Complicated Bereavement: Disease State or State of Being?

The point at which the experience of grief in response to bereavement becomes “pathological” has been debated for many years without resolution. This article reviews the current status of this debate. The debate centers around the extent to which “complicated grief” represents a truly unique pathological entity, when contrasted with major depressive disorder, posttraumatic stress disorder, and “uncomplicated grief.” Significant research findings suggest it may be possible to distinguish grief from depressed as well as traumatic forms of distress, with acceptable reliability and validity. Yet, “complicated grief” relates to both of these types of distress as well as to a unique aspect—separation distress. It is at the intersection of these types of distress with significant disruption of daily life functioning that we find the proposed diagnosis of “complicated grief.” The question is whether this diagnosis should be designated at this time, and, if so, how. This article concludes in favor of a compromise position that the diagnosis should be incorporated into DSM-V but relegated to its Appendix B [disorders proposed for further study] due to the lack of clarity surrounding its diagnostic criteria.

Psychosocial factors and the course of cervical intra-epithelial neoplasia: a prospective study

OBJECTIVE

To investigate the influence of psychosocial factors on the course of cervical intra-epithelial neoplasia (CIN).

METHODS

A group of 93 patients with CIN 1 or 2 was followed for 2.25 years by half-yearly colposcopy and cytology. Negatively-rated life events, social support, and coping style were studied in relation to distress during follow-up and in relation to time till progression and regression of CIN. Human papillomavirus (HPV) infection was controlled for as well as sick role bias caused by suspicion of having cervical cancer and distress due to the abnormal cervical smear.

RESULTS

During follow-up, progression was found in 20 patients (22%), stable disease in 22 patients (24%), and regression in 51 patients (55%). Negatively-rated life events and lack of social support predicted distress longitudinally. No association was found between progression or regression of CIN and negatively-rated life events, lack of social support, coping style, and distress.

CONCLUSION

We found no evidence that psychosocial factors influence the course of CIN.

Psychosocial factors and the grade of cervical intra-epithelial neoplasia: a semi-prospective study

OBJECTIVE

To study the influence of psychosocial factors on the grade of cervical intra-epithelial neoplasia.

METHODS

The influence of psychosocial factors on the grade of cervical intra-epithelial neoplasia (CIN) was studied in a group of 342 patients with an abnormal cervical smear. Participants completed a set of questionnaires after colposcopy directed biopsy before knowing the biopsy result. Negatively rated life events, social support, and coping style were studied in relation to distress and grade of CIN. Infection with human papillomavirus (HPV) types was controlled for, as well as sick role bias caused by suspicion of having cervical cancer and distress due to the abnormal cervical smear.

RESULTS

Negatively rated life events, lack of social support, and emotional coping were significant predictors for level of distress. No significant relationship was found, however, between the psychosocial factors and grade of CIN.

CONCLUSION

No support was found for an influence of negatively rated life events, social support, coping style, and distress on grade of CIN.

Theory-Driven Interventions in Psychoneuroimmunology and HIV-1 Infection

Psychoneuroimmunology (PNI) is a rapidly evolving multidisciplinary field founded on the premise that psychosocial factors, the central nervous system, and the immune system are intimately linked. Following publication of scientific evidence supporting this link, a number of animal and human studies have been published, both inside and outside the area of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. These studies support the existence of bidirectional feedback mechanisms operating between the brain and the immune system. To date, however, there is no all-encompassing model that predicts individual differences in the relationship among psychosocial factors, immunologic measures, and clinical disease progression in HIV type 1 (HIV-1) infection. This variability in human response has been explained by a number of cofactors (host as well as environmental) that appear to accelerate the course of the disease. Since psychosocial factors are highly amenable to behavioral interventions, several models for intervention research have been proposed to evaluate whether such interventions can enhance immune functioning, thereby curtailing disease progression. Examination of these interventions in the context of PNI and HIV-1 infection, however, is rather limited. Therefore, researchers and clinicians must not only consider conceptualizations and paradigms in this area of research, but also focus on empirically testable, theory-driven models that allow for the unique characteristics of individual patients.

Cobalamin level is related to self-reported and clinically rated mood and to syndromal depression in bereaved HIV-1(+) and HIV-1(-) homosexual men

OBJECTIVE

An examination of the relationship of plasma cobalamin (vitamin B(12)) level to overall psychological distress, specific mood states, and major depressive disorder was conducted in 159 bereaved men (90 HIV-1(+) and 69 HIV-1(-)).

METHODS

The relationship of a continuous measure of cobalamin level to psychological distress was examined, while controlling for HIV-1 serostatus, life stressors, social support, and coping styles.

RESULTS

Of this sample, 23.9% were either overtly or marginally cobalamin deficient; however, the deficiency rate was not significantly different by HIV-1 serostatus. Cobalamin level was inversely related to self-reported overall distress level and specifically to depression, anxiety, and confusion subscale scores, as well as to clinically rated depressed and anxious mood. Lower plasma cobalamin levels also were associated with the presence of symptoms consistent with major depressive disorder.

CONCLUSION

These findings suggest that cobalamin level may be physiologically related to depressed and anxious mood level, as well as to syndromal depression.

Psychological distress in HIV-1 disease in relationship to hypocholesterolemia

OBJECTIVE

Altered levels of serum cholesterol, which are prevalent in early HIV-1 infection, have been associated with disturbances in mood state and behavior. The objective of this study was to evaluate the relationship of serum cholesterol status and psychological distress in HIV-1 seropositive and seronegative men.

METHOD

The association between serum cholesterol level and psychological distress, measured with the Profile of Mood States (POMS), was examined in 169 individuals (117 HIV-1 seropositive and 52 seronegative homosexual men), controlling for negative life events, social support, coping style, and HIV-1 serostatus.

RESULTS

Individuals with hypocholesterolemia (serum cholesterol levels < 150 mg/dL), exhibited significantly higher levels of distress, relative to individuals with values of cholesterol > 150 mg/dL (p = 0.01). HIV-1 seropositive men had significantly lower cholesterol levels (p = 0.0001) and higher levels of distress than the seronegative men (p = 0.03). A significant interaction between negative life events and cholesterol status was demonstrated as well (p = 0.04).

CONCLUSIONS

Hypocholesterolemia appears to be associated with increased psychological distress. Whereas the causal direction of the cholesterol-distress association cannot be specified, our results suggest that HIV-1 infected men with low cholesterol levels may benefit from being monitored for changes in distress level, so that appropriate psychosocial intervention can be instituted, as necessary.

Plasma pyridoxine deficiency is related to increased psychological distress in recently bereaved homosexual men

OBJECTIVE

Previous research has demonstrated that a theoretical model including measures of life stressors, social support, and coping style significantly predicts psychological distress. This study tested plasma pyridoxine (vitamin B6) deficiency status as a predictor of overall psychological distress and specific mood states in this model, controlling for HIV-1 serostatus.

METHOD

Subjects included HIV-1+ (N = 76) and HIV-1- (N = 58) recently bereaved homosexual men. At baseline, subjects completed a battery of psychosocial questionnaires, together with a physical examination and venipuncture. The Profile of Mood States (POMS) provided measures of overall psychological distress as well as specific mood states. Pyridoxine deficiency status (a categorical measure of deficient vs. adequate status) was determined with a bioassay of erythrocyte aspartate aminotransferase activity.

RESULTS

Pyridoxine deficiency was a significant predictor of increased overall psychological distress in this model, controlling for life stressors, social support, coping style, and HIV-1 serostatus. In post hoc analyses of specific mood state effects, pyridoxine deficiency status was significantly associated with increases in depressed, fatigued, and confused mood levels, but not with those of anxiety, anger, or vigor.

DISCUSSION

These findings suggest that adequate pyridoxine status may be necessary to avert psychological distress in the setting of bereavement. Inasmuch as pyridoxine is a cofactor for 5-hydroxytryptophan decarboxylase--an enzyme in the biosynthesis pathway of serotonin--serotonin level in the brain is implicated as the mediating factor.

Prenatal diethylstilbestrol exposure and self-reported immune-related diseases

OBJECTIVE

To compare self-reports of immune-related diseases in diethylstilbestrol (DES) daughters and controls. Prenatal exposure to DES has been associated with several malformations in the lower genital tract, a higher prevalence of adenosis, and increased risk of clear cell adenocarcinoma, and estrogen-dependent tumors. Lately, reports have been published indicating a link between DES exposure and alterations in the immune system. The present study focuses on the possible clinical consequences of an affected immune system.

STUDY DESIGN

DES daughters (n=170) and control women (n=123) completed questionnaires containing lists of immune-related diseases, specified into three categories (i) allergies, (ii) auto-immune disorders, and (iii) infectious diseases.

RESULTS

DES daughters reported significantly more disease conditions than the controls. Analyses for separate disease categories (allergies, auto-immune disorders, infectious disease), yielded a statistically significant difference only for infectious disease. Within this last category, two infectious diseases yielded highly significant differences: bladder infection and measles.

CONCLUSION

The present findings suggest that DES daughters are at higher risk of developing immune-related disease states.

"Survivors" and "victims": long-term HIV positive individuals and the ethos of self-empowerment

Recent research on contemporary processes of self-construction has suggested that the concepts of "self", "health", "morality" and "responsibility" have become inextricably interconnected, to the extent that the "pursuit of health has become the pursuit of moral personhood" [R. Crawford (1994) The boundaries of the self and the unhealthy other: reflections on health, culture and AIDS, Social Science & Medicine 38(10), 1347-1365]. What happens then when a person becomes "diseased"? Are they doomed to the stagnant mire of "illness" and "immorality", to the role of undesirable "other"? What if the disease is HIV infection? Is it the case of HIV = AIDS = DEATH = "OTHER" par excellence? This paper addresses these issues by examining the constructions of "self" and "other" used by HIV positive individuals themselves. By reference to a specific group of people living with long-term HIV positive diagnoses, it demonstrates how unhealthy HIV infected "others", as perceived by "healthy" members of society, create their own conceptions of "self" and "other" which microcosmically mirror typical processes of identity construction. The content, function and potential advantages and disadvantages of these processes are highlighted.

Phase II study of psychotherapeutic intervention in advanced cancer

The effect of psychosocial counseling on tumor progression was studied in 96 cancer patients, who were no longer amenable to regular medical treatment. Patients were offered 12 session of individual experiential-existential counseling, each sessions lasting 1.5 to 2 hours. In addition patients participated fortnightly in group counseling meetings. In five out of 35 evaluable patients, tumor growth became stationary during or immediately following therapy. In four patients this stationary period last 3-9 months, and in one patient 2 years. Natural Killer cell activity, self-reported loneliness, depression, purpose in life and locus of control showed no change from pre- to post intervention.

A Research Derived Bereavement Support Group Technique for the Hiv-1 Infected

A brief, semi-structured, bereavement support group for HIV seropositive and at risk homosexual men suffering a recent loss of a close friend or lover is described. The intervention employed a set of topics to stimulate group discussion. These topics were organized into three phases: making contact, venting of emotion, and “moving on.” Our predictive theoretical model integrating life stressor appraisal, social support availability, and active coping was incorporated. Therapeutic foci are active monitoring of stressor load; accurate stressor appraisal; extending, using and evaluating one's social support network; and selection of adaptive coping strategies. Three vignettes illustrate the integration of the research protocol with clinical issues. Implications for clinical care are discussed.