Public stigma of prolonged grief disorder: An experimental study

Prolonged grief reactions and help-seeking in bereaved adults during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic disrupted many care systems limiting bereaved people's ability to access social, community, and professional support. This study investigated help-seeking of people living with probable prolonged grief disorder (PGD) to identify challenges and facilitators of care, with the aim of informing bereavement practice and policy recommendations.

METHODS

Participants (N = 786; 96.3 % female, Mage = 54.51. SD = 11.64) who were 12 or more months post-bereavement completed an online survey indexing pandemic bereavement experiences, mental health and functional outcomes, and help-seeking experiences. Probable PGD was defined as a score ≥30 on the Prolonged Grief Scale 13-Revised (PG-13-R). Results were analyzed using univariate statistics for closed questions and content analysis for free-text responses.

RESULTS

Participants living with probable PGD (39.4 %) were more likely than others to: have sought help from professional or other structured grief supports (χ2(1) = 41.18, p < .001); have unmet bereavement needs (χ2(1) = 91.87, p < .001); and be living with significant functional impairment (t = -26.55, p < .001) and suicidal ideation (χ2(3) = 117.38, p < .001). Lack of provider availability and lack of relevant skills in working with grief and trauma were identified as challenges to care.

LIMITATIONS

The study used a convenience sample recruited online and so care is required before generalizing to less represented populations.

CONCLUSIONS

We identified both pandemic-specific and more general gaps within bereavement support systems. Our findings highlight a need to recognize care needs and elevate bereavement care within pandemic planning and health care systems more generally.

Prolonged Grief Symptoms Predict Social and Emotional Loneliness and Depression Symptoms

A minority of bereaved individuals develops severe, persistent, and disabling grief, termed "prolonged grief." The International Classification of Diseases, eleventh edition (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) include such grief reactions as prolonged grief disorder (PGD). Loneliness is often experienced by bereaved persons and can have severe health consequences. Preliminary research suggests that loneliness may perpetuate grief, but prolonged grief may also aggravate loneliness. Since existing empirical research provides limited information on temporal relationships between both constructs, we aimed to fill this gap in knowledge. Bereaved adults (88% female, mean age 54 years) filled in questionnaires assessing general, social, and emotional loneliness and prolonged grief and depression symptoms across two time points, 6 months apart. Cross-lagged panel model analyses showed that prolonged grief symptoms predicted more severe general, social, and emotional loneliness, as well as more depression symptoms. Loneliness did not predict prolonged grief symptoms and depression symptoms. Depression symptoms did not predict prolonged grief symptoms and loneliness. Additionally, latent change score analyses demonstrated that within person changes in prolonged grief symptoms and loneliness were related. Findings are inconsistent with the notion that loneliness causes prolonged grief and depression. Possibly, severe grief could lead to stigmatization, reduced social support, and feeling socially disconnected, perpetuating loneliness and depression symptoms.

Is pregnancy loss (that) disenfranchised? Evidence from a vignette study

Background: Perceiving that society disregards grief after pregnancy loss (disenfranchised grief) elevates bereaved parents' psychological burden.Objective: In this research, we aimed to compare the disenfranchisement of pregnancy loss with four other loss types considering the bereaved's gender.Method: We collected data from Turkish participants (N = 1,280) using a 5 (loss type) x 2 (gender) between-subjects design with randomly assigned vignettes. Participants reported their expected grief and behavioural tendencies toward the bereaved. We conducted MANOVA and ANOVA analyses.Results: Results revealed that participants expected higher grief for pregnancy loss than two other disenfranchised grief types (former colleague's death, grandfather's diagnosis with Alzheimer's). Expected grief for pregnancy loss was higher than or similar to the level for the best friend's loss across examinations but lower than the level for the one-year-old child's loss. Behaviour tendencies were alike across vignettes, and their results did not paint a coherent picture. Findings did not differ by the bereaved's gender.Conclusion: Pregnancy loss might be less disenfranchised than bereaved parents perceive it, and parents' perceptions could be targeted in therapeutic interventions.

The relationship between bereavement-related guilt and suicide ideation in Turkish bereaved adults

This study investigates risk factors for suicidal ideation among Turkish bereaved adults, focusing on bereavement-related guilt. Utilizing the Prolonged Grief Scale, Bereavement Guilt Scale, and Beck Depression Inventory's suicide item, 570 bereaved participants were assessed. Suicidal ideation prevalence was found to be 20.2%. Higher rates of low income, single status, and unnatural death, as well as younger ages of the bereaved and deceased, were observed in the suicidal ideation group. Additionally, significantly elevated scores on the Prolonged Grief Scale and Bereavement Guilt Scale subscales were found in this group. After controlling for other risk factors, scores for survivor guilt and perceived responsibility for the death significantly increased the likelihood of belonging to the suicidal ideation group. These findings underscore the critical role of addressing feelings of guilt in psychological interventions aimed at mitigating suicidal ideation among bereaved individuals.

Comparing Public Perceptions of Child and Adult Grief Responses to Familial Incarceration

Children of incarcerated parents may grieve this loss, yet perceptions of their grief are understudied. Using vignettes varying by age (adult/child) and grief response (prolonged/resilient), we examined differences between perceptions of adults and children grieving parental incarceration. Participants rated grief response appropriateness, comfort providing support, and grief therapy recommendations for the grieving person in the vignette. Participants perceived resilience as more appropriate than prolonged grief [F (1, 224) = 9.02, p = .003, η2 = .04]. Age did not predict outcomes. Recommending grief therapy was higher for prolonged grief, yet 53% of participants with resilient vignettes recommended the person should seek grief therapy, which is concerning given possible iatrogenic effects. Thus, laypeople may have stigma toward individuals grieving parental incarceration, regardless of age.

Hurricane-Force Grief: A Mirror of Fathers' Love

A child's death is a traumatic experience that profoundly impacts parents' psychological, physical, and social wellbeing. The literature describes gender differences in grief response associated with child loss, yet less is known about fathers' grief in comparison that of mothers due to fathers' underrepresentation in bereavement research. There is a need for scholarly exploration to advance understanding of fathers' grief. This article presents selected findings on fathers' grief responses that emerged from a larger qualitative study, which aimed to describe fathers' lived experience of bereavement after a child's death. Profound grief emerged as one essential theme of fathers' bereavement experience. Participants described the meaning of their grief, their multidimensional grief responses, their grief triggers, and their grief intensity. Findings deepen understanding of fathers' grief associated with child loss and advance the body of parental bereavement literature.

Prolonged Grief Disorder, but Not Death From COVID-19, Elicits Public Stigma: A Vignette-Based Experiment

We investigated the effects of cause of death (COVID-19 with an underlying medical condition vs. without) and prolonged grief disorder status (PGD present or absent) on participants' reported public stigma towards the bereaved. Participants (N = 304, 66% women; Mage = 39.39 years) were randomly assigned to read one of four vignettes describing a bereaved man. Participants completed stigma measures assessing negative attributions, desired social distance, and emotional reactions. Participants reported significantly stronger stigmatizing responses towards an individual with PGD (vs. without PGD) across all stigma measures. There was no significant difference in stigma based on cause of death; however, stigma was reported regardless of cause of death. There was no significant interaction between cause of death and PGD on stigma. This study supports the robust finding of public stigma being reported toward an individual with PGD, suggesting these individuals are at risk of public stigma and not receiving adequate bereavement support.

The stigmatization of prolonged grief disorder and disenfranchised grief: A vignette-based experimental study

People with prolonged grief disorder (PGD) are at risk of public stigma, but research has yet to examine whether stigma is shaped by different types of relationship losses. In an experimental study, we asked participants (N = 306) to read three scenarios in which targets lost their romantic partner, child, or companion animal. Targets with PGD (vs. integrated grief) elicited more negative emotional reactions and attributions, and their experiences were perceived as less legitimate. Targets who lost their companion animal (vs. other relationship losses) were perceived as the most sensitive and their grief as the least legitimate, but they also elicited the lowest prosocial and fear reactions and were perceived as the warmest. Lastly, targets with PGD who lost their companion animal (vs. other relationship losses) elicited more negative emotional reactions and attributions, and their experiences were perceived as less legitimate. Implications and suggestions for future studies are discussed.

Public stigma toward prolonged grief and COVID-19 bereavement: A vignette-based experiment

We investigated the effects of cause of death and the presence of prolonged grief disorder (PGD) on eliciting public stigma toward the bereaved. Participants (N = 328, 76% female; Mage = 27.55 years) were randomly assigned to read one of four vignettes describing a bereaved man. Each vignette differed by his PGD status (PGD diagnosis or no PGD diagnosis) and his wife's cause of death (COVID-19 or brain hemorrhage). Participants completed public stigma measures assessing negative attributions, desired social distance, and emotional reactions. Bereavement with PGD (versus without PGD) elicited large and significantly stronger responses across all stigma measures. Both causes of death elicited public stigma. There was no interaction between cause of death and PGD on stigma. With increased PGD rates expected during the pandemic, the potential for public stigma and reduced social support for people bereaved via traumatic deaths and people with PGD requires mitigation.

On the Classification and Reporting of Prolonged Grief: Assessment and Research Guidelines

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Explain the steps required for diagnosis of mental disorders in diagnostic handbooks.• Identify current procedures for classifying and reporting prolonged grief disorder.

ABSTRACT

Prolonged grief disorder (PGD) was added to the 11th edition of the International Classification of Diseases in 2018 and to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders in its 2022 text revision. Thus, reporting and classifying PGD according to established guidelines has become fundamental for scientific research and clinical practice. Yet, PGD assessment instruments and criteria are still being developed and debated. The purpose of this article is to examine the adequacy of current procedures for classifying and reporting PGD in research and to suggest guidelines for future investigation and dissemination of knowledge. We outline the standard steps required for diagnosis and assessment of a mental disorder (notably, the administration of clinical interviews). In order to illustrate reporting about the presence/prevalence of PGD in recent scientific articles, we conducted a search of Scopus that identified 22 relevant articles published between 2019 and 2023. Our review of the literature shows that standard classification procedures are not (yet) followed. Prevalences of PGD are based on self-reported symptomatology, with rates derived from percentages of bereaved persons reaching a certain cutoff score on a questionnaire, without clinical interviewing. This likely results in systematic overestimation of prevalences. Nevertheless, the actual establishment of PGD prevalence was often stated in titles, abstracts, and results sections of articles. Further, the need for structured clinical interviews for diagnostic classification was frequently mentioned only among limitations in discussion sections-but was not highlighted. We conclude by providing guidelines for researching and reporting self-reported prolonged grief symptoms and the presence/prevalence of PGD.

[When the diagnosis came in … Bereavement care in Germany in 2020/2021: Where do we stand?]

BACKGROUND

In Germany, numerous health care providers work in the field of bereavement care. An epidemiological study of the field immediately after the introduction of the ICD-11 diagnosis "Prolonged Grief Disorder" (PGD) is pending.

METHODS

The second survey of the trend study, which is designed over a total of three measurement points at intervals of one decade each, explores whether and to what extent the field of bereavement care has evolved after the introduction of the grief-specific diagnosis PGD. For this purpose, providers of bereavement care at various organizational levels were asked to participate in an online survey. The survey was conducted from October 2020 to January 2021.

RESULTS

456 questionnaires were included in the study. Data analysis was descriptive. 80.5% of the participants have an additional grief-specific qualification, 59.4% base their work on a grief-specific concept. In view of the PGD diagnosis, only a few respondents have participated in a PGD-related advanced training. Most are afraid that the topic of grief will increasingly be subsumed in the medical-psychological-therapeutic field. An increase in bereavement research and the number and quality of continuing education is also expected.

DISCUSSION

Some positive trends in German bereavement care can be identified. However, there is a need for further development in the areas "designation of the activity", "diagnostics", and "intervention". Also, there is a need for training with regard to PGD.

CONCLUSION

After the introduction of PGD, the field of bereavement care in Germany turns out to be slightly different. The diagnosis is viewed skeptically.

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.

Perceptions of Crime Severity and Stigma Toward Family Members Grieving the Loss of a Person to Incarceration

Family members of incarcerated persons may experience grief related to the incarceration. We examined laypeople's perceptions of family members grieving the loss of an individual to incarceration. Participants (N = 1,095) were randomized to read vignettes that varied by grief trajectory (prolonged vs. resilient), race (Black vs. White vs. Latine), and crime type (violent vs. non-violent). Participants answered questions assessing grief response appropriateness, comfort providing support to the grieving person, beliefs that the grieving person should seek therapy, and how severe they believed the incarcerated person's crime was. Results indicated that prolonged grief trajectories and greater perceived crime severity were associated with decreased ratings of grief response appropriateness. Participants were more likely to endorse the need for therapy-seeking for individuals with prolonged grief (vs. resilience). Participants were less likely to recommend therapy for Black (vs. White) individuals, and women were more likely to recommend seeking therapy than men. The results suggest stigma might exist toward family members grieving the loss of individuals who committed crimes perceived to be more severe by laypeople, which could contribute to negative bereavement outcomes.

Perceptions of grief reactions in family members of incarcerated individuals: A vignette-based experiment

We examined perceptions of individuals grieving the loss of a family member to incarceration. Participants (N = 1095) were randomized to a vignette that varied by race-ethnicity, crime type, and grief trajectory to assess their perceptions. Results indicated: (1) participants perceived prolonged grief as less appropriate than resilience; (2) Black family members grieving someone who committed a violent crime as more appropriate compared to White family members; and (3) women endorsed both grief trajectories as more appropriate and indicated greater comfort supporting the family member. Lastly, participants indicated prolonged, White and Latinx grievers should seek therapy more than resilient or Black individuals.

Culturally and Linguistically Diverse Men's Grief Experiences Following Perinatal Death in Australia

To explore the grief experiences of men from culturally and linguistically diverse (CALD) backgrounds following perinatal death in Australia. Qualitative analysis of interview data using thematic analysis. Participants were health service providers (n = 6), and CALD community members (n = 10) who were either community leaders with experience working with CALD men following perinatal death in Australia (n = 6), or were CALD men who had lived experience of perinatal death (n = 4). Thematic analysis identified four themes related to CALD men's grief. These included the role of religion and rituals, grief as stoic, the partner- and family-centred nature of men's grief, and finally grief as ensuring and changeable over time. This research points to the strong need for CALD men's specific needs to be included in the development of policy and practice surrounding perinatal death.

Examining public stigma and expectations of grief following medical aid and dying in the US: A vignette-based experiment

Objectives

Families bereaved following Medical Aid in Dying (MAID)-related death express concerns about public stigma. As access to MAID expands, research examining MAID is needed, including understanding stigma toward family members. This study examines if stigmatization exists toward bereaved individuals whose family member utilized MAID at differing ages and assess if expectations of grief differ between bereaved individuals whose family member utilized MAID compared to bereaved individuals whose family member died of an illness.

Methods

This study utilized a randomized, between-groups, vignette-based experiment to test the effects of cause of death (MAID vs. illness-related death) and age (28, 38, 70, and 80 years) of the deceased on indicators of public stigma. Participants (N = 428) were recruited from mTURK (Mage = 42.54; SDage = 16.50).

Results

Analyses showed a statistically significant interaction between age and the mode of death (F(7, 400), p = 0.001, $\eta _{\rm p}^2$ = 0.06) and the main effect for age (F(5, 401), p = 0.004, $\eta _{\rm p}^2$ = 0.04) on expectations of grief, whereas emotional reactions and wanting social distance were not significant (p > 0.05). Participants expected more maladaptive grief among family members of 28- and 70-year-olds who died of illness compared to 28- or 38-year-olds who utilized MAID [28-year-old (M = 44.12, SD = 12.03) or 70-year-old (M = 44.32, SD = 10.29) illness-related death vs. 28-year-old (M = 39.3, SD = 11.56; p = 0.01) or 38-year-old (M = 38.71, SD = 11.56; p = 0.007) MAID-related death].

Significance of results

Findings suggest that direct stigma does not exist toward family members of individuals engaging in MAID. The American public may expect that family members of young individuals who utilize MAID are accepting of the death and expect them to experience fewer maladaptive grief symptoms. Future research should investigate differences in bereavement outcomes based on age of bereaved caregivers of individuals engaging in MAID.

Predictors of prolonged grief disorder in Chinese elderly shidu parents: The role of perceived stigma and perceived stress

INTRODUCTION

Parents who have lost their only child and over the age of 60 are known as elderly shidu parents. This study aimed to investigate predictors of prolonged grief disorder (PGD) among Chinese elderly shidu parents.

METHODS

Two hundred and ninety-eight elderly shidu parents from Shenyang were included in this cross-sectional study. Participants completed a questionnaire including the Prolonged Grief questionnaire-13 (PG-13), the PTSD (post-traumatic stress disorder) Checklist for DSM-5 (PCL-5), the Center for Epidemiologic Studies Depression Scales (CES-D), the Self-Rating Anxiety Scale (SAS), and the Perceived Stress Scale-10 (PSS-10). Multiple linear regression was used to examine socio-demographic, bereavement-related and perceived stress associated with PGD symptoms.

RESULTS

The prevalence of PGD among Chinese elderly shidu parents was 13.8%. Among the 41 PGD patients, 29, 39, 36 patients had comorbidity of PTSD, depressive symptoms and anxiety, respectively. Perceived stress, higher educational level, lower annual household income, perceived stigma, violent death of the child, and being in debt were associated with severer PGD symptoms.

DISCUSSION

The present study revealed the prevalence of PGD and the important role of PGD in diagnosing other mental disorders in Chinese elderly shidu parents. Providing financial help, eliminating social stigma, and stress should be included in PGD prevention among Chinese elderly shidu parents.

Public Stigma of Prolonged Grief Disorder: An Experimental Replication and Extension

ABSTRACT

Prolonged grief disorder's (PGD's) recent recognition as a psychiatric diagnosis has elicited concerns about stigmatization. Although prior research demonstrated that PGD elicits public stigma, moderators of this effect are unclear, and the effect requires replication in an English-speaking population. Therefore, we investigated the effects of PGD, sex of the bereaved, and death expectedness on public stigma toward bereaved persons. We randomly assigned 195 Australian adults (77% female; mean age, 35.7 years) to read one of eight vignettes describing a bereaved male or female subject, with or without PGD, after an expected or unexpected death. Participants reported their emotional reactions and negative attributions toward, and desired social distance from, the bereaved person. A person with PGD (vs. without) elicited stronger emotional reactions, negative attributions, and desired social distance. No robust moderator effects emerged. Results validate concerns that PGD causes stigma. Stigmatization may be targeted by information campaigns or psychological treatment.

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.

Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected. Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.

Perception of grief responses: Are maladaptive grief responses and the stages of grief considered normal?

Literature indicates laypeople hold strong opinions about how persons should grieve. This study examined how individuals perceive normal grief. Participants across two distinct samples (Study 1: N = 510 via MTurk; Study 2: N = 210 via Qualtrics panels) completed the Perception of Grief Scale and Grief Expectations Questionnaire. Findings indicated participants endorsed maladaptive grief responses as normal relative to other responses to loss. Endorsement of maladaptive grief responses as normal predicted endorsement of grief work beliefs. If social expectations deem maladaptive grief to be normal, as this study suggests, bereaved individuals might implicitly push themselves to grieve maladaptively.

Does voluntary assisted dying cause public stigma for the bereaved? A vignette-based experiment

OBJECTIVE

Studies in countries where assisted dying is legal show that bereaved people express concern over the potential for social disapproval and social stigma because of the manner of death. There are indications that voluntary assisted dying is judged as less acceptable if the deceased is younger. A vignette-based experiment was used to determine whether public stigma (i.e., negative emotional reactions and desired social distance) and expected grief symptoms are higher for conjugally bereaved people through voluntary assisted dying (vs. long-term illness), when the deceased is a young adult (vs. older adult).

METHOD

A 2 × 2 randomized factorial design was conducted with 164 Australian adults (130 women, 34 men, Mage = 37.69 years). Each participant was randomized online to read one of four vignettes and completed measures of anger, fear, prosocial emotions, desire for social distance, and expectations of grief symptomatology.

RESULTS

A multivariate analysis of variance (MANOVA) was conducted. Death at a young age (28 years) was significantly associated with stronger negative emotional reactions of fear ($\eta _p^2 = 0.04$, P = 0.048) and anger ($\eta _p^2 = 0.06$, P = 0.010). There were no differences in outcomes associated with the mode of death, nor was there an interaction between mode of death and age group.

SIGNIFICANCE OF RESULTS

Concerns that voluntary assisted dying elicits public stigma appear unfounded. The fact that participants reported significantly higher anger and fear in response to bereaved people experiencing loss at a younger (vs. older) age, irrespective of cause of death, indicates that young people who lose their spouse might benefit from additional support.

Public stigma towards prolonged grief disorder: Does diagnostic labeling matter?

The recent introduction of prolonged grief disorder (PGD) as a diagnostic category may cause negative social reactions (i.e. public stigma). Vignette experiments demonstrate that persons with both PGD symptoms and a PGD diagnosis elicit more public stigma than persons who experience integrated grief. However, the strength of the influence of the diagnosis itself remains unclear: We aimed to clarify if the diagnostic label PGD produces additional public stigma beyond PGD symptoms. We further compared whether public stigma varies between the label PGD and the label major depressive episode (MDE) (when PGD symptoms are present) and if gender of the bereaved person influences public stigma or moderates the aforementioned effects. Eight-hundred fifty-two participants (77% female; M_age = 32.6 years, SD = 13.3) were randomly assigned to read online one of eight vignettes describing either a bereaved male or female, with PGD symptoms and PGD diagnosis; PGD symptoms and MDE diagnosis; PGD symptoms and no diagnosis, or no PGD symptoms and no diagnosis (i.e., integrated grief). Following the vignettes, participants indicated which negative characteristics they ascribed to the person, their emotional reactions, and preferred social distance from the person. People with PGD symptoms and PGD (or MDE) diagnosis were attributed more negative characteristics, and elicited more negative emotions and a stronger desire for social distance than people with integrated grief. However, public stigma did not differ for people with both PGD symptoms and diagnosis compared to people only experiencing PGD symptoms. Gender of the bereaved only had an influence on desired social distance, which was larger towards men. Helping severely distressed bereaved people (regardless of diagnostic status) cope with negative social reactions may help them adapt to bereavement. Results demonstrate that the experience of severe grief reactions, yet not a diagnostic label per se, causes public stigma.

Bereavement or breakup: Differences in networks of depression

BACKGROUND

Prior network analyses demonstrated that the death of a loved one potentially precedes specific depression symptoms, primarily loneliness, which in turn links to other depressive symptoms. In this study, we extend prior research by comparing depression symptom network structures following two types of marital disruption: bereavement versus separation.

METHODS

We fitted two Gaussian Graphical Models to cross-sectional data from a Swiss survey of older persons (145 bereaved, 217 separated, and 362 married controls), and compared symptom levels across bereaved and separated individuals.

RESULTS

Separated compared to widowed individuals were more likely to perceive an unfriendly environment and oneself as a failure. Both types of marital disruption were strongly linked to loneliness, from where different relations emerged to other depressive symptoms. Amongst others, loneliness had a stronger connection to perceiving oneself as a failure in separated compared to widowed individuals. Conversely, loneliness had a stronger connection to getting going in widowed individuals.

LIMITATIONS

Analyses are based on cross-sectional between-subjects data, and conclusions regarding dynamic processes on the within-subjects level remain putative. Further, some of the estimated parameters in the network exhibited overlapping confidence intervals and their order needs to be interpreted with care. Replications should thus aim for studies with multiple time points and larger samples.

CONCLUSIONS

The findings of this study add to a growing body of literature indicating that depressive symptom patterns depend on contextual factors. If replicated on the within-subjects level, such findings have implications for setting up patient-tailored treatment approaches in dependence of contextual factors.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

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

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.

Clinical Utility and Global Applicability of Prolonged Grief Disorder in the ICD-11 from the Perspective of Chinese and German-Speaking Health Care Professionals

BACKGROUND

Prolonged grief disorder (PGD) is included in the ICD-11 (11th edition of the International Classification of Diseases). The new PGD criteria reflect the requirements and recommendations of the World Health Organization for improved clinical utility and international applicability. Even though the ICD classification system is globally used, no research has investigated how healthcare professionals (HP) in non-Western countries may adopt this change for their own practice.

OBJECTIVE

The present study explored the extent to which the new PGD criteria were accepted and perceived to meet the standards for clinical utility and international applicability among Chinese and German-speaking HP.

METHODS

Individual semistructured interviews were conducted in person, by phone, or online (e.g., via Skype), with 24 Chinese (n = 10) and German-speaking (n = 14) HP working with bereaved populations in China and Switzerland, and analyzed using a qualitative framework analysis. Questions included "what items are currently missing from the PGD criteria?".

RESULTS

Across all HP, the majority supported the inclusion of PGD and were generally aligned with the current criteria. HP found that the criteria distinguished between normal and abnormal grief and considered the criteria easy to use if their modifications were considered. Merits included, among others, improved clinical decision making, research promotion, and social acknowledgment. Main concerns included misdiagnosis, pathologization, and a lack of specificity of criteria. The importance of international applicability was emphasized across Chinese and German-speaking HP. Different grief-specific symptoms were identified by German-speaking and Chinese HP.

CONCLUSIONS

These findings provide evidence for the clinical utility and international applicability of ICD-11 PGD criteria among German-speaking and Chinese HP, as well as cultural similarities and differences in the barriers to implementation of these criteria.

Attributions About Bereaved Spouses: Testing the Myths of Coping With Loss

Social expectations influence how we cope with loss and how people in our social networks respond to us. Wortman and Silver outlined Western cultural assumptions, or myths, about mourning, thought to influence judgments of one’s grief response. In particular, the two myths hypothesized to affect social judgments about grievers’ adjustment were related to (a) the intensities of the grief response and (b) the duration of the grief response. We assessed if these myths affected the attributions of potential support providers in a convenience sample of 510 Amazon Mechanical Turk community participants. The results indicated preheld expectancies that expressing and processing loss is important to recover from grief was related to attributions about the adjustment of spousally bereaved grievers in vignettes. However, any level of grief symptoms displayed in vignettes was associated with participants, indicating they would discourage expression of grief and distance themselves from the person grieving.

Does prolonged grief or suicide bereavement cause public stigma? A vignette-based experiment

Prolonged grief disorder (PGD), characterized by severe, persistent and disabling grief, is newly included in the International Classification of Diseases 11 (ICD-11). Receiving a PGD diagnosis could lead to stigmatizing public reactions (i.e. public stigma), yet research on this topic is limited. Additionally, while there is evidence that experiencing suicide bereavement causes public stigma, no studies to date have investigated the interaction between PGD and cause of death on public stigma. To fill these knowledge gaps, this experimental study tested if a PGD diagnosis (vs. no diagnosis) and experiencing suicide bereavement (vs. homicide and natural loss) cause public stigma. Three hundred and seventeen adults from the general population were randomly assigned to read one of 6 different vignettes of a person with and without PGD who had lost a spouse through a suicide, homicide or a stroke. After reading a vignette, negative attributions, emotional reactions, and desire for social distance were assessed. Notably, only persons with PGD were attributed relatively more negative characteristics, and elicited more anger, anxiety and pro-social emotions, and a larger preferred social distance in participants. This study supports the claim that PGD causes public stigma, but nuances claims that suicide bereavement induces public stigma.

Normal Complications and Abnormal Assumptions After Perinatal Death

There are several ways, clinically, to approach grief after perinatal death, including from a humanistic or a medicalized perspective. The death of a baby is complicated. The loss is an embodied one that incites deep psychological wounds and can be isolating for many parents. Parents process their grief experiences within a sometimes oppressive social context that either sees their expressions of loss as a normal response to an abnormal tragedy or as pathology. Several diagnostic categories have been proposed relative to the traumatic grief experiences of grieving parents that potentially affect them. We explore this nomenclature and, through the lens of a Social-Cognitive Processing Model, examine social support, attitudes, context, and oppressive interpersonal and social structures that affect parents. Clinical implications are discussed.