The role of self-concept clarity in prolonged grief disorder

A role for event centrality in prolonged grief disorder

Having a traumatic or negative event at the centre of one's identity is associated with adverse psychological outcomes including post-traumatic stress, depression, and prolonged grief disorder (PGD). However, direct investigation of the role of centrality of a bereavement-event in the maintenance of PGD symptoms is scarce and has not compared immediate and long-term changes in event centrality nor examined the nature of the loss. Data from bereaved partners and adult children in The Aarhus Bereavement Study at four time points over 26 months post-loss were included in this study. Participants completed a PGD symptom measure and the Centrality of Events Scale (CES) on each occasion. Results suggest that bereaved partners had higher PGD and CES scores than bereaved adult children at all four post-bereavement time points. Regardless of relationship type, maintaining higher CES scores over time predicted PGD symptoms, over and above initial symptoms. Our findings suggest a risk factor for maintaining PGD symptoms is the continued centrality of the bereavement to ones' life story and autobiographical memory. This finding links the mechanisms for maintaining PGD symptoms to those involved in other disorders such as post-traumatic stress, with implications for theoretical models of prolonged grief as well as treatment.

Examining worry and secondary stressors on grief severity using machine learning

BACKGROUND & OBJECTIVES

Worry and loss-related secondary stressors appear to be important correlates of problematic grief responses. However, the relative importance of these variables in the context of established correlates of grief responding, ranging from indicators of identity disruption and demographic characteristics of the bereaved to characteristics of the loss of quality of the relationship with the deceased, is unknown. Modeling the relative associations of these factors can be problematic, given the high degree of collinearity between these variables. This study used a machine learning approach to provide accurate estimations of the relative importance of these correlates for post-loss symptom severity.

METHODS AND RESULTS

A convenience sample of 428 bereaved people who had lost a parent, spouse, or child in the last 30 to 365 days completed an online survey. Random forest regression modeling examined the effects of worry and secondary stressors on symptom severity in the context of established correlates. Results indicated worry and the number of secondary stressors experienced were among the factors most strongly associated with severity of grief, depression, posttraumatic stress and problems functioning.

CONCLUSIONS

These results also provide insight into the relative importance of worry and secondary stressors affecting grief severity to guide future research.

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.

Self-Compassion for Caregivers of Children in Parentally Bereaved Families: A Theoretical Model and Intervention Example

Family-based bereavement interventions have shown promises to prevent problem outcomes and promote resilience in parentally bereaved children. Evidence of the broad range of mental and physical health problems following the death of a parent supports the need for a transdiagnostic approach that promotes adaptation and reduces multiple problem outcomes for parentally bereaved families. We discuss self-compassion as a promising framework for a transdiagnostic approach. We argue that three elements of self-compassion-mindfulness (vs. over-identification), self-kindness (vs. self-judgment), and common humanity (vs. isolation)-can facilitate loss-oriented coping, restoration-oriented coping, and the oscillation process between the two. This sets the foundation for individual and family processes that support bereavement adjustment. To explain how self-compassion promotes adjustment outcomes in parentally bereaved families, we review the extant literature with a focus on parental emotion regulation and effective parenting and propose a conceptual model with testable hypotheses to guide more research in this area. The model suggests that caregivers' self-compassion is a resilience resource for multiple adaptive outcomes for themselves and for their child through its positive impacts on emotion regulation and effective parenting. We illustrate the utility of the framework with an example of a family-based bereavement prevention program that integrated self-compassion training. Future directions for research are discussed.

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.

It's not who you lose, it's who you are: Identity and symptom trajectory in prolonged grief

The death of a loved one has been associated with a range of emotional and cognitive impacts, with up to 10% of the bereaved population experiencing a prolonged grief reaction. Direct investigation of the role of self-identity in the maintenance of grief symptoms is limited and has not discriminated between relationship type. This longitudinal study investigated the differences in grief symptoms over time depending on relationship to the deceased person (partner or adult child), as well as the association between long-term grief symptoms and identity, attachment, and cognitive interdependence. Data from bereaved partners and adult children in The Aarhus Bereavement Study at two- and 18-months post-bereavement were included in this study. They completed questionnaires measuring their grief symptoms at both time points, a measure of attachment at Time 1, and measures of the interdependence of their pre- and post-loss identity with the deceased, their cognitive interdependence, and everyday memory retrieval failures at Time 4. Compared with adult children, bereaved partners experienced more intense grief symptoms at both time points. Regression analysis identified that over and above immediate grief symptoms, key predictors of prolonged grief symptoms were a merged post-bereavement identity with the deceased, younger age, and everyday memory retrieval difficulties. Relationship type and pre-bereavement identity contributed to initial but not prolonged grief symptoms. We discuss these findings in terms of the role of interdependence in prolonged grief.

The centrality of a loss-event: Patterns, correlates, and predictive value

BACKGROUND AND OBJECTIVES

Evidence shows that the centrality of a loss-event maintains emotional distress following loss. Aims of the current study were to examine (i) if subgroups of bereaved people can be distinguished based on their endorsement of different manifestations of loss-centrality, (ii) if subgroup membership was associated with socio-demographic and loss-related variables, and (iii) the linkage of subgroup membership with symptom-levels of prolonged grief (PG), posttraumatic stress (PTS), and depression assessed concurrently and 6 months later.

METHODS

Three-hundred ninety-eight bereaved people completed the 7-item Centrality of Event Scale, with their loss as anchor-event and completed symptom-measures concurrently and 6 months later. Latent profile analysis (LPA) was used to identity profiles of loss-centrality.

RESULTS

LPA revealed a three-profile solution representing low, average, and high centrality classes, respectively. The death of a partner and younger age increased the likelihood of membership of classes evidencing stronger centrality. Membership of the low centrality class was associated with lower concurrent PG, PTS, and depression; membership of the high centrality class predicted elevated PG 6 months later, beyond baseline PG.

CONCLUSIONS

Subgroups of loss-centrality were distinguished by increasing endorsement of all (rather than some) manifestations of loss-centrality. Clinical implications are discussed.

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.

Associations of depressive rumination and positive affect regulation with emotional distress after the death of a loved one

The death of a loved one may precipitate symptoms of prolonged grief disorder (PGD), post‐traumatic stress disorder (PTSD) and depression. Brooding about the causes and consequences of one's negative affect (NA), also termed depressive rumination, has been linked to distress after loss. The role of dysregulation of positive affect (PA) has received less attention. We examined (1) the factor structure of depressive rumination and PA dysregulation and (2) to what extent these factors were related to PGD, PTSD and depression symptom levels. Self‐report data were included from 235 Dutch bereaved people who completed measures tapping symptoms of PGD, PTSD and depression. Depressive rumination and PA regulation strategies were assessed with the Ruminative Response Scale (RRS) Brooding Scale and the Response to Positive Affect (RPA) Questionnaire (including three subscales: emotion‐focused and self‐focused rumination and dampening), respectively. Confirmatory factor analyses and structural equation modelling were used for data analyses. The four‐factor model (i.e., depressive rumination and the three RPA subscales) showed the best fit. An increase in depressive rumination was related to higher distress levels (across all outcomes in univariate and multivariate analyses). An increase in emotion‐focused rumination about PA was associated with less depression. More dampening of PA was related to higher PTSD levels. Findings suggest that, alongside the regulation of NA, the regulation of PA plays a role in how people respond to the death of a loved one. This points to the need for more research on NA and PA regulation in grief.

Identity confusion in complicated grief: A closer look

Complicated grief (CG) is characterized by a wide range of symptoms, including identity confusion or a sense that a part of oneself has died with the decedent. Although identity confusion is a commonly reported feature of CG, little is known about which specific aspects of self-concept are compromised. In the current study, we used qualitative coding methods to investigate which aspects of the sense of self differed between those with and without CG in a sample of 77 bereaved adults. Relative to individuals without CG, those with CG provided fewer descriptors of their self-concept overall (lower self-fluency), provided sets of descriptors that consisted of fewer categories (lower self-diversity), and had lower proportions of self-relevant preferences and activities. However, group differences were not observed for proportions of any other categories of self-concept descriptors, including references to the loss, the past, or distress-related self-statements. Directions for future research and clinical implications are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement

Repetitive negative thought plays an important role in the maintenance of mental health problems following bereavement. To date, bereavement researchers have primarily focused on rumination (i.e., repetitive thought about negative events and/or negative emotions), yet the interest in worry (i.e., repetitive thought about uncertain future events) is increasing. Both cognitive processes potentially lead to poorer adaptation to bereavement by contributing to loss‐related avoidance and behavioural avoidance of activities. The current study aims to establish the differential associations of rumination and worry with symptoms of depression and prolonged grief and clarify if avoidance processes mediate the associations of rumination and worry with symptom levels. Four hundred seventy‐four recently bereaved adults (82% female) filled out questionnaires assessing rumination, worry, loss‐related and behavioural avoidance, and depression and prolonged grief symptoms. Rumination and worry were both uniquely associated with depression and prolonged grief symptoms. Compared with worry, rumination related more strongly to prolonged grief symptoms, whereas correlations of both cognitive styles with depression symptoms did not differ. Loss‐related avoidance and behavioural avoidance partially mediated the associations of rumination and worry with prolonged grief symptoms. Behavioural avoidance partially mediated the associations of rumination and worry with depression symptoms. Findings suggest that exposure and behavioural activation may be effective interventions to reduce repetitive thinking and psychopathology after bereavement.

With or Without You? Loss of Self Following Marital Separation

When romantic relationships end, many people experience a loss in identity or loss of self with subsequent psychological distress. To evaluate the predictive validity of loss of self in a sample of separated/divorced adults (N = 133), we use self-report data and judge ratings of behavioral observation to explore if loss of self is associated with psychological distress over five months. We identify predictors of loss of self by examining how judge-rated perceptions of the former partner might lead to changes in loss of self and subsequent psychological distress. Results indicate that higher levels of self-reported and judge-rated loss of self are associated with higher levels of psychological distress. Higher self-reported loss of self at the initial visit was associated with higher levels of psychological distress three months later. Finally, the more divorcing adults spontaneously differentiated and distinguished their identities from their former partners, the smaller their declines in loss of self three months later, and the smaller their declines in psychological distress five months later. Our findings suggest that judge-rated loss of self is associated with psychological distress above-and-beyond self-reported loss of self. Further, it highlights differentiation as a key variable that underpins changes in loss of self and subsequent distress.

Attachment reorganization following divorce: normative processes and individual differences

This paper uses attachment theory as a lens for reviewing contemporary research on how adults cope with marital separation and loss. The first section of the paper discusses the process of normative attachment reorganization, or the psychology of adaptive grief responses following relationship transitions. We argue that changes two processes, in particular, can be uses to track changes in this normative reorganization process: narrative coherence and self-concept clarity. The second section of the paper suggest that individual differences in attachment anxiety and avoidance shape the variability in this normative reorganization process, largely as a result of the characteristic ways in which these styles organize emotion-regulatory tendencies. The paper closes with a series of integrative questions for future research, including a call for new studies aimed at understanding under what contexts anxiety and avoidance may be adaptive in promoting emotion recovery to separation and divorce experiences.

Exploration of the Associations Between Responses to Affective States and Psychopathology in Two Samples of People Confronted With the Loss of a Loved One

Adaptive regulation of positive and negative affect after the loss of a loved one may foster recovery. In two studies, using similar methods but different samples, we explored the association between positive (i.e., dampening and enhancing) and negative (i.e., rumination) affect regulation strategies and symptoms levels of postloss psychopathology. Study 1 used data from 187 people confronted with the death of a loved one. In study 2, the sample consisted of 134 relatives of long-term missing persons. Participants completed self-reports tapping prolonged grief, depression, posttraumatic stress symptoms, and affect regulation strategies. Hierarchical regression analyses showed that both negative and positive affect regulation strategies explained significant amounts of variance symptom levels in both samples. In line with previous work, our results suggest that negative and positive affect regulation strategies relate to postloss psychopathology. Future research should explore how both affect regulation strategies may adequately be addressed in treatment.

Self-Identity After Bereavement: Reduced Self-Clarity and Loss-Centrality in Emotional Problems After the Death of a Loved One

There is evidence that both the centrality of a loss-event as well as reduced self-concept clarity are involved in emotional problems after the death of a loved one. One issue that is still unexplored is the relative importance of these two concepts in predicting bereavement outcome. The current study examined the degree to which both concepts contribute to emotional distress after loss, both concurrently and longitudinally. Data were available from 124 individuals, all bereaved within the previous half year, who completed measures of prolonged grief, posttraumatic stress, and depression at inclusion into the study and again 6 months later. Loss-centrality and self-unclarity were associated with all three outcome measures, in cross-sectional analyses. Longitudinal analyses indicated that loss-centrality predicted symptom levels of prolonged grief, self-unclarity predicted symptom levels of depression, and both loss-centrality and self-unclarity were associated with posttraumatic stress 6 months after baseline. Implications of these findings are discussed.

Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement

This study examined associations of Prospective IU and Inhibitory IU with symptom-levels of Prolonged Grief Disorder (PGD), Posttraumatic Stress-Disorder (PTSD), and depression in a sample of bereaved individuals. Specifically, 265 bereaved individuals completed measures of IU, PGD, PTSD, and depression in the first year after the death of a loved one; 134 participants again completed symptom-measures six months later. Cross-sectional analyses showed that Inhibitory IU (but not Prospective IU) was positively associated with symptom-levels of PTSD and depression (but not PGD), even when controlling for neuroticism, worry, and rumination. Prospective analyses showed that Prospective IU (but not Inhibitory IU) at baseline, predicted PGD severity six months later (but not PTSD or depression at follow-up) while controlling for baseline symptom-levels. The findings support the notion that IU is a vulnerability factor for different emotional problems, including those developing after the death of a loved one. Clinical implications of these findings are discussed.

Anxious and depressive avoidance behavior in post-loss psychopathology: a longitudinal study

BACKGROUND

Avoidance behavior is a central component of cognitive behavioral theories of bereavement-related psychopathology. Yet, its role is still not well understood. This study examined associations of anxious and depressive avoidance behaviors with concurrently and prospectively assessed symptom-levels of prolonged grief disorder (PGD), depression, and posttraumatic stress disorder (PTSD).

DESIGN AND METHODS

Two hundred and ninety-one individuals, confronted with loss maximally three years earlier, completed self-report measures of anxious and depressive avoidance and emotional distress and again completed distress measures one year later.

RESULTS

Anxious and depressive avoidance were concurrently associated with symptom-levels of PGD, depression, and PTSD, even when controlling for the shared variance between both forms of avoidance and relevant socio-demographic and loss-related variables. Prospective analyses showed that baseline anxious avoidance predicted increased symptom-levels of PGD, depression, and PTSD one year later, among participants who were in their first year of bereavement but not among those who were beyond this first year. Baseline depressive avoidance was significantly associated with elevated PTSD one year later, irrespective of time since loss.

CONCLUSIONS

Both anxious and depressive avoidance are associated with different indices of poor long-term adjustment following loss. However, anxious avoidance seems primarily detrimental in the first year of bereavement.

Me After You

Individuals in ongoing romantic relationships incorporate attributes from their partner into their own self-concepts. However, little research has investigated what happens to these attributes should the relationship end. Across three studies, the present research sought to examine factors that predicted whether individuals retain or reject attributes from their self-concept that they initially gained during a relationship. We predicted that individuals would be more likely to reject attributes from their self post-dissolution if their ex-partner was influential in them adding those attributes to the self in the first place. However, we expected this effect to be moderated such that individuals who exerted greater, versus lesser, effort in maintaining relevant attributes would retain them as part of the self, regardless of whether the attribute originated from the partner. In addition, in two of our three studies, we explored the roles of partner influence, effort, and attribute rejection on individuals’ post-dissolution self-concept clarity.

Prolonged grievers: a qualitative evaluation of a support group intervention

OBJECTIVE

The aim of this project was to study prolonged grievers psychosocial processes and experience during participation in a group intervention and 6-8 weeks after discontinuation. The intervention in this study was a group therapy with the aim of getting in contact with their pain and loss and confronting and working with this loss.

METHODS

Data was collected by using diaries and tape-recorded interviews, analyzed with grounded theory. The participants were 11 females between the ages of 33 and 71.

RESULTS

The main process that was found in the qualitative data was: Ambivalence when struggling and learning through work and rest towards a balance. Sub-processes were: To share and be confirmed in the group through sense of cohesion; To dare/venture to discover problems and solutions; To react when you get emotionally involved, and to compare and discover.

SIGNIFICANCE OF RESULTS

This study gives insight into prolonged grievers' thinking, which is valuable knowledge. Rather than assuming that all individuals suffering from prolonged grief need the same treatment, we suggest that there should be a range of different therapies.

A Cognitive Attachment Model of prolonged grief: integrating attachments, memory, and identity

Prolonged grief (PG), otherwise known as complicated grief, has attracted much attention in recent years as a potentially debilitating condition that affects approximately 10% of bereaved people. We propose a model of PG that integrates processes of attachment, self-identity, and autobiographical memory. The paper commences with a discussion of the PG construct and reviews current evidence regarding the distinctiveness of PG from other bereavement related-outcomes. We then review the evidence regarding the dysfunctional attachments, appraisals, and coping styles that people with PG display. Recent evidence pertaining to the patterns of autobiographical memory in PG is described in the context of the self-memory system. This system provides a unifying framework to understand the roles of personal memories, identity, attachments, and coping responses in PG. The proposed model places emphasis on how one's sense of identity influences yearning, memories of the deceased, appraisals, and coping strategies, to maintain a focus on the loss. The model is discussed in relation to existing models of PG. The potential for shaping treatment strategies to shift perceptions of the self is then outlined. Finally, we outline future directions to test propositions stemming from the model and enhance our understanding of the mechanisms underlying PG.

Variables mediating the linkage between loss centrality and postloss psychopathology

Event centrality refers to the degree to which the memory of a negative life event is a core component of a person's identity. There is evidence that greater event centrality is associated with more intense psychopathology after different events, including the death of a loved one. This study sought to advance our understanding of the variables mediating the linkage between loss centrality and postloss psychopathology. Specifically, using multiple mediation analyses, we examined the role of a) intrusiveness of memories about the loss event, b) negative future cognitions and catastrophic misinterpretations of one's own grief reactions, and c) depressive avoidance and rumination in mediating the associations between loss centrality and postloss psychopathology. The outcomes showed that memory intrusiveness, the two cognitive variables, and the two behavioral strategies emerged as unique, independent mediators of the linkages between loss centrality and the indices of postloss psychopathology when controlling for the shared variance between the proposed mediators. The implications of these findings are discussed.