Commentary on evidence in support of a grief-related condition as a DSM diagnosis

Grief in Children in the Aftermath of the COVID-19 Pandemic

PURPOSE OF REVIEW

This review aims at reporting the current evidence of the impact of COVID-19 pandemic on grief in children.

RECENT FINDINGS

Evidence from the scientific literature shows that the severity of grief in children is impacted by numerous risk factors which can lead to prolonged grief disorder (PGD). Among these risk factors are the unpredictability of the death, the lack of understanding about what is happening by the child, the global insecurity raised by the context of the pandemic or again the impossibility for the child to find comfort with his peers due to the lock-down. No medical-based approach has proven efficient on PGD in children. However, cognitive based therapy can lower the severity of the symptoms. Future efforts should focus on developing therapeutic strategies to specifically fit the needs of children with PGD, in the context of a major crisis such as this pandemic.

Testing the latent structure of ICD-11 prolonged grief disorder symptoms in the U.K. adult population: An exploratory structural equation modeling approach

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.

What we know about grief intervention: a bibliometric analysis

Background

Grief is a natural and individualized response to different losses, but if grief persists or becomes pathological, professional interventions are required. Grief and corresponding interventions have received increasing attention, as the related concepts have been incorporated into the DSM-5 and ICD-11. Therefore, we conducted a bibliometric analysis to explore the developments in the field of grief intervention research.

Methods

Articles on grief interventions were systematically searched and screened from the Web of Science Core Collection. The retrieved data were analyzed and visualized using VOSviewer and Bibliometrix software for journals, authors, institutions, countries, references, and keywords.

Results

A total of 9,754 articles were included. The number of articles on grief interventions has increased significantly each year since 1990. Death Studies was the journal that published the most articles in this field. We identified 25,140 authors contributed to this research area and these authors were from 123 countries and 6,630 institutions. Boelen PA secured the first position in article production, Columbia University emerged as the most productive affiliation and the United States was the foremost leading in grief intervention research. The prevalent keywords utilized in this field comprised bereavement, grief, death, depression, and palliative care.

Conclusion

The quantity of publications regarding grief interventions is increasing. Although most prior studies have focused on mortality, grief, and health, emerging themes such as COVID-19, grief among workers, and disfranchised grief have drawn increasing attention in recent years. Future studies may focus on investigating the complexities and challenges of grief, including its underlying mechanisms and impact on mental well-being.

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

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

Competing aspects of the rural Arab mothers' bereavement experience

The study applied relational dialectics theory to explore competing discourses in bereaved Arab mothers' talk about their bereavement experience in a collective space in rural areas of Israel, and to understand how the interaction between these discourses gives meaning to their experience. Fifteen bereaved mothers were interviewed. The mothers, aged 28-46 years, had children (aged 1-6 years) who died between 2 and 7 years previously. Analysis of the interviews revealed three main discursive struggles that characterize mothers' bereavement experience: (a) moving closer versus keeping one's distance; (b) social harmony versus personal needs; and (c) criticism of ongoing grief versus criticism of returning to routine functioning. The advantage of being part of a close-knit social network is that it provides emotional cushioning to the bereaved. This cushioning, however, does not preclude the struggle to attain normalcy after the tragedy within the parameters of the contradictory societal expectations and needs of the mourner.

The Inventory of Complicated Grief-A Systematic Psychometric Review and Conceptual Replication Study of the Structural Validity

The Inventory of Complicated Grief (ICG) is a commonly used self-report measure in psycho-oncology, best supportive care, and palliative medicine. However, existing validation studies yielded conflicting results regarding the structural validity. This study provides a psychometric review and conceptual replication of the ICG latent structure to test the hypothesis that existing studies overfit unreliable sources of variance, which overshadow the unidimensionality of the ICG. All proposed latent models identified in the psychometric review were tested in a series of confirmatory and exploratory structural equation models. Specifically, at least five to six latent intercorrelated factors were necessary to reach acceptable model fit. However, a general CG factor accounted for most variance and ICG sum scores showed predictable associations with anxiety and depressive symptoms, which suggests that the ICG is essentially unidimensional. There are indications that other measures of pathological grief show similar inconsistencies. Overall, potentially emerging subfacets of the ICG should not be interpreted as distinct "symptom clusters." If time constraints are an issue as is often the case in clinical research, complicated grief may just be measured by a reduced item set without a significant loss of information or complexity.

Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial

BACKGROUND

Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce.

OBJECTIVE

The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement.

METHODS

The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures.

RESULTS

A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η²=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health.

CONCLUSIONS

The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer.

TRIAL REGISTRATION

German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001.

A Latent Class Analysis on Symptoms of Prolonged Grief, Post-Traumatic Stress, and Depression Following the Loss of a Loved One

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.

Machine yearning: How advances in computational methods lead to new insights about reactions to loss

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.

The role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief

Few studies examine the relationship of grief with interrelated and broad concepts. In this study, the role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief was investigated with individuals (N = 254) who have lost a close person in the last 5 years. Mediation and moderated mediation analyses revealed that individuals with early maladaptive schemas may experience more complicated grief symptoms through the effect of early maladaptive schemas. For individuals with self-sacrifice schema, difficulties in the grief process were regulated by moderate to high levels of sense of coherence.

Rising Tide: Responding to the Mental Health Impact of the COVID-19 Pandemic

(Reprinted with permission from Depress Anxiety. 2020;37:505-509).

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

Challenges in Obtaining and Assessing Salivary Cortisol and α-Amylase in an Over 60 Population Undergoing Psychotherapeutic Treatment for Complicated Grief: Lessons Learned

Biomarkers may serve as objective measures in complicated grief (CG) potentially capturing responses to stress reduction treatment. This paper reports challenges in obtaining and assessing salivary cortisol and α-amylase (sAA) for a recent randomized clinical trial. Within-session changes in salivary cortisol and sAA for 54 older adults with CG who received Accelerated Resolution Therapy were compared with perceived stress measured by Subjective Units of Distress Scale. Bivariate correlations and multiple regressions examined changes in biomarkers. Protocols, study logs, and audit reports identified challenges. Challenges included obtaining unstimulated passive drool salivary samples and their analyses. Our sample of older females on multiple medications may have resulted in a perfect storm of moderating and intervening variables which affected the stress response. This paper contributes to the discussion on designing clinical trials for older adults which must account for physiologic changes, multimorbidity, and polypharmacy common in this population and makes recommendations moving forward.

Grief and Posttraumatic Growth Among Chinese Bereaved Parents Who Lost Their Only Child: The Moderating Role of Interpersonal Loss

Objective: Losing the only child is considered as the most severe kind of bereavement. It can trigger intense grief symptoms along with loss of psychosocial resources, but meanwhile, it can also lead to posttraumatic growth (PTG). The current study aimed to examine (a) whether a curvilinear relationship exists between grief and PTG and (b) the moderating role of resources-loss among Chinese bereaved parents who lost their only child (shidu parents). Methods: One hundred and ninety-nine shidu parents from five provinces completed the assessment packet covering prolonged grief symptoms and PTG, as well as resource loss. Hierarchical regression analyses were computed to examine the curvilinear relationship and the moderating effect of interpersonal loss and socio-economic loss. Results: There was no significant curvilinear relationship between grief and PTG in shidu parents. Under the high levels of interpersonal loss, shidu parents' PTG scores decreased as the severity of grief increased. However, the socio-economic loss did not show a significant moderating effect. Conclusion: The results of the current study did not show a significant curvilinear relationship between grief and PTG in shidu parents. High levels of grief coupled with high levels of interpersonal loss may interfere with their ability to achieve PTG. Therefore, evaluating degrees of interpersonal loss seems to be an important part of the treatment process when working with shidu parents. To facilitate their adaptation from a positive perspective, helping them maintain existing or develop new interpersonal relationships may be helpful.