Peritraumatic dissociation after loss: latent structure and associations with psychopathology

Do prolonged grief disorder symptoms predict post-traumatic stress disorder symptoms following bereavement? A cross-lagged analysis

BACKGROUND

Bereavement can precipitate different forms of psychopathology, including prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptoms. How these symptoms influence each other is unclear. The aim of this study was to examine the temporal relationship of symptoms of PGD and PTSD following bereavement.

METHODS

We included 204 individuals, confronted with the loss of a loved one within the past year, who completed self-report measures of PGD and PTSD and again completed these measures one year later. We conducted a cross-lagged analysis to explore cross-lagged and autoregressive relationships.

RESULTS

A significant cross-lagged relationship was found between PGD symptoms at time point 1 (T1) and PTSD symptoms at time point 2 (T2) (β=0.270, p<0.001). Furthermore, PGD symptoms at T1 predicted PGD symptoms at T2 and PTSD symptoms at predicted PTSD symptoms at T2 (β=0.617 and β=0.458, ps<0.001, respectively). In addition, PGD and PTSD symptoms were significantly correlated on both time points.

CONCLUSIONS

We found that PGD symptoms predict PTSD symptoms after a loss. Potentially, this could help to design new strategies and interventions for bereaved individuals. Additionally, PGD symptom levels predicted PGD symptom levels one year later, independently of the PTSD levels. This finding adds to the accumulating evidence that PGD is a distinct disorder.

The Mediating Role of Integration of Loss in the Relationship Between Dissociation and Prolonged Grief Disorder

OBJECTIVE

Findings from the field of trauma have shown that there is a negative relationship between dissociation and integration of loss into the self-narrative. At the same time, an increasing amount of literature on grief has stressed the importance of an integrated self-narrative in the grieving process. Accordingly, the current study examined the possible mediating role played by the extent to which individuals have integrated their loss into their self-narrative in the relationship between dissociation and symptoms of prolonged grief disorder (PGD).

METHOD

The Prolonged Grief Disorder Scale (PGD-13), the Outcome Questionnaire, the Integration of Stressful Life Experiences Scale, the Dissociative Experiences Scale, and a sociodemographic questionnaire were administered to 66 individuals who had lost a loved one.

RESULTS

The hypothesized mediation model of integration was confirmed.

CONCLUSION

The effect of people's dissociative tendencies on their PGD symptoms seems to occur via the impairment of their ability to integrate the memory of their loss into their general autobiographical memory. Empirical and clinical implications are discussed.

Therapeutic Assessment With a Client With Persistent Complex Bereavement Disorder: A Single-Case Time-Series Design

This article presents the results of a study into the effectiveness of therapeutic assessment (TA), a brief form of intervention that incorporates the results of assessment findings into psychological treatment. The history of Anthony, a man who reported symptoms of persistent complex bereavement disorder (PCBD), associated with major depression disorder (MDD) and post-traumatic stress disorder (PTSD), is presented. After his parents’ deaths, Anthony became detached from reality, lost all pleasure in his everyday life, and found it impossible to overcome the devastating feelings related to the loss. Following TA principles, the assessor created a supportive and empathic relationship with Anthony and helped him attain his goals for the assessment. The assessment was monitored using a single-case quasi-experimental design with time-series analysis. Results of this study revealed a specific trajectory of Anthony’s self-reported symptoms and a statistically significant trend toward improvement in severity at the end of the TA. This case study highlights the utility and efficacy of TA in helping clients process traumatic losses and complicated bereavements.

Peritraumatic reactions in relation to trauma exposure and symptoms of posttraumatic stress in high school students

Background: Exposure to traumatic events is clearly associated with a diversity of subsequent mental health problems, with posttraumatic stress disorder (PTSD) as the most prevalent disorder. Epidemiologically, trauma exposure rates are more prevalent than PTSD, indicating that most trauma victims do not develop PTSD. More knowledge is needed to understand the development of the different posttraumatic pathways including the significance of pretraumatic, peritraumatic and posttraumatic risk factors. Objective: To study peritraumatic reactions in relation to trauma exposure and symptoms of posttraumatic stress and to enhance our understanding of peritraumatic reactions as mediators between trauma and later symptomatology. Method: The study was composed of a representative community sample of 5332 second year high school students (mean age 17.3 years) who completed the Juvenile Victimization Questionnaire (SAQ/JVQ), Trauma Symptom Checklist for Children (TSCC) and answered questions about peritraumatic reactions. Mediation effects of peritraumatic reactions on the trauma exposure relationship to symptoms was tested using the PROCESS macro for SPSS. Results: Traumatic events are common (84.1%) and are accompanied in three-quarters of the students with at least one form of peritraumatic reaction. Peritraumatic reactions, especially peritraumatic dissociative reactions, mediate the relationship between trauma exposure and symptoms, and gender moderates the effect of peritraumatic dissociation. This moderating effect was found to be larger for boys than for girls, indicating gender differences in response to trauma. Conclusions: The results indicate the need to screen for peritraumatic reactions as early as possible after a traumatic event in order to identify those at risk for PTSD.

Peritraumatic Distress and Dissociation in Prolonged Grief and Posttraumatic Stress Following Violent and Unexpected Deaths

This study examined associations between the violence of a loss and the suddenness of a loss and symptom levels of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) after the death of a loved one. A further aim was to investigate whether peritraumatic distress (i.e., fear, helplessness, and horror) and peritraumatic dissociation mediate the emotional impact of violent losses and unexpected losses. We obtained self-reported data from 265 individuals bereaved in the previous 3 years by losses due to violent causes (17%) or illness (83%). Outcomes showed that participants who experienced violent losses (due to homicide, suicide, or accident) reported more PGD symptoms and PTSD symptoms compared to those confronted with illness loss. In this latter group, greater perceived unexpectedness was positively associated with PGD severity and PTSD severity. Multiple mediation analyses showed that the impact of violent loss and unexpectedness of the loss on PGD severity and PTSD severity was fully mediated by peritraumatic distress and dissociation; peritraumatic helplessness and peritraumatic dissociation (but not peritraumatic fear and horror) emerged as unique mediators. Findings suggest that both violent and unexpected losses exacerbate postloss psychopathology, which is at least partially because of such losses yielding more intense acute helplessness and dissociative responses.

[Stress-induced dissociation in the trajectory of schizotypal personality disorder (on the model of nosogenias in oncologic patients)]

OBJECTIVE

Stress-induced dissociative disorders (DD) have high prevalence in psychiatry and general medicine but the psychopathological differentiation of DD and contribution of personality disorders in their development is less studied. Authors conducted a clinical analysis of stress-induced persistent DD and underlying constitutional abnormalities.

MATERIAL AND METHODS

It was examined 20 patients with DD induced by the stress caused by a cancer diagnosis, including 10 patients of detachment-dissociation group (denial of the disease, non-compliance) and 10 patients with compartment-dissociation (complete or partial detachment of stress response components (emotional, cognitive), adequate compliancy). The groups were matched for demographic and cancer characteristics. Clinical and psychological methods were used.

RESULTS AND CONCLUSION

DD are secondary psychopathological phenomena. Detachment-dissociation develops in the frames of schizophrenic nosogenic reactions based on overvalued ideas of somatic well-being (or complete recovery from cancer) and has some similarities to schizotypal personality disorder. Compartment-dissociation develops within the limits of neurotic nosogenic reactions on the basis of binary psychogenic complexes - pathology of the imagination ("the beautiful indifference") concomitant to anxiety about the real illness and is similar to hysterical personality spectrum.

Treating complicated grief

IMPORTANCE

The death of a loved one is one of life's greatest, universal stressors to which most bereaved individuals successfully adapt without clinical intervention. For a minority of bereaved individuals, grief is complicated by superimposed problems and healing does not occur. The resulting syndrome of complicated grief causes substantial distress and functional impairment even years after a loss, yet knowing when and how to intervene can be a challenge.

OBJECTIVE

To discuss the differential diagnosis, risk factors for and management of complicated grief based on available evidence and clinical observations.

EVIDENCE REVIEW

MEDLINE was searched from January 1990 to October 2012. Additional citations were procured from references of select research and review articles. Available treatment studies targeting complicated grief were included.

RESULTS

A strong research literature led to inclusion of complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (termed persistent complex bereavement disorder as a subtype of other specified trauma and stressor-related disorders), although it is a condition for which more research is formally recommended, and there is still ongoing discussion about the optimal name and diagnostic criteria for the disorder. Reliable screening instruments are available, and the estimated prevalence rate is 7% of bereaved people. Randomized controlled data support the efficacy of a targeted psychotherapy including elements that foster resolution of complicating problems and facilitate the natural healing process. Preliminary studies suggest antidepressant medications may be helpful.

CONCLUSION AND RELEVANCE

Individuals with complicated grief have greater risk of adverse health outcomes, should be diagnosed and assessed for suicide risk and comorbid conditions such as depression and posttraumatic stress disorder, and should be considered for treatment.

Periloss dissociation, symptom severity, and treatment response in complicated grief

BACKGROUND

Complicated grief (CG) is a bereavement-specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e., periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD-adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop-out rate.

METHODS

PLD data collected as part of a randomized controlled trial of two loss-focused psychotherapy approaches for CG were examined. Treatment-seeking individuals with primary CG (n = 193) were assessed for PLD at the initial visit, 95 of whom were randomized and completed at least one treatment session.

RESULTS

The PLD-adapted Peritraumatic Dissociative Experiences Questionnaire was found to be internally consistent (α = 0.91) with good convergent and divergent validity. After controlling for age, gender, time since loss, and current comorbid psychiatric diagnosis, self-reported PLD was associated with greater CG symptom severity (P < .01). However, contrary to our hypotheses, after controlling for age, baseline symptoms severity, psychiatric comorbidity, and treatment arm, PLD was predictive of better treatment response (P < .05) and lower study discontinuation (P < .01).

CONCLUSIONS

PLD may be useful in identifying individuals at risk for CG and those who might respond to psychotherapy. Additional research should investigate the relationship of PLD with treatment outcome for different treatment approaches, and whether PLD prospectively predicts the development of CG.