey
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Nijborg LC, Kunst MJ, Westerhof GJ, de Keijser J, Lenferink LI. Grief and delivering a statement in court: a longitudinal mixed-method study among homicidally bereaved people. Eur J Psychotraumatol 2024; 15:2297541. [PMID: 38285899 PMCID: PMC10826785 DOI: 10.1080/20008066.2023.2297541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/02/2023] [Indexed: 01/31/2024] Open
Abstract
Background: Participating in a criminal trial may increase the likelihood of developing psychopathology. In 2021, people bereaved by a plane disaster (flight MH17) had the opportunity to deliver a victim personal statement (VPS) in Dutch court.Objective: This longitudinal mixed-method study examined different aspects of 84 bereaved people's experiences with VPS delivery.Method: Motivations to deliver, or not deliver, an oral VPS were examined qualitatively using thematic content analysis. Whether background and loss-related variables were related to the decision to deliver a VPS was examined using binary logistic regression analyses. Between-group (delivered VPS vs. did not) and within-group (pre- vs. post-VPS) comparisons were made regarding prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression levels using t-tests and paired t-tests.Results: Bereaved people were most frequently motivated to deliver an oral VPS to describe the impact of the incident, while those who did not deliver an oral VPS commonly wanted to protect themselves from the perceived emotional burden. None of the correlates - i.e. biological sex, age, level of education, number of losses, and (closest) relationship to the deceased - were related to the decision to deliver a VPS. Lastly, significantly higher PGD, PTSD, and depression levels were reported by people who delivered a VPS than those who did not, before and after the court hearing. No significant within-group differences were found over time.Conclusions: Professionals may provide emotional support to bereaved people who want to deliver a VPS and manage their expectations if they want to deliver a VPS for the purpose of symptom reduction. Future research may benefit from examining other ways in which VPS delivery might have beneficial or detrimental effects for specific individuals. Overall, implementing VPS delivery in court on the basis of emotional restoration remains empirically unsupported, if defined as a reduction in psychopathological levels.
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Affiliation(s)
- Lieke C.J. Nijborg
- Department of Psychology, Health, and Technology, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, the Netherlands
| | - Maarten J.J. Kunst
- Institute for Criminal Law and Criminology, Faculty of Law, Leiden University, Leiden, the Netherlands
| | - Gerben J. Westerhof
- Department of Psychology, Health, and Technology, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, the Netherlands
| | - Jos de Keijser
- Department of Clinical Psychology, Faculty of Behavioural, and Social Sciences, University of Groningen, Groningen, the Netherlands
| | - Lonneke I.M. Lenferink
- Department of Psychology, Health, and Technology, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, the Netherlands
- Department of Clinical Psychology, Faculty of Behavioural, and Social Sciences, University of Groningen, Groningen, the Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, the Netherlands
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Childbirth, trauma and family relationships. Eur J Psychotraumatol 2023; 14:2157481. [PMID: 37052080 PMCID: PMC9848292 DOI: 10.1080/20008066.2022.2157481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Childbirth is a major life event with expected positive outcomes, yet for some women postnatal psychopathological symptoms may harm women's interpersonal relationships. We hypothesized that higher levels of postnatal depression, post-traumatic stress (PTSD) symptoms, and fear of childbirth would be associated with mother-baby bond disorders and relationship dissatisfaction in couples.Method: A cross-sectional self-report online questionnaire was used to survey partnered women who had delivered in the year prior to the study. We used a convenience sample of 228 women recruited through purposive and snowball sampling. Childbirth experience, PTSD symptoms, attachment style, depression, mother-baby bond disorders, and couple relationship dissatisfaction were measured.Results: Women with higher PTSD and postnatal depression scores reported higher levels of mother-baby bond disorders-a relationship fully mediated by postnatal depression symptoms. Women who perceived childbirth as fearful or anxiety provoking had higher levels of PTSD and postnatal depression symptoms. Fearful and anxious birth perception was positively associated with mother-baby bond disorders-an association partly mediated by PTSD symptoms. Insecure attachment style was not found to be significantly associated with fearful or anxious perceptions of childbirth.Limitations: Women who have postnatal PTSD/depression are less inclined to participate in a study of this nature. Also, online surveys prevented the use of clinical diagnoses of PTSD and depression.Discussion and conclusions: Our results suggest that PTSD and postnatal depression affect women's mental health and family bonding. Women should be assessed for negative traumatic birth experiences, PTSD, and depression, to allow targeted observation for psychopathologies and therapeutic interventions.
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Shevlin M, Redican E, Murphy J, Hyland P, Karatzias T. Testing the latent structure of ICD-11 prolonged grief disorder symptoms in the U.K. adult population: An exploratory structural equation modeling approach. J Trauma Stress 2023; 36:1077-1089. [PMID: 37703294 DOI: 10.1002/jts.22972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 09/15/2023]
Abstract
The latent structure of ICD-11 prolonged grief disorder (PGD), as measured using the International Prolonged Grief Disorder Scale (IPGDS), was assessed in a large general population sample of bereaved adults from the United Kingdom. Data were derived from Wave 5 of the COVID-19 Psychological Research Consortium Study (C19PRC-UK). Exploratory structural equation modeling (ESEM) was used to assess the latent structure of the IPGDS. Identified factors were explored in relation to known correlates (i.e., gender, age of the bereaved, income, bereavement timeframe, age of the deceased) and functional impairment. Three factors-Loss, Emotional Numbing, and Emotional Reactivity-emerged in the best-fitting ESEM model, χ2 (92, N = 1,763) = 273.70, p < .001, CFI = .97, TLI = .96, RMSEA = .048, SRMR = .020. All factors were significantly associated with bereavement timeframe, βs = -.15--.20, and age of the deceased, βs = -.22--.31. Lower income predicted both Loss and Emotional Numbing; younger age of the bereaved predicted both Loss and Emotional Reactivity; and female gender was a unique predictor of Loss. Functional impairment was associated only with Emotional Numbing, β = .89. The findings highlight the multidimensional structure of PGD. However, the patterns of factor/cross-factor loadings observed in the present study indicate that a "simple" structure was not attainable. Associations between factors and covariates attest to the discriminant validity of the factors, and the association between Emotional Numbing and functional impairment may afford clinicians an opportunity to better understand and target the most disruptive features of grief.
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Affiliation(s)
- Mark Shevlin
- School of Psychology, Ulster University, Coleraine, Northern Ireland
| | - Enya Redican
- School of Psychology, Ulster University, Coleraine, Northern Ireland
| | - Jamie Murphy
- School of Psychology, Ulster University, Coleraine, Northern Ireland
| | - Philip Hyland
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Thanos Karatzias
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom
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Sobański JA, Klasa K, Dembińska E, Mielimąka M, Citkowska-Kisielewska A, Jęda P, Rutkowski K. Central psychological symptoms from a network analysis of patients with anxiety, somatoform or personality disorders before psychotherapy. J Affect Disord 2023; 339:1-21. [PMID: 37399849 DOI: 10.1016/j.jad.2023.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/05/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Cross-sectional network analysis examines the relationships between symptoms to explain how they constitute disorders. Up to now, research focuses mostly on depression, posttraumatic stress disorder, and rarely assesses larger networks of various symptoms measured with instruments independent of classifications. Studies on large groups of psychotherapy patients are also rare. METHODS Analyzing triangulated maximally filtered graph (TMFG) networks of 62 psychological symptoms reported by 4616 consecutive nonpsychotic adults in 1980-2015. RESULTS Case-dropping and nonparametric bootstrap proved the accuracy, stability and reliability of networks in patients' sex-, age-, and time of visit divided subgroups. Feeling that others are prejudiced against the patient was the most central symptom, followed by catastrophic fears, feeling inferior and underestimated. Sadness, panic, and sex-related complaints were less central than we expected. All analysed symptoms were connected, and we found only small sex-related differences between subsamples' networks. No differences were observed for time of visit and age of patients. LIMITATION Analyses were cross-sectional and retrospective, not allowing examination of directionality or causality. Further, data are at the between-person level; thus, it is unknown whether the network remains constant for any person over time. One self-report checklist and building binary network method may bias results. Our results indicate how symptoms co-occured before psychotherapy, not longitudinally. Our sample included public university hospital patients, all White-Europeans, predominantly females and university students. CONCLUSIONS Hostile projection, catastrophic fears, feeling inferior and underestimated were the most important psychological phenomena reported before psychotherapy. Exploring these symptoms would possibly lead to enhancement of treatments.
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Affiliation(s)
- Jerzy A Sobański
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland.
| | - Katarzyna Klasa
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland
| | - Edyta Dembińska
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland
| | - Michał Mielimąka
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland
| | | | - Patrycja Jęda
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland
| | - Krzysztof Rutkowski
- Jagiellonian University Medical College, Faculty of Medicine, Department of Psychotherapy, Poland
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Ennis N, Bottomley J, Sawyer J, Moreland AD, Rheingold AA. Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments. TRAUMA, VIOLENCE & ABUSE 2023; 24:2346-2362. [PMID: 35616367 PMCID: PMC9699905 DOI: 10.1177/15248380221093694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Naomi Ennis
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | - Jamison Bottomley
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | | | - Angela D. Moreland
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | - Alyssa A. Rheingold
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
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Wen FH, Prigerson HG, Chou WC, Huang CC, Hu TH, Chiang MC, Chuang LP, Tang ST. ICU Bereaved Surrogates' Transition Through States of Co-Occurring Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Depression Symptoms. Crit Care Med 2023; 51:1159-1167. [PMID: 37114931 DOI: 10.1097/ccm.0000000000005884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Grief-related psychological distress often co-occurs to conjointly impair function during bereavement. Knowledge of comorbid grief-related psychological distress is limited: no longitudinal study has examined dynamic patterns of co-occurring prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression, and previous assessment time frames have been variable and potentially inadequate given the duration criterion for PGD. Therefore, the purpose of this study was to investigate the transition of distinct symptom states based on the co-occurrence of PGD, PTSD, and depression symptoms for ICU bereaved surrogates over their first two bereavement years. DESIGN Prospective, longitudinal, observational study. SETTING Medical ICUs at two academically affiliated medical centers in Taiwan. PATIENTS/PARTICIPANTS Three hundred three family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Evaluation II scores > 20) from a disease. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Participants were assessed by 11 items of the Prolonged Grief Disorder (PG-13) scale, the Impact of Event Scale-Revised, and the depression subscale of the Hospital Anxiety and Depression Scale at 6, 13, 18, and 24 months postloss. PGD-PTSD-depression-symptom states and their evolution were examined by latent transition analysis. The following four distinct PGD-PTSD-depression-symptom states (prevalence) were initially identified: resilient (62.3%), subthreshold depression-dominant (19.9%), PGD-dominant (12.9%), and PGD-PTSD-depression comorbid (4.9%) states. These PGD-PTSD-depression-symptom states remained highly stable during the first two bereavement years, with transitions predominantly toward resilience. Prevalence for each state at 24 months postloss was 82.1%, 11.4%, 4.0%, and 2.5%, respectively. CONCLUSIONS Four highly stable PGD-PTSD-depression-symptom states were identified, highlighting the importance of screening for subgroups of ICU bereaved surrogates with increased PGD or comorbid PGD, PTSD, and depression symptoms during early bereavement.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taiwan, Republic of China
| | | | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, Republic of China
- School of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Republic of China
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, Republic of China
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Haws JK, Laifer LM, Acosta LM, Ralston AL, Ruggiero KJ, Davidson TM, Andrews AR. A Distinction Without a Difference? A Multi-Method Approach to Understanding PTSD and Depression Symptom Overlap Among Disaster-Exposed Adolescents. Res Child Adolesc Psychopathol 2023; 51:1021-1035. [PMID: 36881210 DOI: 10.1007/s10802-023-01042-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
Among adolescents exposed to trauma, posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur. Despite the prevalence of comorbidity, the question of how PTSD and MDD are related and appropriate conceptual models for understanding their linkage in adolescence remains unclear. This study applies a multi-methodological approach to advance conceptual and theoretical understanding of the overlap between PTSD and MDD diagnoses/symptoms. We tested three methodological approaches with three distinct theoretical underpinnings on the structure of each disorder proposed in the literature: confirmatory factor analysis (CFA) with dimensional constructs, latent class analysis (LCA) with person-based categorical constructs, and network analysis with symptom-to-symptom associations. Across the three different analytical approaches, there was a significant overlap between PTSD and MDD. Overall, there was no compelling evidence for distinct boundaries between disorders among trauma-exposed adolescents. Instead, we found considerable evidence that the typical latent-construct-based conceptualizations, whether categorical or dimensional, may need revision.
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Affiliation(s)
- James Kyle Haws
- Department of Family Medicine, and the Adult and Child Adult & Child Center for Outcomes Research & Delivery Science, University of Colorado School of Medicine, 13199 E. Montview Blvd, Suite 300, Aurora, CO, 80045, USA.
| | - Lauren M Laifer
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Laura M Acosta
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Allura L Ralston
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Kenneth J Ruggiero
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Tatiana M Davidson
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Arthur R Andrews
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
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Weed E, Fusaroli R, Simmons E, Eigsti IM. Different in different ways: A network-analysis approach to voice and prosody in Autism Spectrum Disorder. LANGUAGE LEARNING AND DEVELOPMENT : THE OFFICIAL JOURNAL OF THE SOCIETY FOR LANGUAGE DEVELOPMENT 2023; 20:40-57. [PMID: 38486613 PMCID: PMC10936700 DOI: 10.1080/15475441.2023.2196528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
The current study investigated whether the difficulty in finding group differences in prosody between speakers with autism spectrum disorder (ASD) and neurotypical (NT) speakers might be explained by identifying different acoustic profiles of speakers which, while still perceived as atypical, might be characterized by different acoustic qualities. We modelled the speech from a selection of speakers (N = 26), with and without ASD, as a network of nodes defined by acoustic features. We used a community-detection algorithm to identify clusters of speakers who were acoustically similar and compared these clusters with atypicality ratings by naïve and expert human raters. Results identified three clusters: one primarily composed of speakers with ASD, one of mostly NT speakers, and one comprised of an even mixture of ASD and NT speakers. The human raters were highly reliable at distinguishing speakers with and without ASD, regardless of which cluster the speaker was in. These results suggest that community-detection methods using a network approach may complement commonly-employed human ratings to improve our understanding of the intonation profiles in ASD.
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Affiliation(s)
- Ethan Weed
- Linguistics, Cognitive Science, and Semiotics, Aarhus University, Aarhus, Denmark
| | - Riccardo Fusaroli
- Linguistics, Cognitive Science, and Semiotics, Aarhus University, Aarhus, Denmark
| | - Elizabeth Simmons
- Communication Disorders, Sacred Heart University, Fairfield, Connecticut, USA
| | - Inge-Marie Eigsti
- Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
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Killikelly C, Maercker A. The cultural supplement: A new method for assessing culturally relevant prolonged grief disorder symptoms. CLINICAL PSYCHOLOGY IN EUROPE 2023; 5:e7655. [PMID: 37065001 PMCID: PMC10103155 DOI: 10.32872/cpe.7655] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 11/14/2022] [Indexed: 04/03/2023] Open
Abstract
Background
The new diagnosis of prolonged grief disorder (PGD) is both an opportunity and a challenge for researchers, clinicians, and bereaved individuals. The latest definition of PGD includes a refreshing and novel feature: the cultural caveat, i.e., clinicians must determine that the grief presentation is more severe and of longer duration than would be expected by an individual’s culture and context. Currently, there are no guidelines on how to operationalize the cultural caveat in mental health care settings.
Method
To respond to this important demand we have developed, piloted, and tested the cultural supplement module of the International Prolonged Grief Disorder scale (IPGDS). The cultural supplement aims to provide clinicians with a catalogue of culturally relevant symptoms of grief that indicate probable PGD alongside a simple framework for cultural adaptation for use in specific clinical settings.
Results
In this short report we outline the rationale and aim of the cultural supplement and provide a summary of our latest validation studies of the IPGDS with bereaved German-speaking, Chinese and Swiss migrant individuals. We also provide a step-by-step framework for adaptation of the cultural supplement that clinicians and researchers may use when working with different cultural groups.
Conclusion
To date, this is the first PGD questionnaire based on the ICD-11, and the first to include a cultural supplement that can be adapted to different contexts and groups. This cultural supplement will provide clinicians and researchers an easy-to-use assessment tool with the aim to improve the global applicability of the ICD-11 PGD definition.
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12
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Ashouri A, Yousefi S. Validation of the Persian Traumatic Grief Inventory- Self Report Plus (TGI-SR+) to Assess Prolonged Grief Severity. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231162730. [PMID: 36916138 DOI: 10.1177/00302228231162730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) is a self-report measure to assess Prolonged Grief Disorder (PGD) in terms of ICD-11 and DSM-5-TR. Till now this measure has shown to yield good psychometric properties in Dutch and French speaking bereaved people. This study aimed to evaluate the psychometric properties of the Persian TGI-SR+. 461 individuals (280 women) fully completed the scales. The participants were recruited using convenience sampling. The Confirmatory factor analysis and concurrent validity, and reliability of the Persian version of the TGI-SR+ were evaluated. Confirmatory factor analysis results of a two-dimensional model support the construct validity of this version of the TGI-SR+, while concurrent validity was shown with significant correlations between the TGI-SR+ and measures of depression, anxiety, and ptsd. These results indicate satisfactory psychometric properties of the instrument, thus supporting the use of the TGI-SR + as a valid measure of PGD in bereaved Iranian adults.
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Affiliation(s)
- Ahmad Ashouri
- Mental Health Research Center, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
| | - Shahab Yousefi
- Mental Health Research Center, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
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Rossi AA, Panzeri A, Taccini F, Parola A, Mannarini S. The Rising of the Shield hero. Development of the Post-Traumatic Symptom Questionnaire (PTSQ) and Assessment of the Protective Effect of self-esteem from trauma-related Anxiety and Depression. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2022; 17:1-19. [PMID: 36532142 PMCID: PMC9734448 DOI: 10.1007/s40653-022-00503-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 06/17/2023]
Abstract
Background Adverse life events such as life-threatening accidents, domestic and/or sexual violence, organic diseases (i.e., cancer), or COVID-19 can have a strong traumatic impact - generating reactions as intrusive thoughts, hyperarousal, and avoidance. Indeed, the traumatic impact of COVID-19 seems to lead individuals to experience anxiety and depression. However, the Anxiety-Buffer Hypothesis suggests that self-esteem could be considered a shield (buffer) against traumatic experiences and their outcomes (i.e., anxiety and depression). The present study has two objectives. First, to develop a measure of the impact of the traumatic event considering the aforementioned reactions. Second, to test the process - triggered by COVID19-related traumatic experience - in which self-esteem buffers the path that leads to anxiety and depression. Method In Study 1 (N = 353), the Post-Traumatic Symptom Questionnaire (PTSQ) was developed and a deep investigation of its psychometric properties was conducted. In Study 2 (N = 445), a structural equation model with latent variables was performed to assess the buffering effect of self-esteem. Results The PTSQ has excellent fit indices and psychometric properties. According to the ABH, results confirm the buffering effect of self-esteem in the relationships between traumatic symptoms and both anxiety and depression. Conclusion On the one hand, the PTSQ is a solid and reliable instrument. On the other hand, that self-esteem is a protective factor against anxiety and depression related to a traumatic experience - such as COVID-19. Targeted psychological interventions should be implemented to minimize the psychological burden of the illness while promoting adaptation and positive aspects of oneself. Supplementary Information The online version contains supplementary material available at 10.1007/s40653-022-00503-z.
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Affiliation(s)
- Alessandro Alberto Rossi
- Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
- Interdepartmental Center for Family Research, University of Padova, Padova, Italy
| | - Anna Panzeri
- Department of General Psychology, University of Padova, Padova, Italy
| | - Federica Taccini
- Interdepartmental Center for Family Research, University of Padova, Padova, Italy
- Department of Developmental Psychology and Socialisation, University of Padova, Padova, Italy
| | - Anna Parola
- Department of Humanities, University of Naples Federico II, Naples, Italy
| | - Stefania Mannarini
- Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
- Interdepartmental Center for Family Research, University of Padova, Padova, Italy
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14
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Piloting Group-Based Behavioral Activation Therapy for Families of Deceased COVID-19 Patients. Crit Care Explor 2022; 4:e0803. [PMID: 36506831 PMCID: PMC9726309 DOI: 10.1097/cce.0000000000000803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Surrogate decision-making is a stressful process for many family members of critically ill patients. The COVID-19 pandemic may have amplified the risk for anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms in ICU surrogates. OBJECTIVES This study piloted an online group-based behavioral intervention with family members of deceased COVID-19 patients. Participant engagement, perceptions, and responses related to the intervention were assessed. DESIGN A single-arm pilot study was conducted with bereaved families. Quantitative analysis of measures of anxiety, depression, and PTSD symptoms was conducted with mixed models. Qualitative data were analyzed to identify themes in surrogates' experiences with the intervention. SETTING Participants were recruited from ICUs at a tertiary academic medical center. Participants completed the intervention, measures, and interviews online. SUBJECTS Participants were family members of patients who died from COVID-19. INTERVENTIONS The intervention involved six online group-based behavioral activation sessions. Sessions covered topics pertinent to grieving and engagement in personally meaningful activities. MEASUREMENTS AND MAIN RESULTS Semi-structured interviews explored participants' experiences with the intervention. Surrogates also completed measures of anxiety, depression, and PTSD symptoms before and after the intervention. Nineteen of 26 participants (73.1%) completed the study. Thematic analysis suggested that surrogates found the group helpful for overcoming perceived isolation, receiving validation, and developing coping skills. Significant pre-to-post reductions were observed in symptoms of Hospital and Anxiety Disorder Scale (HADS) anxiety (pre-mean = 9.27, sd = 5.30 vs post-mean = 6.80, sd = 4.16; p = 0.0271), HADS depression (pre-mean =6 .65, sd = 4.58 vs post- mean = 4.89, sd = 3.40; p = 0.0436), and Impact of Events Scale-Revised PTSD (pre-mean = 36.86, sd = 16.97 vs post-mean = 24.14, sd = 13.49; p = 0.0008). LIMITATIONS This was a preliminary study based on qualitative and self-report measures. Future studies should include a control group. CONCLUSIONS Online group-based behavioral activation therapy appears to be a potentially useful intervention for family members of ICU patients who died from COVID-19.
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Buiter MY, Boelen PA, Kunst M, Gerlsma C, de Keijser J, Lenferink LIM. The mediating role of state anger in the associations between intentions to participate in the criminal trial and psychopathology in traumatically bereaved people. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2022; 85:101840. [PMID: 36274496 DOI: 10.1016/j.ijlp.2022.101840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
Victims of crimes have been granted increasing procedural rights to participate in the juridical process since the mid 1990s. However, knowledge about the (anti)-therapeutic effect of participation is limited. We examined the associations between symptom levels of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression and the intention to participate in a criminal trial. Furthermore, we investigated the mediating role of state anger in these associations. People who lost loved ones after a plane disaster with flight MH17 (N = 203) completed questionnaires within three weeks before the start of the criminal trial. Mediation analyses indicated that people, who did not intend to actively participate in the trial by delivering a written or oral victim statement, were less likely to experience anger, which is, in turn, associated with attenuated psychopathology levels. State anger explains 68% of the effect of the intention to exercise the right to speak on PCBD levels. An important limitation is the cross-sectional study design, which precludes conclusions about temporal associations. More research is needed to improve preparation and support of bereaved people when they intend to exercise their victim rights during a criminal trial.
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Affiliation(s)
- M Y Buiter
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712, TS, Groningen, the Netherlands
| | - P A Boelen
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, P.O. Box 80140, 3508, TC, Utrecht, the Netherlands; Foundation Centrum' 45, Nienoord 5, 1112 XE Diemen, the Netherlands; ARQ National Psychotrauma Centre, Nienoord 5, 1112 XE Diemen, the Netherlands
| | - M Kunst
- Institute for Criminal Law and Criminology, Faculty of Law, Leiden University, P.O. Box 9520, 2300, RA, Leiden, the Netherlands
| | - C Gerlsma
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712, TS, Groningen, the Netherlands
| | - J de Keijser
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712, TS, Groningen, the Netherlands
| | - L I M Lenferink
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712, TS, Groningen, the Netherlands; Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, P.O. Box 80140, 3508, TC, Utrecht, the Netherlands; Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands.
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16
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Trachik B, Elliman TD, Ganulin ML, Dretsch MN, Riviere LA, Cabrera OA, Thomas JL, Hoge CW. Order effects in PTSD network analysis: important implications for diagnostic conceptualization, treatment refinement, and research. Psychol Med 2022; 52:2492-2499. [PMID: 33261701 DOI: 10.1017/s0033291720004377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses. METHODS The current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined. RESULTS The prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably. CONCLUSION Order effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.
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Affiliation(s)
- Benjamin Trachik
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | - Toby D Elliman
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Michelle L Ganulin
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | - Michael N Dretsch
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | | | - Oscar A Cabrera
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | | | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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17
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Grafiadeli R, Glaesmer H, Wagner B. Loss-Related Characteristics and Symptoms of Depression, Prolonged Grief, and Posttraumatic Stress Following Suicide Bereavement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191610277. [PMID: 36011928 PMCID: PMC9408305 DOI: 10.3390/ijerph191610277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 05/13/2023]
Abstract
(1) Background: The aim of the present study was to examine symptom classes of major depressive disorder (MDD), prolonged grief disorder (PGD), and posttraumatic stress disorder (PTSD) in a sample of suicide-bereaved individuals, while accounting for loss-related characteristics. (2) Methods: A latent class analysis was conducted to identify classes of the suicide bereaved, sharing symptom profiles, in a German suicide-bereaved sample (N = 159). (3) Results: Our analyses revealed three main classes: a resilient class (16%), a class with high endorsement probability for PGD symptoms (50%), and a class with high endorsement probability for combined PGD/PTSD symptoms (34%). Prolonged grief and intrusive symptoms emerged across all classes, while MDD showed low endorsement probability. Our results indicate an association between class membership and time passed since the loss; however, this applies only to the comparison between the PGD and the resilient class, and not for the PGD/PTSD class. (4) Conclusions: Our results may provide information about the predictability of symptom clusters following suicide bereavement. The findings also represent a significant step towards tailoring treatments based on the needs of relevant suicide-bereaved subgroups through a symptom-level approach. Time passed since loss might explain differences between symptom clusters.
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Affiliation(s)
- Raphaela Grafiadeli
- Department of Psychology, Medical School Berlin, Rüdesheimerstraße 50, 14197 Berlin, Germany
- Correspondence:
| | - Heide Glaesmer
- Department of Medical Psychology and Medical Sociology, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103 Leipzig, Germany
| | - Birgit Wagner
- Department of Psychology, Medical School Berlin, Rüdesheimerstraße 50, 14197 Berlin, Germany
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18
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Johannsen M, Schlander C, Farver-Vestergaard I, Lundorff M, Wellnitz KB, Komischke-Konnerup KB, O'Connor M. Group-based compassion-focused therapy for prolonged grief symptoms in adults - Results from a randomized controlled trial. Psychiatry Res 2022; 314:114683. [PMID: 35717855 DOI: 10.1016/j.psychres.2022.114683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/18/2022]
Abstract
Prolonged grief disorder is a debilitating condition, which affects approximately one out of ten who lose a loved one. While existing meta-analyses have synthesized evidence regarding the overall effect of psychological interventions for pathological grief across different types of psychotherapy, it remains clinically relevant to explore whether specific types of psychological interventions are efficacious in the treatment of grief. The present study investigated the efficacy of group-based Compassion-Focused Therapy (CFT) for adults who had lost a spouse or a parent, and who reported clinically relevant levels of prolonged grief symptoms (PGS) at 11 months post-loss. A total of 82 participants were randomized to the CFT group (n = 42) or the waitlist control (n = 40). Time × group interactions showed no statistically significant effects of the intervention on the primary outcome PGS at post-intervention or 6-month follow-up. Likewise, no statistically significant effects were found for any of the secondary outcomes or process variables, with the exception of posttraumatic stress symptoms and self-reassurance. Taken together, in the present study group-based CFT did not emerge as an efficacious treatment for PGS. Possible explanations include that CFT may not target core maintaining processes in PGS and that the group-based, 8-week operationalization of CFT may be less than optimal.
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Affiliation(s)
- Maja Johannsen
- Unit for Bereavement Research, Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Aarhus C DK-8000, Denmark; Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Bartholins Allé 9, Bld. 1350, Aarhus C DK-8000, Denmark
| | - Christina Schlander
- Centre for Compassion-Focused Therapy, Møllestien 52, Aarhus C DK-8000, Denmark
| | | | - Marie Lundorff
- Department of Communication, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark
| | - Kaare Bro Wellnitz
- Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Bartholins Allé 9, Bld. 1350, Aarhus C DK-8000, Denmark; Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Universitetsbyen 21-23, Aarhus C DK-8000, Denmark
| | - Katrine B Komischke-Konnerup
- Unit for Bereavement Research, Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Aarhus C DK-8000, Denmark; Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Bartholins Allé 9, Bld. 1350, Aarhus C DK-8000, Denmark
| | - Maja O'Connor
- Unit for Bereavement Research, Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Aarhus C DK-8000, Denmark; Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Alle 11, Bartholins Allé 9, Bld. 1350, Aarhus C DK-8000, Denmark.
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19
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Wang N, Chung MC, Zhang J, Fang S. Network analysis on the relationship between posttraumatic stress disorder, psychiatric co-morbidity and posttraumatic growth among Chinese adolescents. J Affect Disord 2022; 309:461-470. [PMID: 35513114 DOI: 10.1016/j.jad.2022.04.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/14/2021] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study investigated the association between posttraumatic stress disorder (PTSD), psychiatric co-morbidity and posttraumatic growth (PTG) among Chinese adolescents using network analysis. METHODS 867 Chinese adolescents (male = 424, female = 443) were recruited from three secondary schools. They completed the Posttraumatic Stress Disorder Checklist for DSM-5, the Posttraumatic Growth Inventory, and the General Health Questionnaire-28. RESULTS Domains of each construct mainly clustered within their respective communities with several bridging edges identified. The prominent roles of bridging nodes and edges (positive and negative) were highlighted. Key bridging nodes were negative alterations in cognitions and mood for PTSD, anxiety and insomnia for psychiatric co-morbidity and appreciation of life for PTG. LIMITATIONS The cross-sectional nature of the present study may preclude the identification of real causal relationships between nodes. CONCLUSIONS Following a trauma, adolescents displayed posttraumatic stress along with general psychological disorder symptoms. These distress reactions could affect the way they appreciated life and their motivation to seek future life possibilities. Findings from the current study may provide some clue for the facilitation of posttraumatic growth among clinical patients.
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Affiliation(s)
- Na Wang
- Department of Educational Psychology, The Chinese University of Hong Kong, Hong Kong
| | - Man Cheung Chung
- Department of Psychology, Zayed University, Dubai, United Arab Emirates
| | - Jieting Zhang
- College of Psychology, Shenzhen University, Shenzhen, China
| | - Siqi Fang
- Department of Social and Behavioral Sciences, City University of Hong Kong, Hong Kong.
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20
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Snijdewind MC, de Keijser J, Casteelen G, Boelen PA, Smid GE. "I lost so much more than my partner" - Bereaved partners' grief experiences following suicide or physician-assisted dying in case of a mental disorder. BMC Psychiatry 2022; 22:454. [PMID: 35799148 PMCID: PMC9261256 DOI: 10.1186/s12888-022-04098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/23/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND There is a lack of existing research on grief following the intentional death of people suffering from a mental disorder. Our study aims to provide insight into grief experiences and social reactions of bereaved persons who lost their life partners, who were suffering from a mental disorder, to physician-assisted dying (PAD) or suicide. METHODS For this mixed-methods research, we conducted a survey and in-depth interviews with 27 persons living in the Netherlands and bereaved by the death of their life partners. The deceased life partners suffered from a mental disorder and had died by physician-assisted dying (n = 12) or suicide (n = 15). Interviews explored grief experiences and social reactions. In the survey we compared self-reported grief reactions of partners bereaved by suicide and PAD using the Grief Experience Questionnaire. RESULTS Compared to suicide, physician-assisted dying was associated with less severe grief experiences of the bereaved partners. Participants reported that others rarely understood the suffering of their deceased partners and sometimes expected them to justify their partners' death. Following physician-assisted dying, the fact that the partner's euthanasia request was granted, helped others understand that the deceased person's mental suffering had been unbearable and irremediable. Whereas, following suicide, the involvement of the bereaved partners was sometimes the focus of judicial inquiry, especially, if the partner had been present during the death. CONCLUSION When individuals suffering from a mental disorder die by suicide or PAD, their bereaved partners may experience a lack of understanding from others. Although both ways of dying are considered unnatural, their implications for bereaved partners vary considerably. We propose looking beyond the dichotomy of PAD versus suicide when studying grief following the intentional death of people suffering from a mental disorder, and considering other important aspects, such as expectedness of the death, suffering during it, and partners' presence during the death.
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Affiliation(s)
- M. C. Snijdewind
- ARQ Centrum’45, Nienoord 5, 1112 XE, Diemen, The Netherlands ,grid.5650.60000000404654431Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - J. de Keijser
- grid.4830.f0000 0004 0407 1981Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, The Netherlands
| | - G. Casteelen
- Expertisecentrum Euthanasie, P.O. Box 13480, 2501 EL Den Haag, The Netherlands
| | - P. A. Boelen
- ARQ Centrum’45, Nienoord 5, 1112 XE, Diemen, The Netherlands ,grid.491097.2ARQ National Psychotrauma Centre, Nienoord 5, 1112 XE, Diemen, The Netherlands ,grid.5477.10000000120346234Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlands
| | - G. E. Smid
- ARQ Centrum’45, Nienoord 5, 1112 XE, Diemen, The Netherlands ,grid.491097.2ARQ National Psychotrauma Centre, Nienoord 5, 1112 XE, Diemen, The Netherlands ,grid.449771.80000 0004 0545 9398Department of Humanistic Chaplaincy Studies, University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD Utrecht, the Netherlands
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Role of polygenic and environmental factors in the co-occurrence of depression and psychosis symptoms: a network analysis. Transl Psychiatry 2022; 12:259. [PMID: 35732632 PMCID: PMC9217963 DOI: 10.1038/s41398-022-02022-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/29/2022] [Accepted: 06/08/2022] [Indexed: 11/08/2022] Open
Abstract
Depression and psychosis are often comorbid; they also have overlapping genetic and environmental risk factors, including trauma and area-level exposures. The present study aimed to advance understanding of this comorbidity via a network approach, by (1) identifying bridge nodes that connect clusters of lifetime depression and psychosis symptoms and (2) evaluating the influence of polygenic and environmental risk factors in these symptoms. This study included data from European ancestry participants in UK Biobank, a large population-based sample (N = 77,650). In Step 1, a network model identified bridge nodes between lifetime symptoms of depression and psychosis and functional impairment. In Step 2, genetic and environmental risk factors were incorporated to examine the degree to which symptoms associated with polygenic risk scores for depression and schizophrenia, lifetime exposure to trauma and area-level factors (including deprivation, air pollution and greenspace). Feelings of worthlessness, beliefs in unreal conspiracy against oneself, depression impairment and psychosis impairment emerged as bridges between depression and psychosis symptoms. Polygenic risk scores for depression and schizophrenia were predominantly linked with depression and psychosis impairment, respectively, rather than with specific symptoms. Cumulative trauma emerged as a bridge node associating deprivation with feelings of worthlessness and beliefs in unreal conspiracy, indicating that the experience of trauma is prominently linked with the co-occurrence of depression and psychosis symptoms related to negative views of oneself and others. These key symptoms and risk factors provide insights into the lifetime co-occurrence of depression and psychosis.
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22
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The course of symptoms in the first 27 months following bereavement: A latent trajectory analysis of prolonged grief, posttraumatic stress, and depression. Psychiatry Res 2022; 311:114472. [PMID: 35248806 PMCID: PMC9159380 DOI: 10.1016/j.psychres.2022.114472] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/08/2022] [Accepted: 02/19/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Much remains unknown about the course of grief in the early months following bereavement, including the prevalence and timing of a recovery trajectory, whether specific symptoms mark a failure to recover, and the co-occurrence of chronic prolonged grief (PG), posttraumatic stress (PTS) and depression symptoms. METHODS Two hundred fifty-nine participants completed PG, PTS and depression questionnaires up to eleven times every six weeks during the two years post-bereavement. We used Latent Class Growth Mixture Modeling (LCGMM) to identify subgroups of bereaved individuals sharing similar trajectories for each disorder. We used repeated measures ANOVA to evaluate differences in individual symptoms between trajectories. Finally, we investigated to what extent chronic trajectories of these three disorders co-occurred. RESULTS Three trajectories of PG symptoms emerged: resilient (66.4%), chronic (25.1%) and acute recovery (8.4%). The overall severity and symptom profile of the acute recovery group were indistinguishable from that of the chronic group through 6 months post-bereavement, followed by reduction in PG from 6 to 18 months post-bereavement. Chronic PTS in the first-year post-bereavement tended to co-occur with chronic PG and/or chronic depression. CONCLUSIONS Twenty five percent of those with initial elevations in grief recovered in the period of 6 to 12 months post-bereavement. These findings highlight the clinical importance of severe grief in the initial months following loss, but also suggests caution in diagnosing a grief disorder within the first-year post-bereavement.
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Xu X, Xie T, Zhou N, Shi G, Wen J, Wang J, Li X, Poppen PJ. Network analysis of PGD, PTSD and insomnia symptoms in Chinese shidu parents with PGD. Eur J Psychotraumatol 2022; 13:2057674. [PMID: 35401947 PMCID: PMC8986251 DOI: 10.1080/20008198.2022.2057674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/17/2022] [Indexed: 12/31/2022] Open
Abstract
Background Chinese shidu parents (bereaved parents over the age of 49 who have lost their only child) are potentially at a high risk of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD) and insomnia. Objective The current study aimed to estimate three network models in 310 shidu parents who met the ICD-11 criteria for PGD: (1) a PGD network to identify central symptoms; (2) a comorbidity network to explore bridge symptoms between PGD and PTSD; (3) a comorbidity network to examine the associations between PGD and insomnia symptoms. Methods The R-packages bootnet, qgraph and networktools were used to investigate the structure of network models and centrality indices of symptoms. In addition, robustness and significance analyses for the edge weights and the order of centrality were performed. Results Emotional pain and numbness emerged as the most central symptoms in the PGD network. In the PGD-PTSD comorbidity network, the highest bridge strength symptoms were inability to trust others (PGD) and feeling upset (PTSD). Inability to trust others (PGD), avoidance (PGD), and impairment of life quality (insomnia) were possible bridge symptoms connecting PGD and insomnia. Conclusions Reducing emotional pain and numbness may be a viable target in PGD interventions for shidu parents. Additionally, findings suggest that future studies could examine the role of inability to trust others and avoidance in PGD comorbidities. HIGHLIGHTS • Emotional pain and numbness were the most influential symptoms in shidu parents with PGD. The role of PGD symptoms of inability to trust others and avoidance in the comorbidities of PGD with PTSD and insomnia might be worthy of further study.
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Affiliation(s)
- Xin Xu
- Beijing Key Laboratory of Applied Experimental Psychology, National Demonstration Center for Experimental Psychology Education (Beijing Normal University), Faculty of Psychology, Beijing Normal University, Beijing, People’s Republic of China
| | - Tong Xie
- Beijing Key Laboratory of Applied Experimental Psychology, National Demonstration Center for Experimental Psychology Education (Beijing Normal University), Faculty of Psychology, Beijing Normal University, Beijing, People’s Republic of China
| | - Ningning Zhou
- Shanghai Key Laboratory of Mental Health and Psychological Crisis Intervention, School of Psychology and Cognitive Science, East China Normal University, Shanghai, People’s Republic of China
| | - Guangyuan Shi
- Center for psychological development, Tsinghua University, Beijing, People’s Republic of China
| | - Jun Wen
- Beijing Key Laboratory of Applied Experimental Psychology, National Demonstration Center for Experimental Psychology Education (Beijing Normal University), Faculty of Psychology, Beijing Normal University, Beijing, People’s Republic of China
| | - Jianping Wang
- Beijing Key Laboratory of Applied Experimental Psychology, National Demonstration Center for Experimental Psychology Education (Beijing Normal University), Faculty of Psychology, Beijing Normal University, Beijing, People’s Republic of China
| | - Xin Li
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing, People’s Republic of China
| | - Paul J. Poppen
- Department of Psychological and Brain Sciences, The George Washington University, Washington, DC, USA
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Boelen PA, Eisma MC, de Keijser J, Lenferink LIM. Traumatic stress, depression, and non-bereavement grief following non-fatal traffic accidents: Symptom patterns and correlates. PLoS One 2022; 17:e0264497. [PMID: 35226697 PMCID: PMC8884715 DOI: 10.1371/journal.pone.0264497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/11/2022] [Indexed: 11/18/2022] Open
Abstract
Non-fatal traffic accidents may give rise to mental health problems, including posttraumatic stress (PTS) and depression. Clinical evidence suggests that victims may also experience grief reactions associated with the sudden changes and losses caused by such accidents. The aim of this study was to examine whether there are unique patterns of symptoms of PTS, depression, and grief among victims of non-fatal traffic accidents. We also investigated associations of emerging symptom patterns with sociodemographic variables and characteristics of the accident, and with transdiagnostic variables, including self-efficacy, difficulties in emotion regulation, and trauma rumination. Participants (N = 328, Mage = 32.6, SDage = 17.5 years, 66% female) completed self-report measures tapping the study variables. Using latent class analysis (including symptoms of PTS, depression, and grief), three classes were identified: a no symptoms class (Class 1; 59.1%), a moderate PTS and grief class (Class 2; 23.1%), and a severe symptoms class (Class 3; 17.7%). Summed symptom scores and functional impairment were lowest in Class 1, higher in Class 2, and highest in Class 3. Psychological variables were similarly ordered with the healthiest scores in Class 1, poorer scores in Class 2, and the worst scores in Class 3. Different sociodemographic and accident related variables differentiated between classes, including age, education, and time since the accident. In a regression including all significant univariate predictors, trauma rumination differentiated Class 2 from Class 1, all three psychological variables differentiated Class 3 from Class 1, and difficulties with emotion regulation and trauma rumination differentiated Class 3 from Class 2. This study demonstrates that most people respond resiliently to non-fatal traffic accident. Yet, approximately one in three victims experiences moderate to severe mental health symptoms. Increasing PTS coincided with similarly increasing grief, indicating that grief may be considered in interventions for victims of traffic accidents. Trauma rumination strongly predicted class membership and appears a critical treatment target to alleviate distress.
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Affiliation(s)
- Paul A. Boelen
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
- ARQ National Psychotrauma Centre, Diemen, The Netherlands
| | - Maarten C. Eisma
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Jos de Keijser
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Lonneke I. M. Lenferink
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
- Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
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25
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Sekowski M, Prigerson HG. Disorganized attachment and prolonged grief. J Clin Psychol 2022; 78:1806-1823. [PMID: 35132649 DOI: 10.1002/jclp.23325] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 01/18/2022] [Accepted: 01/23/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE While the relationship between attachment anxiety and avoidance and the severity of prolonged grief disorder (PGD) has been well-studied, less is known about the relationship between disorganized attachment and PGD. We test the associations between disorganized attachment and the interaction between it and attachment avoidance and anxiety on PGD. METHOD Participants (N = 258) who had lost a family member from 0.5 to 8.0 years before the survey completed the experiences in close relationships-revised, the adult disorganized attachment scale, and the PGD-13 scale. RESULTS The model explaining PGD symptoms through attachment, taking into account the level of disorganized attachment, explained variance in PGD significantly better than the model taking into account only the level of attachment anxiety and avoidance as predictors. Additionally, the relationships between attachment avoidance and PGD were positive, negative, or neither, depending on the configuration of the levels of disorganized attachment and attachment anxiety. CONCLUSION Future research into the relationships between attachment and PGD should take into account disorganized attachment. Attachment-informed grief therapy focused on insecure styles of attachment - including the disorganized style - to the deceased person and other loved ones may prove a promising approach for bereaved persons who experience PGD.
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Affiliation(s)
- Marcin Sekowski
- Department of Psychology, The Maria Grzegorzewska University, Warsaw, Poland
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York City, New York, USA.,Department of Medicine, Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York City, New York, USA
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26
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Groen SPN, Menninga MC, Cath DC, Smid GE. Let's talk about grief: Protocol of a study on the recognition and psychoeducation of prolonged grief disorder in outpatients with common mental disorders. Front Psychiatry 2022; 13:944233. [PMID: 36159934 PMCID: PMC9492871 DOI: 10.3389/fpsyt.2022.944233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recognition that the loss of a loved one may result in prolonged grief disorder (PGD) has gained broad attention recently. PGD may disturb daily functioning to such a degree that mental health treatment is required. Because PGD symptoms often resemble symptoms of common mental disorders (CMD) such as anxiety, depressive, and post-traumatic stress disorder, clinicians may not consider a PGD diagnosis. Moreover, cultural varieties in expression of PGD may complicate recognition. This study explores the prevalence of PGD among both natives and refugees with anxiety, depressive, or trauma- and/or stressor-related disorders as well as clinicians' awareness and knowledge of PGD symptoms. In addition, a psychoeducation module on PGD symptoms is developed through patient expert collaboration. METHODS Prevalence of PGD symptoms is investigated among 50 participants who are referred to outpatient clinics for anxiety, depression, or post-traumatic stress, using the Traumatic Grief Inventory-Self Report Plus (TGI-SR+) and the Bereavement and Grief-Cultural Formulation Interview (BG-CFI). Clinicians will be interviewed on knowledge (gaps) with respect to PGD symptoms. Finally, focus groups with patient experts are held to develop a psychoeducation module tailored to the patients' needs, norms and values. RESULTS This study will show prevalence of PGD among patients who are referred for anxiety, depression, and post-traumatic stress, awareness and knowledge of clinicians on PGD symptoms, and will offer patient expert informed psychoeducation. DISCUSSION Research on prevalence and recognition of PGD is vital. Study results of the prevalence of PGD will be compared to previous studies. Recognition of PGD as distinct disorder from CMDs requires clinicians' awareness of symptoms related to the loss of a loved one. Thereby, clinicians need to take cultural aspects related to death, bereavement and mourning into consideration. ETHICS AND DISSEMINATION The study protocol will be carried out in accordance with relevant guidelines and regulations. Exploratory research to assess the prevalence of PGD in patients suffering from CMDs will facilitate adequate diagnosis by increasing clinician's awareness of PGD symptoms. Tailored PGD psychoeducation, co-created by culturally diverse patient experts and clinicians will be made publicly available.
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Affiliation(s)
- Simon P N Groen
- De Evenaar Center for Transcultural Psychiatry Drenthe Mental Health Care, Beilen, Netherlands
| | - Marijke C Menninga
- De Evenaar Center for Transcultural Psychiatry Drenthe Mental Health Care, Beilen, Netherlands
| | - Daniëlle C Cath
- Department of Psychiatry, University Medical Center Groningen, Rob Giel Onderzoekscentrum, Groningen, Netherlands.,Drenthe Mental Health Care, Assen, Netherlands.,Department of Medical Sciences, University of Groningen, Groningen, Netherlands
| | - Geert E Smid
- Department of Humanist Chaplaincy Studies, University of Humanistic Studies, Utrecht, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands
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Li K, Zhan X, Ren L, Liu N, Zhang L, Li L, Chen T, Feng Z, Luo X. The Association of Abuse and Depression With Suicidal Ideation in Chinese Adolescents: A Network Analysis. Front Psychiatry 2022; 13:853951. [PMID: 35418891 PMCID: PMC8995894 DOI: 10.3389/fpsyt.2022.853951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Abuse experiences in adolescents are associated with the risk of depression and suicide. Thus, there is an urgent need to develop prevention and intervention measures for clinicians, policymakers, and researchers. METHODS Network analysis method was used to analyze the cross-sectional data of Chinese adolescents in this study. The Patient Health Questionnaire for Adolescents (PHQ-A) was used for assessing depression, in which item 9 of the PHQ-A was used to assess suicide ideation, and International Society for the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool-Children's Home Version (ICAST-CH) was used for assessing abuse. RESULTS The prevalence of suicidal ideation among Chinese adolescents was 21.46% (95% CI, 20.79-22.16%). The prevalence of moderate or severe depression was 16.76%, and the prevalence of violence exposure, psychological victimization, neglect, and physical victimization was 33.5%, 59.5%, 28.37%, and 31.51% in the past years, respectively. Network analysis results showed that the most central nodes in the network of abuse and depression were "unimportant," "not cared," and "pushed." The bridge nodes were "suicidal ideation" and "unimportant." The nodes "sadness," "failure," and "unimportant" explained the largest proportion of the variance of suicidal ideation in our network. Differences were found in the structure of both abuse and depression networks between adolescents with or without suicidal ideation. LIMITATIONS The self-reporting-based cross-sectional surveys and community sample groups limit the inference of causality and the generalization of the results. CONCLUSION This study shows that "unimportant" is the central and bridge nodes in the abuse and depression networks and also explains a part of variance of suicidal ideation. The effect of "unimportant" should be considered in the prevention and intervention of depression and suicide in adolescents with abuse experience. Future study is needed to confirm its role in clinical intervention.
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Affiliation(s)
- Kuiliang Li
- Department of Medical English, School of Basic Medical Sciences, Army Medical University, Chongqing, China.,School of Psychology, Army Medical University, Chongqing, China
| | - Xiaoqing Zhan
- Department of Medical English, School of Basic Medical Sciences, Army Medical University, Chongqing, China
| | - Lei Ren
- Department of Military Medical Psychology, Fourth Military Medical University, Xi'an, China
| | - Nan Liu
- Department of Health Examination, People's Hospital of Wansheng Economic Development Zone, Chongqing, China
| | - Lei Zhang
- Department of Medical English, School of Basic Medical Sciences, Army Medical University, Chongqing, China
| | - Ling Li
- College of General Education, Chong Qing Water Resources and Electric Engineering College, Chongqing, China
| | - Ting Chen
- Department of Health Examination, People's Hospital of Wansheng Economic Development Zone, Chongqing, China
| | - Zhengzhi Feng
- School of Psychology, Army Medical University, Chongqing, China
| | - Xi Luo
- Department of Medical English, School of Basic Medical Sciences, Army Medical University, Chongqing, China
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28
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Heeke C, Franzen M, Hofmann H, Knaevelsrud C, Lenferink LIM. A Latent Class Analysis on Symptoms of Prolonged Grief, Post-Traumatic Stress, and Depression Following the Loss of a Loved One. Front Psychiatry 2022; 13:878773. [PMID: 35693969 PMCID: PMC9184516 DOI: 10.3389/fpsyt.2022.878773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/05/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The loss of a significant other can lead to variety of responses, including prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. The aim of this study was to replicate and extend previous research that indicated that three subgroups of bereaved individuals can be distinguished based one similar post-loss symptom profiles using latent class analysis (LCA). The second aim was to examine whether sociodemographic and loss-related characteristics as well as the extent of meaning making were related to classes with more pervasive psychopathology. METHODS Telephone-based interviews with 433 Dutch and German speaking persons who had lost a significant other at last 6 months earlier were conducted. Self-rated PGD, PTSD, and depression symptoms were assessed. LCA was conducted and correlates of class-membership were examined using the 3step approach. RESULTS The LCA resulted in three distinct classes: a no symptoms class (47%), a moderate PGD, low depression/PTSD class (32%), and a high PGD, moderate depression/PTSD class (21%). A multivariate analysis indicated that female gender, a shorter time since loss, an unexpected loss and less meaning made to a loss were significantly associated with membership to the moderate PGD, low depression/PTSD and high PGD, moderate depression/PTSD class compared to membership to the no symptom class. Losing a child or spouse, a shorter time since loss, and having made less meaning to the loss further distinguished between the high PGD, moderate depression/PTSD symptom class and the moderate PGD, low depression/PTSD class. DISCUSSION We found that the majority of individuals coped well in response to their loss since the no symptom class was the largest class. Post-loss symptoms could be categorized into classes marked by different intensity of symptoms, rather than qualitatively different symptom patterns. The findings indicate that perceiving the loss as more unexpected, finding less meaning in the loss, and loss-related factors, such as the recentness of a loss and the loss of a partner or child, were related to class membership more consistently than sociodemographic factors.
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Affiliation(s)
- Carina Heeke
- Department of Clinical-Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Minita Franzen
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands
| | - Hendrik Hofmann
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands
| | - Christine Knaevelsrud
- Department of Clinical-Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Lonneke I M Lenferink
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands.,Department of Psychology, Health, and Technology, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
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29
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Rezaiye M, Radfar M, Hemmati MaslakPak M. Depression facilitators from the perspective of Iranian patients with major depressive disorder: a qualitative research. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00300-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Major depressive disorder is the most common psychological disorder and affects many people worldwide. Therefore, it is important to identify the factors that cause or facilitate this disorder.
Objectives
The aim of this qualitative study was to identify the facilitating factors of depression from the perspective of Iranian patients with major depressive disorder.
Methods
This qualitative study was conducted by content analysis method. Data were collected via purposeful sampling (maximum variation sampling) by conducting semi-structured interviews until reaching data saturation. In-depth interviews were conducted with 12 participants, including patients with major depressive disorder and their families in Razi Psychiatric Training and Treatment Center in Urmia (RPsTT) from November 2018 to February 2020. The process of data analysis was based on the Landman and Grenheim method. The accuracy and trustworthiness of the data were obtained through the Lincoln and Guba criteria.
Results
The analysis of interviews with the participants indicated four major categories: a. Environmental factors (approved by 8 participants), b. Attitudinal factors (approved by 12 participants), c. Economic factors (approved by 9 participants) and d. Situational factors (approved by 10 participants).
Conclusion
In order to prevent major depressive disorder or to reduce the signs of this disorder and improve these patients quality of life, paying attention to the facilitating factors from patient’s perspective based on their community culture can be effective. Among facilitating factors, attitudinal factors have the most impact on the incidence and exacerbation of this disorder from the perspective of patients.
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30
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Elovainio M, Lipsanen J, Pulkki-Råback L, Suvisaari J, Hakulinen C. Is symptom connectivity really the most important issue in depression? Depression as a dynamic system of interconnected symptoms revisited. J Psychiatr Res 2021; 142:250-257. [PMID: 34391079 DOI: 10.1016/j.jpsychires.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
According to the network theory strong associations between symptoms drive the disease process. We compared those with and without diagnosed depressive disorders (DD+/DD-) and analysed the effects of differences in (a) network connectivity, (b) symptom thresholds, and (c) autoregressive loops (i.e. how strongly specific symptoms predict themselves) on the potential activation of symptoms over time using simulations developed by Cramer and others (2016). The parameters for the simulation (symptom connectivity and symptom threshold) were obtained from Ising models and cross-lagged panel network analyses. Data were from the nationally representative samples (Health 2000-2011 Study) of 4190 participants measured in 2011 (cross-sectional analyses) and 3201 participants measured in 2000 and 2011 (longitudinal analyses). DD diagnosis was based on the Composite International Diagnostic Interview and depressive symptoms were self-reported using the 13-item version of the Beck Depression Inventory (BDI). Differences in symptom connectivity between participants with and without DD were not observed, but the mean probability (threshold) of symptom existence in the DD + group was higher than in the DD-group (0.41 vs. 0.12). Simulation showed that there are more active symptoms in the DD + group after 10 000 time points (means 1.2 vs. 4.6) than in the DD-group. This difference largely disappeared when we used longitudinal networks, including autoregressive loops, in the connectivity matrix. Our results suggest that the differences in symptom thresholds and autoregressive loops may be more important features than symptom connectivity in differentiating people with and without DD.
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Affiliation(s)
- Marko Elovainio
- Research Program Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland; National Institute for Health and Welfare, Helsinki, Finland.
| | - Jari Lipsanen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Laura Pulkki-Råback
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jaana Suvisaari
- National Institute for Health and Welfare, Helsinki, Finland
| | - Christian Hakulinen
- National Institute for Health and Welfare, Helsinki, Finland; Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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31
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Ferrajão P. Worldviews about the self mediate the impact of immature and mature defense styles on posttraumatic symptoms in bereaved parents. DEATH STUDIES 2021; 46:1390-1400. [PMID: 34514966 DOI: 10.1080/07481187.2021.1975176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The present study analyzed the mediating role of assumptive worldviews on the effect of defense mechanisms on post-traumatic stress symptoms (PTS) in bereaved parents. Sample included a convenience sample of 153 bereaved parents and a control group of 157 nonbereaved parents. Structural equation modeling was conducted to examine our hypotheses. Bereaved parents presented higher levels of PTS and more negative assumptions compared to nonbereaved participants. Worthiness of the self mediated the effect of both immature and mature defense styles on PTS levels, and neurotic defense style directly predicted PTS levels.
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Affiliation(s)
- Paulo Ferrajão
- Faculdade de Ciências da Saúde e do Desporto, Universidade Europeia, Lisbon, Portugal
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32
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Robinaugh DJ, Toner ER, Djelantik AAAMJ. The causal systems approach to prolonged grief: Recent developments and future directions. Curr Opin Psychol 2021; 44:24-30. [PMID: 34543876 DOI: 10.1016/j.copsyc.2021.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 11/03/2022]
Abstract
The network theory of prolonged grief posits that causal interactions among symptoms of prolonged grief play a significant role in their coherence and persistence as a syndrome. Drawing on recent developments in the broader network approach to psychopathology, we argue that advancing our understanding of the causal system that gives rise to prolonged grief will require that we (a) strengthen our assessment of each component of the grief syndrome, (b) investigate intra-individual relationships among grief components as they evolve over time within individuals, (c) incorporate biological and social components into network studies of grief, and (d) generate formal theories that posit precisely how these biological, psychological, and social components interact with one another to give rise to prolonged grief disorder.
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Affiliation(s)
- Donald J Robinaugh
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Emma R Toner
- University of Virginia, Department of Psychology, Charlottesville, VA, USA
| | - A A A Manik J Djelantik
- University Medical Centre Utrecht, Department of Psychiatry, Utrecht, the Netherlands; Altrecht GGZ, Department Youth KOOS, Utrecht, the Netherlands
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33
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Bolaséll LT, da Cruz Oliveira VC, Kristensen CH. The Effects of Exposure to Factors Related to Death in Mental Health. JOURNAL OF LOSS & TRAUMA 2021. [DOI: 10.1080/15325024.2021.1959854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Laura Teixeira Bolaséll
- Department of Psychology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
- Centre of Studies and Research in Traumatic Stress, Pontifical Catholic University of Rio Grande do Sul PUCRS, Porto Alegre, Brazil
| | | | - Christian Haag Kristensen
- Department of Psychology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
- Centre of Studies and Research in Traumatic Stress, Pontifical Catholic University of Rio Grande do Sul PUCRS, Porto Alegre, Brazil
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Boelen PA. Symptoms of prolonged grief disorder as per DSM-5-TR, posttraumatic stress, and depression: Latent classes and correlations with anxious and depressive avoidance. Psychiatry Res 2021; 302:114033. [PMID: 34134030 DOI: 10.1016/j.psychres.2021.114033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022]
Abstract
Bereavement may precipitate significant mental health problems. Prolonged grief disorder (PGD) is included in section 2 of the forthcoming DSM-5 text-revision (DSM-5-TR). Research using earlier criteria of disordered grief showed that bereaved people may have distinct symptom patterns-including high, low, and comorbid symptomatology. Building on that work, we used latent class analysis to identity subgroups of bereaved individuals based on their endorsement of symptoms of PGD (per DSM-5-TR), posttraumatic stress, and depression. We also examined if class-membership was associated with socio-demographic and loss-related variables and anxious and depressive avoidance behaviors. Self-reported data were available from 436 people, mostly women, mostly bereaved by the death of their partner or child. Three subgroups were identified, evidencing low symptom levels (34.2%), predominantly PGD symptoms (38.7%), and high symptom levels (27%), respectively. Shorter time since loss, lower education, loss of a partner, and unnatural/violent deaths increased chances of inclusion in the high symptoms class. Anxious and depressive avoidance were lowest in the low symptoms class, higher in the PGD class, and strongest in the high symptoms class. Findings show that PGD per DSM-5-TR is a distinct condition and underscore that reducing avoidance behaviors is important in the treatment of post-loss psychopathology.
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Affiliation(s)
- Paul A Boelen
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, PO Box 80140, 3508 TC Utrecht, the Netherlands; ARQ National Psychotrauma Centre, Nienoord 5, NL-1112 XE Diemen, the Netherlands.
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35
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Machine yearning: How advances in computational methods lead to new insights about reactions to loss. Curr Opin Psychol 2021; 43:13-17. [PMID: 34261030 DOI: 10.1016/j.copsyc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/22/2022]
Abstract
The loss of a loved one is a potentially traumatic event that can result in disparate outcomes and symptom patterns. Machine learning methods offer computational tools to probe this heterogeneity and understand grief psychopathology in its complexity. In this article, we examine the latest contributions to the scientific study of bereavement reactions garnered through the use of computational methods. We focus on findings originating from trajectory modeling studies, as well as the recent insights originating from the network analysis of prolonged grief symptoms. We also discuss applications of artificial intelligence for the accurate identification of major depression and post-traumatic stress, as examples for their potential applications to the study of loss reactions.
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36
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Kokou-Kpolou CK, Park S, Lenferink LIM, Iorfa SK, Fernández-Alcántara M, Derivois D, Cénat JM. Prolonged grief and depression: A latent class analysis. Psychiatry Res 2021; 299:113864. [PMID: 33756206 DOI: 10.1016/j.psychres.2021.113864] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 03/07/2021] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Cyrille Kossigan Kokou-Kpolou
- Department of Psychology, University of Picardy Jules Verne, France.; School of Psychology, University of Ottawa, Ontario, Canada.
| | - Sunyoung Park
- Graduate School of Psychology, California Lutheran University, Thousand Oaks, US
| | - Lonneke I M Lenferink
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, P.O. Box 80140, 3508 TC, Utrecht, The Netherlands; Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS, Groningen, The Netherlands
| | | | | | - Daniel Derivois
- Laboratory of Psychology Psy-DREPI (EA 7458), Université Bourgogne Franche Comté, Dijon, France
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Co-occurrence of prolonged grief symptoms and symptoms of depression, anxiety, and posttraumatic stress in bereaved adults: A systematic review and meta-analysis. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021. [DOI: 10.1016/j.jadr.2021.100140] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Asch RH, Esterlis I, Southwick SM, Pietrzak RH. Risk and resilience factors associated with traumatic loss-related PTSD in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. Psychiatry Res 2021; 298:113775. [PMID: 33578060 DOI: 10.1016/j.psychres.2021.113775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Sudden death of a loved one is the most prevalent potentially traumatic event worldwide, yet little is known about risk and resilience factors associated with traumatic loss-related posttraumatic stress disorder (PTSD). METHODS Data from a nationally representative sample of U.S. military veterans were analyzed to identify sociodemographic, military, health and psychosocial correlates of traumatic loss-related PTSD. RESULTS Loneliness, somatic symptoms, and attachment style were the strongest correlates of PTSD symptom severity and positive screens for traumatic loss-related PTSD. CONCLUSION Loneliness, somatic symptoms, and attachment style may represent therapeutic targets to help mitigate traumatic loss-related PTSD in U.S. veterans.
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Affiliation(s)
- Ruth H Asch
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Irina Esterlis
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Steven M Southwick
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
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Killian MO, Sanchez K, Eghaneyan BH, Cabassa LJ, Trivedi MH. Profiles of depression in a treatment-seeking Hispanic population: Psychometric properties of the Patient Health Questionnaire-9. Int J Methods Psychiatr Res 2021; 30:e1851. [PMID: 32862484 PMCID: PMC7992282 DOI: 10.1002/mpr.1851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/30/2020] [Accepted: 07/28/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Screening instruments can be powerful tools in assisting primary care providers with detecting depression in their patients and monitoring treatment response. Health disparities among racial and ethnic minorities result from inaccurate assessment in primary care. METHODS The current study used baseline data from two federally funded research studies of treatment for depression among Hispanics in primary care. The Patient Health Questionnaire-9 (PHQ-9) was administered at baseline prior to the study interventions, and 499 participants provided responses. RESULTS Confirmatory factor analyses found excellent factor validity for the PHQ-9, yet reliability remained poor. Possible heterogeneity in depressive item scores was examined, and latent profile analysis identified four distinct profiles of PHQ-9 responses. Profiles included a lower depression, moderate/somatization, moderate/negative self-view, and severe depression profiles. Results indicate modest support for the PHQ-9 and its use among Hispanics for the purpose of depression screening. CONCLUSION Capturing four profiles of depression in a large primary care sample helps characterize the manifestation of depression in a Hispanic population. The single item related to fatigue had the greatest variation across groups indicating it might be useful as a screening item. Inadequate evaluation of symptoms could lead to significant under identification of the disorder among Hispanics.
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Affiliation(s)
- Michael O Killian
- College of Social Work, Florida State University, Tallahassee, Florida, USA
| | - Katherine Sanchez
- School of Social Work, University of Texas at Arlington, Arlington, Texas, USA.,Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Brittany H Eghaneyan
- Department of Social Work, California State University, Fullerton, Fullerton, California, USA
| | - Leopoldo J Cabassa
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
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Revet A, Suc A, Auriol F, Djelantik AAAMJ, Raynaud JP, Bui E. Peritraumatic distress predicts prolonged grief disorder symptom severity after the death of a parent in children and adolescents. Eur J Psychotraumatol 2021; 12:1936916. [PMID: 34249245 PMCID: PMC8245082 DOI: 10.1080/20008198.2021.1936916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: In 2015 nearly 140 million children and adolescents under 18 had experienced the death of one or both parents. Parental death is often considered the most traumatic event that a child can experience in their lifetime. While parental loss may lead to the development of prolonged grief disorder (PGD), little is known about risk factors for such negative mental health outcome in children. Objective: The present study aims to examine peritraumatic reactions as predictors of PGD in children who lost a parent. Method: Thirty-four children (M age = 10.9, SD = 3.2, 67.6% females) who lost a parent (time since death = 4.6 months, SD = 2.3) were assessed for peritraumatic distress and peritraumatic dissociation experienced at the time of the loss, and for PGD symptom severity at three timepoints post-loss (<6 months; 6-12 months; >12 months). Results: PGD score was correlated with peritraumatic distress (.61; p < .01) but not with peritraumatic dissociation (.24; p = .3). Results from the mixed-model regression analysis identified peritraumatic distress as the only significant predictor of PGD symptom severity (B = 1.58, SE = .31; p < .0001), with no statistically significant effect of peritraumatic dissociation (B = - .43, SE = .36; p = .2), or time (B = - 3.84, SE = 2.99; p = .2). Conclusion: Our results suggest that peritraumatic distress might be useful to identify children at risk for developing PGD, and in need of further support. The development of early preventive strategies to prevent PGD in parentally bereaved children who experienced high peritraumatic distress is warranted.
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Affiliation(s)
- Alexis Revet
- Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, CHU de Toulouse, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France.,CIC 1436, Team PEPSS « Pharmacologie En Population cohorteS et biobanqueS », Toulouse University Hospital, France
| | - Agnès Suc
- Centre de Ressource Douleur Soins Palliatifs Pédiatriques, CHU de Toulouse, Toulouse, France
| | - Françoise Auriol
- Unité de recherche clinique pédiatrique module plurithématique pédiatrique CIC Toulouse 1436, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - A A A Manik J Djelantik
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department Youth - KOOS, Altrecht GGZ, Utrecht, The Netherlands
| | - Jean-Philippe Raynaud
- Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, CHU de Toulouse, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, University of Caen Normandy & Caen University Hospital, Caen, France
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41
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Djelantik AAAMJ, Bui E, O'Connor M, Rosner R, Robinaugh DJ, Simon NM, Boelen PA. Traumatic grief research and care in the aftermath of the COVID-19 pandemic. Eur J Psychotraumatol 2021; 12:1957272. [PMID: 34567440 PMCID: PMC8462871 DOI: 10.1080/20008198.2021.1957272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A significant increase in the number of individuals suffering from prolonged grief disorder is expected in the aftermath of the COVID-19 pandemic for two main reasons. First, the number of excess deaths has contributed to an immense number of bereaved individuals. Second, recent literature has shown that circumstances associated with COVID-19 deaths may be contributing to increased risk for the development of prolonged grief disorder. OBJECTIVE To best support those affected by loss during the COVID-19 pandemic, it is important to inform clinicians and researchers about the development, the nature and the treatment of prolonged grief disorder and employ sound research. METHOD In this editorial, we discuss important themes regarding prolonged grief disorder in the aftermath of the COVID-19 pandemic, to gather and present useful information for clinicians and researchers. RESULTS The following themes were addressed: 1. Harmonization in the diagnosis of prolonged grief disorder. 2. Screening tools and interventions. 3. Pharmacotherapy. 4. Special attention for the elderly. 5. Special attention for children and adolescents. 6. A causal system perspective for understanding grief and prolonged grief disorder. CONCLUSIONS If those involved in bereavement research and care manage to collaborate, the tragic consequences of COVID-19 might catalyse improvement of care for those most impaired following the loss of a loved one.
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Affiliation(s)
- A A A Manik J Djelantik
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department Youth - KOOS, Altrecht GGZ, Utrecht, The Netherlands
| | - Eric Bui
- Department Psychiatry, University of Caen Normandy, Caen, France
| | - Maja O'Connor
- Department of Psychology, Unit for Bereavement Research, Aarhus University/The Danish National Center for Grief, Aarhus, Denmark
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Donald J Robinaugh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Naomi M Simon
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Paul A Boelen
- ARQ National Psychotrauma Centre, Diemen, The Netherlands.,ARQ Centrum'45, Diemen, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherland
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42
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Lenferink LIM, van den Munckhof MJA, de Keijser J, Boelen PA. DSM-5-TR prolonged grief disorder and DSM-5 posttraumatic stress disorder are related, yet distinct: confirmatory factor analyses in traumatically bereaved people. Eur J Psychotraumatol 2021; 12:1-14. [PMID: 34912501 PMCID: PMC8667936 DOI: 10.1080/20008198.2021.2000131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results. OBJECTIVE In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes. METHODS Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted. RESULTS For PTSD, a seven factor, so-called 'Hybrid' model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD). CONCLUSIONS This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.
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Affiliation(s)
- L I M Lenferink
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands.,Department of Psychology, Health, & Technology, Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, The Netherlands
| | - M J A van den Munckhof
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands
| | - J de Keijser
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - P A Boelen
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands.,Foundation Centrum '45, Diemen, the Netherlands.,ARQ National Psychotrauma Centre, Diemen, the Netherlands
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43
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Wichers M, Riese H, Hodges TM, Snippe E, Bos FM. A Narrative Review of Network Studies in Depression: What Different Methodological Approaches Tell Us About Depression. Front Psychiatry 2021; 12:719490. [PMID: 34777038 PMCID: PMC8581034 DOI: 10.3389/fpsyt.2021.719490] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
The network theory of psychopathology proposes that mental disorders arise from direct interactions between symptoms. This theory provides a promising framework to understand the development and maintenance of mental disorders such as depression. In this narrative review, we summarize the literature on network studies in the field of depression. Four methodological network approaches are distinguished: (i) studies focusing on symptoms at the macro-level vs. (ii) on momentary states at the micro-level, and (iii) studies based on cross-sectional vs. (iv) time-series (dynamic) data. Fifty-six studies were identified. We found that different methodological approaches to network theory yielded largely inconsistent findings on depression. Centrality is a notable exception: the majority of studies identified either positive affect or anhedonia as central nodes. To aid future research in this field, we outline a novel complementary network theory, the momentary affect dynamics (MAD) network theory, to understand the development of depression. Furthermore, we provide directions for future research and discuss if and how networks might be used in clinical practice. We conclude that more empirical network studies are needed to determine whether the network theory of psychopathology can indeed enhance our understanding of the underlying structure of depression and advance clinical treatment.
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Affiliation(s)
- Marieke Wichers
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, Netherlands
| | - Harriëtte Riese
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, Netherlands
| | - Taylor M Hodges
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, Netherlands
| | - Evelien Snippe
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, Netherlands
| | - Fionneke M Bos
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, Netherlands.,University of Groningen, University Medical Center Groningen, Department of Psychiatry, Rob Giel Research Center, Groningen, Netherlands
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44
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Cross-cultural generalizability of the ICD-11 PGD symptom network: Identification of central symptoms and culturally specific items across German-speaking and Chinese bereaved. Compr Psychiatry 2020; 103:152211. [PMID: 33049644 DOI: 10.1016/j.comppsych.2020.152211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/10/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prolonged grief disorder (PGD) is a newcomer to psychopathology and the new ICD-11 diagnostic criteria are conceptualized with an eye towards global applicability. Yet, previous network studies have not used official ICD-11 criteria nor tested whether network structures generalize across cultural groups even though much current research relies on ICD-11 PGD criteria. METHODS To overcome these limitations, the present study used data from 539 German-speaking (n = 214) and Chinese (n = 325) bereaved individuals to investigate similarities and differences in network structures of ICD-11 PGD criteria. In addition, network structures were investigated for an expanded supplementary questionnaire of culturally-bound grief symptoms hypothesized to be of relevance in each cultural context. RESULTS Results suggested both similarities and differences in network structures between the two samples. Across cultural groups, intense feelings of sorrow and inability to experience joy or satisfaction since the death emerged as most central symptoms. Compared to the standard PGD network, the expanded network showed a better average predictability for Chinese participants, but no improvement for the German-speaking context. Unhealthy behavior change was the most central symptom for Chinese bereaved when additional grief symptoms were included. CONCLUSIONS Results of the present study suggest there are culturally-bound symptoms of grief which are not included in the current ICD-11 PGD criteria. These findings provide areas of special clinical attention concerning screening and treatment and present a first step towards a more cultural-sensitive understanding of grief. CLINICAL TRIALS NCT03568955.
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45
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Abstract
The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor's functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.
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Affiliation(s)
- Geert E Smid
- ARQ National Psychotrauma Centre, Diemen, The Netherlands.,University of Humanistic Studies, Utrecht, The Netherlands
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46
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Boelen PA, Eisma MC, Smid GE, Lenferink LIM. Prolonged grief disorder in section II of DSM-5: a commentary. Eur J Psychotraumatol 2020; 11:1771008. [PMID: 33029316 PMCID: PMC7473035 DOI: 10.1080/20008198.2020.1771008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Paul A Boelen
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands.,ARQ National Psychotrauma Centre, Diemen, The Netherlands
| | - Maarten C Eisma
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands
| | - Geert E Smid
- ARQ National Psychotrauma Centre, Diemen, The Netherlands.,University of Humanistic Studies, Utrecht, The Netherlands
| | - Lonneke I M Lenferink
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands
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Buqo T, Ward-Ciesielski EF, Krychiw JK. Do Coping Strategies Differentially Mediate the Relationship Between Emotional Closeness and Complicated Grief and Depression? OMEGA-JOURNAL OF DEATH AND DYING 2020; 84:985-997. [DOI: 10.1177/0030222820923454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although complicated grief (CG) following the death of a loved one has traditionally been viewed as avoidance-driven, recent research implicates approach behavior. Researchers have investigated how coping styles predict CG; however, emotional closeness remains unexamined. This study investigated the differential relationship of approach- and avoidance-focused coping on CG and depressive symptoms. Bereaved adults ( n = 340) completed questionnaires about their loss, coping styles, CG, and depression. Results suggest that approach-, but not avoidance-, focused coping mediates the relationship of emotional closeness on CG, while emotional closeness of the relationship had no direct impact on depressive symptoms. This suggests closeness of the relationship plays a unique role in CG.
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Affiliation(s)
- Tom Buqo
- Department of Psychology, Hofstra University, Hempstead, New York, United States
| | - Erin F. Ward-Ciesielski
- Department of Psychology, Hofstra University, Hempstead, New York, United States
- Department of Psychological and Brain Sciences, Boston University, MA, United States
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Baumann I, Künzel J, Goldbeck L, Tutus D, Niemitz M. Prolonged Grief, Posttraumatic Stress, and Depression Among Bereaved Parents: Prevalence and Response to an Intervention Program. OMEGA-JOURNAL OF DEATH AND DYING 2020; 84:837-855. [DOI: 10.1177/0030222820918674] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bereaved parents may experience diverse psychological symptoms. Possible interventions are not yet well established. In this study, the psychological symptoms of 323 bereaved parents (mean age = 39.97, SD = 7.21, 52.0% female), referred to a 4-week family-oriented rehabilitation (FOR) program, were assessed. The baseline assessments indicated that 160 (49.5%) parents showed symptoms of prolonged grief disorder (PGD). Complicated grief was indicated in 272 (84.2%), depression in 191 (59.1%), and posttraumatic stress disorder in 242 (74.9%) parents. Mothers were at higher risk of complicated grief ( p ≤ .001), depression ( p = .029), and posttraumatic stress disorder ( p = .004), compared to fathers. Significant remissions of symptoms between admission and discharge from the program are presented as symptoms of complicated grief, depression, and posttraumatic stress. The effect sizes ranged between d = 0.68 and 1.22. In addition, significantly fewer parents fulfilled PGD criteria on discharge from the FOR program ( p ≤ .001). The special FOR program appears promising with regard to improving the bereaved parents’ mental health.
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Affiliation(s)
- Ines Baumann
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University
| | - Jochen Künzel
- Psychosocial department, Family-Oriented Rehabilitation Clinic Tannheim, Tannheim, Germany
| | - Lutz Goldbeck
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University
| | - Dunja Tutus
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University
| | - Mandy Niemitz
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University
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49
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Simon NM, Shear K, Reynolds CF, Cozza SJ, Mauro C, Zisook S, Skritskaya N, Robinaugh DJ, Malgaroli M, Spandorfer J, Lebowitz B. Commentary on evidence in support of a grief-related condition as a DSM diagnosis. Depress Anxiety 2020; 37:9-16. [PMID: 31916663 PMCID: PMC7430251 DOI: 10.1002/da.22985] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 10/03/2019] [Accepted: 10/31/2019] [Indexed: 12/11/2022] Open
Abstract
The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.
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Affiliation(s)
- Naomi M. Simon
- Department of Psychiatry, NYU Langone Health/NYU School of Medicine, New York, NY
| | | | | | - Stephen J. Cozza
- Center for the Study of Traumatic Stress, Uniformed Services University for the Health Sciences
| | - Christine Mauro
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Sidney Zisook
- University of California San Diego and San Diego Healthcare System, San Diego, CA
| | | | - Donald J. Robinaugh
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Matteo Malgaroli
- Department of Psychiatry, NYU Langone Health/NYU School of Medicine, New York, NY
| | - Julia Spandorfer
- Department of Psychiatry, NYU Langone Health/NYU School of Medicine, New York, NY
| | - Barry Lebowitz
- University of California San Diego and San Diego Healthcare System, San Diego, CA
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50
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Djelantik AAAMJ, de Heus A, Kuiper D, Kleber RJ, Boelen PA, Smid GE. Post-Migration Stressors and Their Association With Symptom Reduction and Non-Completion During Treatment for Traumatic Grief in Refugees. Front Psychiatry 2020; 11:407. [PMID: 32547428 PMCID: PMC7273964 DOI: 10.3389/fpsyt.2020.00407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Resettled refugees exposed to trauma and loss are at risk to develop mental disorders such as posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder (PCBD). Post-migration stressors have been linked to poor mental health and smaller treatment effects. AIM Our aim was to evaluate reductions in PTSD and PCBD symptoms and to explore the presence of post-migration stressors and their associations with symptom change and non-completion in a traumatic grief focused treatment in a cohort of refugees. METHODS Paired sample t-tests were used to test the significance of the symptom reductions in PTSD and PCBD symptoms during treatment. The presence of post-migration stressors was derived from a qualitative analysis of the patient files. Associations between post-migration stressors and symptom reductions as well as non-completion were calculated. RESULTS In this uncontrolled study, 81 files of consecutive patients were included. Significant reductions in both PCBD and PTSD symptomatology with medium effect sizes were found. Patients experienced a mean of three different post-migration stressors during the treatment. Undocumented asylum seekers were more likely to be non-completers. Ongoing conflict in the country of origin was associated with smaller PTSD symptom reductions and the total number of post-migration stressors was associated with smaller PCBD symptom reductions. CONCLUSIONS Treatment for resettled refugees for traumatic grief coincides with alleviations in both PCBD and PTSD symptomatology. Specific post-migration stressors were associated with reduced treatment effects and increased non-completion. This is a first step towards well-informed improvements of mental health interventions for resettled refugees.
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Affiliation(s)
- A A A Manik J Djelantik
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Annemiek de Heus
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands
| | - Diede Kuiper
- Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Rolf J Kleber
- ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Paul A Boelen
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Geert E Smid
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands.,University of Humanistic Studies, Utrecht, Netherlands
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