Experiential avoidance moderates the association between motivational sensitivity and prolonged grief but not posttraumatic stress symptoms

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Grief and bereavement beliefs and their associations with death anxiety and complicated grief in a U.S. college student sample

This study examined beliefs about grief and bereavement, and how the endorsement of myths is related to death anxiety and complicated grief. Results from a sample of college students in the United States (N = 391) suggested that myths about grief and bereavement are prevalent in this group. Additionally, the endorsement of certain myths significantly explained both death anxiety and complicated grief. Findings from this study provide additional support for death education in college and university settings to promote grief literacy. Implications for education, advocacy, research, and practice are discussed.

Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

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.

The relationship between sleep disturbance and obsessive- compulsive symptoms: the mediation of repetitive negative thinking and the moderation of experiential avoidance

Background

Studies have found that sleep disturbance is associated with obsessive-compulsive symptoms. This study aimed to elaborate on the mediating and moderating mechanisms between these two variables. We hypothesized that repetitive negative thinking plays a mediating role in the relationship between sleep disturbance and obsessive-compulsive symptoms, and experiential avoidance plays a moderating role.

Method

This study included 639 Chinese adults. A questionnaire survey was used to assess sleep quality, obsessive-compulsive symptoms, experiential avoidance, repetitive negative thinking, and depression symptoms. A moderated mediation model was established.

Results

After controlling for depressive symptoms, repetitive negative thinking partially mediated the positive correlation between sleep disturbance and obsessive-compulsive symptoms. This indirect relationship was significant in individuals with lower experiential avoidance levels. Particularly, the relationship between sleep disturbance and repetitive negative thinking was significant among individuals with lower experiential avoidance levels, but not among individuals with higher experiential avoidance levels.

Conclusion

This study demonstrated that repetitive negative thinking partially mediated the impact of sleep disturbance on obsessive-compulsive symptoms. The findings suggest that when providing support to individuals with sleep disturbance and obsessive-compulsive symptoms, assessing their level of experiential avoidance is necessary for performing targeted interventions. Individuals with low experiential avoidance may benefit from a clinical intervention targeting repetitive negative thinking to improve sleep quality and obsessive-compulsive symptoms.

The Network Structure of ICD-11 Disorders Specifically Associated with Stress: Adjustment Disorder, Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Complex Posttraumatic Stress Disorder

INTRODUCTION

The ICD-11 includes a new grouping for "disorders specifically associated with stress" that contains revised descriptions of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) and new diagnoses in the form of complex PTSD (CPTSD) and prolonged grief disorder (PGD). These disorders are similar in that they each require a life event for the diagnosis; however, they have not yet been assessed together for validity within the same sample. We set out to test the distinctiveness of the four main ICD-11 stress disorders using a network analysis approach.

METHODS

A population-based, cross-sectional design. A nationally representative sample of adults from the Republic of Ireland aged 18 years and older (N = 1,020) completed standardized measures of PTSD, CPTSD, AjD, and PGD. A network analysis was conducted at the symptom level. Outcome measures included the International Trauma Questionnaire, the Inventory of Complicated Grief, and the International Adjustment Disorder Questionnaire.

RESULTS

Consistent with the taxonomic structure of the ICD-11, our results showed that although the four conditions clustered independently at the disorder level, the specific symptoms of PTSD, CPTSD, PGD, and AjD clustered together very strongly but more strongly than with symptoms of the other disorders. The majority (61%) of the variation in each symptom could be explained by its neighboring symptoms. The strongest transdiagnostically connecting symptom was "startle response."

DISCUSSION/CONCLUSION

Mental health professionals caring for people who have experienced a range of stressors and traumatic life events can be confident in diagnosing these conditions that have clear diagnostic boundaries. Interventions addressing stress-associated disorders should be based on diagnostic assessment to ensure close fit between symptoms and treatment.

The role of experiential avoidance in the relationship between traumatic distress and yearning in sudden and unexpected bereavement

BACKGROUND

Distressing preoccupation with the circumstances of the death, experiential avoidance, and yearning often manifest in pathological forms of grief following the sudden or unexpected death of a loved one. Traumatic distress-the emotional distress linked to circumstances or reminders of a death-often leads to avoidance behaviors, whereas yearning has been conceptualized as an emotional state which leads to proximity-seeking behaviors following bereavement. A gap exists in the literature explaining how these variables may interact and perpetuate one another.

AIMS

The present study aims to examine the role of experiential avoidance in the relationship between traumatic distress and yearning in a sample of suddenly and unexpectedly bereaved young adults. Results suggest that the association between traumatic distress and yearning may be partially mediated by experiential avoidance. Implications of these findings for theoretical models of grief and yearning are discussed.

MATERIALS & METHODS

Data include a sample of 606 bereaved young adults (Mage = 21.25; 77.4% female) who participated in a larger, online survey study conducted at two universities in the United States exploring the prevalence of trauma exposure in college students.

RESULTS

Mediation analysis demonstrated experiential avoidance as partially mediating the relationship between traumatic distress and yearning (ab = .21, SE = .10, 95% CI [.02, .40]) when controlling for presence at the scene of death or injury. This indirect effect accounted for 11.67% of the total effect. An additional moderated mediation analysis indicated this indirect effect was present across all levels of prolonged grief disorder (PGD) symptom severity.

DISCUSSION

Results indicate that the association between traumatic distress and yearning may be partially mediated by experiential avoidance across all levels of PGD symptom severity.

CONCLUSION

Findings suggest that bereaved individuals experiencing recurrent, death-related intrusive thoughts, imagery, and/or other memories related to the circumstances of the death may be more likely to experience intense yearning for the deceased in part due to attempts to avoid painful internal experiences associated with such cues.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

OBJECTIVE

The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes.

METHOD

Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.

RESULTS

Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30).

SIGNIFICANCE OF RESULTS

Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Prolonged Grief Disorder in a Diverse College Student Sample

Objective: The purpose of this study was to explore the rate of prolonged grief disorder (PGD) and associated factors in a large sample of diverse college students. Sources of grief support and perceived helpfulness of support were also examined. Method: An online survey was administered to bereaved students at three colleges at the City University of New York. PGD measured by the Inventory of Complicated Grief was the primary outcome. Chi-squared and t-tests were used to assess the association between PGD and associated factors. Results: A total of n = 899 participants completed the Inventory of Complicated Grief (ICG) based on a significant death loss = >12 months. An estimated 13.4% (n = 120/899) met criteria for PGD. The rate of PGD was associated with race, history of anxiety or depression, trauma other than the death, insecure attachment style, kinship to the deceased, closeness to the deceased, cause of death, and sudden/unexpected death. The majority of students sought grief support from a friend or family member. Conclusion: The rate of PGD in this sample of college students is similar to that of adults and most prevalent for students of color. Identification of those most at risk is critical to referring these students to effective treatments.

Anxiety Sensitivity Moderates the Association Between Peritraumatic Distress and Bereavement Outcomes Among Sudden Loss Survivors

Peritraumatic distress and anxiety sensitivity are associated with complications in bereavement, including posttraumatic stress and prolonged grief reactions. The extent to which these factors interact to contribute to bereavement-related distress, however, remains unclear. This study investigates whether anxiety sensitivity moderates the association between peritraumatic reactions and posttraumatic stress and prolonged grief symptoms in a sample of young adults with a history of bereavement due to sudden, unexpected deaths. Participants were 606 undergraduate students recruited from two US universities. Results suggest that peritraumatic emotional and physical distress and anxiety sensitivity are all independently associated with both posttraumatic stress and prolonged grief reactions. Furthermore, the association between peritraumatic distress and prolonged grief, but not posttraumatic stress, is moderated by anxiety sensitivity. These findings point to several potentially important, clinically modifiable factors associated with a variety of bereavement-related mental health problems among a vulnerable group of grievers.

Differential Associations of Coping Strategies With Grief and Depression in Young Adults: The Role of Cause of Death and Relationship to the Deceased

Introduction: The impact of loss by death in young adults has been underinvestigated, although higher rates of traumatic deaths are reported at this developmental stage. This study examined the relative differential consequences of bereavement-related factors for Persistent Complex Bereavement Disorder (PCBD) and depression. In addition, coping strategies predicting the study outcomes were examined as a function of bereavement-related factors.

Methods: The study included 580 bereaved young adults with up to 5-year post loss. They were administered a battery of valided tools measuring PCBD symptoms, normal acute grief reactions as measured by the Core Bereavement Items scale, depressive symptoms, coping strategies, and bereavement-related characteristics. Covariance and regression analyses were used.

Results: We found that the dimensions of PCBD and depressive symptoms were differentially associated with the bereavement-related factors. More specifically, the death of an immediate family member was associated with higher levels of PCBD-separation distress, whereas the traumatic death of a friend and romantic partner was more associated with PCBD-social and identity disruption. Furthermore, the study revealed differential associations between PCBD severity, depressive symptoms, and coping strategies as functions of bereavement-related factors.

Discussion: The study has provided better understanding of clinical manifestations of PCBD as a function of etiologic risk factors. The results clarifying risk and protective factors are especially useful for improving effective bereavement-health counseling interventions among bereaved young adults.