Prolonged grief: where to after Diagnostic and Statistical Manual of Mental Disorders, 5th Edition?

Rates of Prolonged Grief Disorder: Considering relationship to the person who died and cause of death

BACKGROUND

Prolonged Grief Disorder (PGD) was recently included in DSM-5-TR. The rate of PGD is known to vary according to a number of factors and little is known about how bereaved individuals view the diagnosis.

METHODS

This cross-sectional study assessed PGD rates using the Prolonged Grief-13-Revised (PG-13-R) among a large sample (n = 1137) of bereaved individuals, considering the relationship to the deceased and cause of death. It also investigated bereaved individuals' attitudes toward the diagnosis.

RESULTS

Overall, 34.3 % of the sample met PGD criteria. Bereaved parents had the highest rate (41.6 %), followed by bereaved spouses/partners (33.7 %) and siblings (29.4 %). According to cause of death, those bereaved by substance overdose had the highest rate (59.1 %), followed by homicide/suicide (46 %) and accidental (36 %). The majority of respondents (65-95.6 %) viewed their responses, as measured by the PG-13-R items, as normal, and 98.1 % agreed that their responses in general were normal. Fewer than 12 % reported that a PGD diagnosis would be helpful to them.

LIMITATIONS

This study used a self-selecting, non-representative sample that was predominantly female and white. Findings may or may not apply to more diverse groups and cannot be generalized. This study also used a self-report measure rather than a clinical interview.

CONCLUSIONS

In line with prior research, this study found higher rates of PGD in specific subgroups, including bereaved parents, spouses, and those who lost loved ones to substance overdose, homicide/suicide, or accidents. Bereaved individuals in this sample generally did not view receiving a diagnosis of PGD as helpful.

The cultural supplement: A new method for assessing culturally relevant prolonged grief disorder symptoms

Background

The new diagnosis of prolonged grief disorder (PGD) is both an opportunity and a challenge for researchers, clinicians, and bereaved individuals. The latest definition of PGD includes a refreshing and novel feature: the cultural caveat, i.e., clinicians must determine that the grief presentation is more severe and of longer duration than would be expected by an individual’s culture and context. Currently, there are no guidelines on how to operationalize the cultural caveat in mental health care settings.

Method

To respond to this important demand we have developed, piloted, and tested the cultural supplement module of the International Prolonged Grief Disorder scale (IPGDS). The cultural supplement aims to provide clinicians with a catalogue of culturally relevant symptoms of grief that indicate probable PGD alongside a simple framework for cultural adaptation for use in specific clinical settings.

Results

In this short report we outline the rationale and aim of the cultural supplement and provide a summary of our latest validation studies of the IPGDS with bereaved German-speaking, Chinese and Swiss migrant individuals. We also provide a step-by-step framework for adaptation of the cultural supplement that clinicians and researchers may use when working with different cultural groups.

Conclusion

To date, this is the first PGD questionnaire based on the ICD-11, and the first to include a cultural supplement that can be adapted to different contexts and groups. This cultural supplement will provide clinicians and researchers an easy-to-use assessment tool with the aim to improve the global applicability of the ICD-11 PGD definition.

Locked in grief: a qualitative study of grief among family members of missing persons in southern Sri Lanka

INTRODUCTION

The psychological and social issues experienced by family members of missing persons are different from normal grief following the death of a loved one. The term "Ambiguous loss" describes this psychological phenomenon. Ambiguous loss acts as a barrier to adjusting to grief, leading to symptoms of depression and intra and interpersonal relational conflicts. An in-depth phenomenological understanding of this subjective experience is important.

METHOD

A qualitative study was conducted among close family members of persons who had gone missing during the civil conflict and the 2004 tsunami in southern Sri Lanka following formal ethical approval from an university ethics review committee. Purposive and snowballing sampling methods were used to recruit the participants. Theoretical sample saturation was achieved with 24 family members of missing persons. Responders were mothers, fathers, wives, husbands, and siblings of missing individuals. In-depth interviews were recorded with the help of a semi-structured guide, after informed consent. The recordings were transcribed and coded by three independent investigators. The investigators through consensus arrived at the phenomenological themes and grounded them through reflexivity. The triangulation process involved cross-checking observational notes made by the interviewers and consulting the interviewees.

RESULTS

We interviewed 24 first degree relatives of missing individuals. Twenty-one of the interviewees were unsure about the fate of the missing individual, while three of them believed the missing individual to be dead. Of the 24 missing individuals, 20 were males and 18 had gone missing in civil conflicts and 6 in the Indian Ocean Tsunami. Six predominant phenomenological themes were identified. Those were lack of closure, hope, guilt, helplessness, perpetual suffering, and an emotional vacuum. These phenomenological experiences are highlighted by the interviewees through a range of utterances that hold profound cultural, social and emotional significance of unresolved and vacillating grief.

CONCLUSION

The highlighted phenomenology of grief in surviving family members of those who go missing following traumatic events demands a response from health and social services in every country that experiences disaster. The surviving loved one is 'locked in grief' indefinitely and future research on evidence-based interventions to overcome this predicament is warranted.

An Exploratory Cohort Study of the Association between the Level of Testosterone and Suicidal Ideation in Hospitalized Adolescent Females with Depression in China

BACKGROUND

To date, around 4 per 100,000 adolescents committed suicide within the 29 OECD countries. The suicidal behavior is related to psychological factors, genetics, neurobiology, and other biomarkers. The aim of this study was to examine risk factors for the development of suicidal ideation in adolescent females with depression, focusing on the relationship between different testosterone levels and suicidal ideation, in order to help develop strategies to intervene in suicidal behavior in female adolescents with depression.

METHOD

In this single-center prospective cohort study, we enrolled adolescent females with depression. We collected information on their baseline data, testosterone levels, symptom self-rating scale scores, suicidal ideation, non-suicidal self-injurious (NSSI) behaviours, and suicide attempts. We used multivariate logistic regression to identify risk factors for the development of suicidal ideation in adolescent females with depression.

RESULTS

A total of 113 hospitalized adolescent females were enrolled with a mean age of 13.5 (1.20). Among these patients, there were 86 (76.11%) subjects who suffered from suicidal ideation, 59 (52.21%) had NSSI and 23 (20.35%) had suicide attempt behavior. In the final model, higher level of testosterone (p=0.04) and higher age (p=0.02) were associated with the higher odds of having suicidal ideation.

CONCLUSION

In this exploratory cohort study, the emergence of suicidal ideation was common among adolescent females with depression. This study is consistent with the other studies. It shows that the age is a potential predictor for suicidal ideation in hospitalized adolescent females with depression.

Grief Reactions and Grief Counseling among Bereaved Chinese Individuals during COVID-19 Pandemic: Study Protocol for a Randomized Controlled Trial Combined with a Longitudinal Study

COVID-19 has caused nearly 4.3 million deaths all around the world. People who have experienced loss during this special period may find it difficult to adapt to life after loss, and may even suffer from prolonged grief disorder or other mental health problems. However, there is a huge gap of grief research in China, with almost no comprehensive grief intervention training system or very few professional grief consultants. Considering the large number of bereaved individuals who are suffering from grief and other mental health problems, it is significant to develop a suitable and effective intervention protocol immediately. This article illustrates a study protocol initiated by a Chinese university to investigate the mental health of bereaved individuals during the COVID-19 pandemic and train grief counselors to provide grief counseling to the bereaved, as well as to evaluate the effectiveness of the grief counseling. The method is as follows: (1) 300 psychological counselors will be recruited to attend the grief counseling training. Assessments will be conducted at three time points: baseline (T0), after the basic training (T1), and after the advanced training (T2); (2) 500 bereaved Chinese will be recruit to join the online survey and will be assessed at two time points with a six-month interval; and (3) a two-armed (grief counseling versus wait-list controls) RCT (random control trials) will be conducted with 160 bereaved individuals. Assessments will be conducted at three time points: before randomization (baseline, T0), at the post-counseling (T1), and three months after the post-counseling (T2). Primary outcomes will be assessed by the Prolonged Grief Questionnaire (PG-13), the 20-item PTSD Checklist for DSM-5 (PCL-5), the Depression Anxiety and Stress Scale (DASS-21), and the Posttraumatic Growth Inventory (PTGI). This research will help develop grief research and grief counseling in China, as well as provide professional mental health services for individuals who may suffer from grief-related disorders in the future.

The discursive transformation of grief throughout history

In recent decades, the phenomenon of grief, when you lose a loved one, has been the subject of exploration and discussion among researchers. Because of this, prolonged grief is now recognized as a possible mental disorder as the latest version of the diagnosis manual; 'International Classification of Diseases' (ICD-11) being published in 2018 is featuring a new diagnosis called 'prolonged grief disorder'. The commencement of this new disorder indicates a shift in the way grief is being articulated why the notion of rupture from the French philosopher Michel Foucault is applied as a philosophical approach in this paper. A Foucault-inspired discourse analysis has been prepared and by considering the issue historically and tracing how the concept of grief has been articulated in different time periods throughout history, the aim is to map out the discursive transformation that has taken place and to gain insight into how the societal context has supported and enabled this transformation. This paper takes a historical look back from the 1800s to present and identifies when changes can be observed in the way grief is being articulated. These changes or ruptures are identified in the work of Søren Aabye Kierkegaard, Sigmund Freud and Margaret Stroebe & Henk Schut who all must be assumed to have contributed significantly to how grief is perceived in various historical time periods. The discourse analysis identifies how prominent thinkers have articulated grief in each period and how today's perception of grief, as a possible mental disorder, both relates to these prominent thinkers but also reflects dominant societal values and ideologies.

Prolonged Grief, Posttraumatic Stress, and Depression Among Bereaved Parents: Prevalence and Response to an Intervention Program

Bereaved parents may experience diverse psychological symptoms. Possible interventions are not yet well established. In this study, the psychological symptoms of 323 bereaved parents (mean age = 39.97, SD = 7.21, 52.0% female), referred to a 4-week family-oriented rehabilitation (FOR) program, were assessed. The baseline assessments indicated that 160 (49.5%) parents showed symptoms of prolonged grief disorder (PGD). Complicated grief was indicated in 272 (84.2%), depression in 191 (59.1%), and posttraumatic stress disorder in 242 (74.9%) parents. Mothers were at higher risk of complicated grief ( p ≤ .001), depression ( p = .029), and posttraumatic stress disorder ( p = .004), compared to fathers. Significant remissions of symptoms between admission and discharge from the program are presented as symptoms of complicated grief, depression, and posttraumatic stress. The effect sizes ranged between d = 0.68 and 1.22. In addition, significantly fewer parents fulfilled PGD criteria on discharge from the FOR program ( p ≤ .001). The special FOR program appears promising with regard to improving the bereaved parents’ mental health.

Increased Amygdala Activations during the Emotional Experience of Death-Related Pictures in Complicated Grief: An fMRI Study

Complicated grief (CG) is associated with alterations in various components of emotional processing. The main aim of this study was to identify brain activations in individuals diagnosed with CG while they were observing positive, negative, and death-related pictures. The participants included 19 individuals with CG and 19 healthy non-bereaved (NB) individuals. Functional magnetic resonance imaging (fMRI) scans were obtained during an emotional experience task. The perception of death-related pictures differed between the CG group and the NB group, with a greater activation in the former of the amygdala, putamen, hypothalamus, middle frontal gyrus, and anterior cingulate cortex. Amygdala and putamen activations were significantly correlated with Texas Revised Inventory of Grief scores in the CG group, suggesting that the higher level of grief in this group was associated with a greater activation in both brain areas while watching death-related pictures. A significant interaction between image type and group was observed in the amygdala, midbrain, periaqueductal gray, cerebellum, and hippocampus, largely driven by the greater activation of these areas in the CG group when watching death-related pictures and the lower activation when watching positive-valence pictures. In this study, individuals with CG showed significantly distinct brain activations in response to different emotional images.

Unconfirmed death as a predictor of psychological morbidity in family members of disappeared persons

BACKGROUND

The 2004 tsunami, the civil conflict until 2009 and the youth insurrection in the late 1980s in Sri Lanka resulted in many persons being classified as 'missing' as they disappeared and were unaccounted for. Our aim was to compare the prevalence of major depressive disorder (MDD) and prolonged grief disorder (PGD) in families of disappeared individuals, who eventually received the mortal remains and those who did not.

METHOD

An ethically approved cross sectional study was conducted in a purposively selected sample after informed consent. Information on the circumstances of the family member going missing was gathered. Culturally adapted versions of the General Health Questionnaire and the Beck Depression Scale were administered. Those who screened positive were assessed by a psychiatrist on Diagnostic and Statistical Manual of Mental Disorders-5 criteria to arrive at a diagnosis.

RESULTS

Of 391 cases of disappearances studied, MDD (17.5% v. 6%) and PGD (22% v. 7%) were significantly higher in those who did not eventually receive the mortal remains of the disappeared person. Among those who did not receive the mortal remains, being unsure whether the disappeared person was dead or alive was highly predictive of MDD and PGD. Mothers and wives, older family members and those with a family history of mental illness were more vulnerable.

CONCLUSIONS

Family members of missing individuals unsure whether their loved one was alive or dead have higher psychological morbidity in the form of MDD and PGD.

Psychiatrists', psychologists' and counselors' attitudes regarding complicated grief

BACKGROUND

Complicated grief encompasses various presentations where aspects of grief do not become integrated into the bereaved person's life. Professionals' attitudes to complicated grief may impact how they engage with bereaved patients/clients. The aim of this study was to empirically examine the attitudes of mental health professionals, specifically psychologists, psychiatrists and counselor/psychotherapists, regarding complicated grief and to investigate any between profession-differences.

METHOD

Psychiatrists, counselor/psychotherapists and psychologists were recruited using publicly available databases managed by professional bodies. A total of 185 professionals (71.8% female), returned a questionnaire containing usable data (23.8% response rate).

RESULTS

Over two-thirds of the professionals (68.5%) supported the inclusion of complicated grief in diagnostic manuals while only a quarter (25.1%) thought that recognition of complicated grief might lead to the pathologization of 'normal' grief. The majority of respondents (83.0%) thought that diagnosing complicated grief would increase the likelihood of clients accessing support and there was no significant difference between the groups.

LIMITATIONS

Although the response rate compares favorably with other studies it is nonetheless somewhat lower than optimum, and it is possible that those who responded were more interested in bereavement and consequently, that the attitudes held by participants are different from those who did not participate.

CONCLUSION

The attitude to a diagnosis of complicated grief was more positive than the specialist literature suggests, with the benefits of having a diagnosis of complicated grief outweighing the risks of pathologization.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua

BACKGROUND

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

METHODS

Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

RESULTS

The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27).

CONCLUSIONS

Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua

PURPOSE

Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services.

METHODS

Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea.

RESULTS

The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (β = 0.16, P = 0.03), duration since displacement [(β = 0.10, P = 0.02)] and postmigration living difficulties (β = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified.

CONCLUSIONS

Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.

Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: a network analysis

BACKGROUND

Complicated and persistent grief reactions afflict approximately 10% of bereaved individuals and are associated with severe disruptions of functioning. These maladaptive patterns were defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as persistent complex bereavement disorder (PCBD), but its criteria remain debated. The condition has been studied using network analysis, showing potential for an improved understanding of PCBD. However, previous studies were limited to self-report and primarily originated from a single archival dataset. To overcome these limitations, we collected structured clinical interview data from a community sample of newly conjugally bereaved individuals (N = 305).

METHODS

Gaussian graphical models (GGM) were estimated from PCBD symptoms diagnosed at 3, 14, and 25 months after the loss. A directed acyclic graph (DAG) was generated from initial PCBD symptoms, and comorbidity networks with DSM-5 symptoms of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) were analyzed 1 year post-loss.

RESULTS

In the GGM, symptoms from the social/identity PCBD symptoms cluster (i.e. role confusion, meaninglessness, and loneliness) tended to be central in the network at all assessments. In the DAG, yearning activated a cascade of PCBD symptoms, suggesting how symptoms lead into psychopathological configurations. In the comorbidity networks, PCBD and depressive symptoms formed separate communities, while PTSD symptoms divided in heterogeneous clusters.

CONCLUSIONS

The network approach offered insights regarding the core symptoms of PCBD and the role of persistent yearnings. Findings are discussed regarding both clinical and theoretical implications that will serve as a step toward a more integrated understanding of PCBD.

Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability

A new mental health disorder, prolonged grief disorder (PGD), will be included in the 11th edition of the International Classification of Diseases (ICD-11). We provide a brief overview of the historical conceptualizations of disordered grief and the previous research efforts to assess and define this condition. We describe the new ICD-11 PGD symptom criteria and how they are conceptualized in terms of the World Health Organization's call for improved clinical utility. Finally, we review the research evidence for the clinical utility of the new ICD-11 PGD symptom structure and usability in the international arena.

Development and Psychometric Evaluation of a Revised Sense of Coherence Scale

Abstract. The present study introduces a revised Sense of Coherence (SOC) scale, a new conceptualization and operationalization of the resilience indicator SOC. It outlines the scale development and aims for testing its reliability, factor structure, and validity. Literature on Antonovsky’s SOC (SOC-A) was critically reviewed to identify needs for improving the scale. The scale was investigated in two samples. Sample 1 consisted of 334 bereaved participants, Sample 2 of 157 healthy controls. The revised SOC Scale, SOC-A, and theoretically relevant questionnaires were applied. Explorative and confirmatory factor analyses established a three-factor structure in both samples. The revised SOC Scale showed significant but discriminative associations with related constructs, including self-efficacy, posttraumatic growth, and neuroticism. The revised measure was significantly associated with psychological health indicators, including persistent grief, depression, and anxiety, but not to the extent as the previous SOC-A. Stability over time was sufficient. The study provides psychometric support for the revised SOC conceptualization and scale. It has several advantages over the previous SOC-A scale (unique variance, distinct factor structure, stability). The scale could be used for clinical and health psychological testing or research into the growing field of studies on resilience over the life span.

User acceptability of the diagnosis of prolonged grief disorder: How do professionals think about inclusion in ICD-11?

BACKGROUND

For the next edition of the International Statistical Classification of Diseases (ICD-11) it is proposed to include prolonged grief disorder as a new diagnosis. The diagnosis describes persistent intensive and disabling grief reactions to bereavement (WHO, 2016b). The aim of the present survey was to determine the extent to which the diagnosis is accepted by practitioners in the healthcare and psychosocial field.

METHODS

A total of 2088 German-speaking professionals in the fields of psychotherapy, psychology, counselling, medicine and palliative care completed the online survey.

RESULTS

42.4% of the participants felt that the advantages of including the diagnosis outweigh the disadvantages, 32.9% came to the conclusion that there are more disadvantages. The remaining 24.7% stated that advantages and disadvantages are balanced. The proposed classification as separate diagnosis was supported by 24.8%, while 60.0% preferred alternatives (e.g. as subtype of adjustment disorder). Furthermore, a time criterion of at least 12 months was voted for considerably more frequently (49.2%) than the proposed 6 months (11.3%). Objections were predominantly expressed with regard to pathologization of normal grief and to the difficulty of adequate crosscultural application of the diagnosis.

LIMITATIONS

Results are limited to predominantly German health-care professionals. The items did not undergo psychometric analyses.

CONCLUSIONS

The disagreement about the diagnosis found in specialist literature is also reflected in the responses by the participants. The present results provide stimulation for future questions and validation studies carried out as part of the ICD revision.

The latent nature of prolonged grief - A taxometric analysis: Results from a representative population sample

Individuals suffering from prolonged grief disorder (PGD) show severe grief reactions after the death of a significant other, even beyond a period of grieving that is within a person's cultural and religious context. In addition to this core element, PGD can manifest in various ways. Symptoms may include persistent preoccupation, intense emotional pain, or impairment in important life domains. The symptoms, furthermore, have to be of culturally or religiously inappropriate extent or severity, taking into account different norms of grieving. PGD is discussed as a distinct diagnostic category in the revision of the International Classification of Diseases (ICD-11). Nosology of PGD has been highly debated surrounding the suggested inclusion in the DSM-5, which had been declined due to insufficient evidence. This paper addresses the latent nature of PGD. Using a short form of the Inventory of Complicated Grief-Revised (ICG-R), we applied three popular taxometric methods: MAXEIG, MAMBAC and L-Mode. Data stemmed from a subsample of N = 1445 bereaved individuals that participated in a large representative German population survey (N = 2520). The analysis strongly indicated a dimensional latent structure of PGD. Implications of the conceptualization of PGD on a continuum are discussed, regarding measurement, diagnosis, etiology and future research.

Moving on: Factors associated with caregivers' bereavement adjustment using a random population-based face-to-face survey

BACKGROUND

Providing care at end of life has consequences for caregivers' bereavement experience. 'Difficulty moving on with life' is an informative and unbiased symptom of prolonged grief disorder. Predictors of bereaved caregivers' ability to 'move on' have not been examined across the population.

AIM

To identify the characteristics of bereaved hands-on caregivers who were, and were not, able to 'move on' 13-60 months after the 'expected' death of someone close.

DESIGN

The South Australian Health Omnibus is an annual, random, cross-sectional community survey. From 2000 to 2007, respondents were asked about providing care for someone terminally ill and their subsequent ability to 'move on'. Multivariable logistic regression models explored the characteristics moving on and not moving on.

SETTING

Respondents were aged ⩾15 years and lived in households within South Australia. They had provided care to someone who had died of terminal illness in the preceding 5 years.

RESULTS

A total of 922 people provided hands-on care. In all, 80% of caregivers (745) had been able to 'move on'. Closeness of relationship to the deceased, increasing caregiver age, caregiver report of needs met, increasing time since loss, sex and English-speaking background were significantly associated with 'moving on'. A closer relationship to the deceased, socioeconomic disadvantage and being male were significantly associated with not 'moving on'.

CONCLUSION

These results support the relevance of 'moving on' as an indicator of caregivers' bereavement adjustment. Following the outcomes of bereaved caregivers longitudinally is essential if effective interventions are to be developed to minimise the risk of prolonged grief disorder.

Risk and Resilience Factors Related to Parental Bereavement Following the Death of a Child with a Life-Limiting Condition

This paper reviews the theoretical and empirical literature on risk and resilience factors impacting on parental bereavement outcomes following the death of a child with a life-limiting condition. Over the past few decades, bereavement research has focussed primarily on a risk-based approach. In light of advances in the literature on resilience, the authors propose a Risk and Resilience Model of Parental Bereavement, thus endeavouring to give more holistic consideration to a range of potential influences on parental bereavement outcomes. The literature will be reviewed with regard to the role of: (i) loss-oriented stressors (e.g., circumstances surrounding the death and multiple losses); (ii) inter-personal factors (e.g., marital factors, social support, and religious practices); (iii) intra-personal factors (e.g., neuroticism, trait optimism, psychological flexibility, attachment style, and gender); and (iv) coping and appraisal, on parental bereavement outcomes. Challenges facing this area of research are discussed, and research and clinical implications considered.

Networks of loss: Relationships among symptoms of prolonged grief following spousal and parental loss

The death of a loved one can trigger a range of emotional, behavioral, motivational and cognitive reactions collectively labeled as "grief." There has been a recent resurgence of empirical interest in grief reactions, and there is now a general consensus that 7%-10% of bereaved individuals experience intense and chronic reactions termed Prolonged Grief (PG). However, there is ongoing debate about how best to conceptualize the construct. Recent studies have advanced this debate by applying a network, or causal systems approach. Whereas traditional views of psychopathology posit symptoms of disorders reflect the independent actions of latent entities, the network approach argues that the symptoms themselves interact to give rise to the disorder. A network conceptualization offers novel approaches to studying the mechanisms that contribute to PG. To date, however, research has focused only on spousal loss and only used a single archival data set. Therefore, in this paper we apply network analysis to examine relationships among PG symptoms in samples of individuals bereaved by loss of a spouse (Study 1, N = 193) and a parent (Study 2, N = 180). Participants completed the PG-13 and a measure of depression. A comparison test suggested the networks produced from each sample were not reliably different. The strongest link in both networks was between yearning and emotional pain. Meaninglessness was relatively central, whereas avoidance was peripheral in both networks. Findings are discussed with reference to theoretical models and the potential benefits a network approach may hold for understanding relationships between symptoms of PG. (PsycINFO Database Record

Normal grief and its correlates in Lubumbashi, an urban city in the Democratic Republic of Congo

Introduction

Grief is a universal experience faced at one time or another by most people during their lives. Response to grief and bereavement losses can lead to psychiatric disorders such as mood disorders, post traumatic responses, insomnia loss of appetite, anxiety, and depression. The aim of our study is to value in our community the physical and psychological complications of a normal grief.

Methods

We conducted a cross-sectional study from March 2012 to September 2012 in Lubumbashi, Democratic Republic of Congo. Two questionnaires, the Hamilton Anxiety Scale and the Beck Depression Inventory scale were used as screening tool. A snow ball sampling method was performed and the questionnaires were administered only to those who consented to participate in the study.

Results

A total of 78 subjects were included in the study of which 87.2% were aged between 14-50 years old. The majority of the subjects were female 65.4%, and about a quarter (28%) was unemployed. The main correlates of the grief reported in the present study were being treated as witchcraft or accused to be responsible of a death (68%), being rejected by family and not being allowed to inherit (32%). Being homeless was reported in 26%. The main psychological symptoms reported were psychological distress after 1 year (65%) and related physical health problems after the death (72%). Depression and mild anxiety were the most reported disorders, with respectively 92.3% and 74.4% of the subjects.

Conclusion

Grief in Lubumbashi is associated with a large number of psychological, social and health problems. Health problems such as gastric is, high blood pressure were often reported. Being accused of witchcraft remains the main social impact. Depression and anxiety were the most psychological problem associated with grief.

Treatment for complicated grief: state of the science and ways forward

PURPOSE OF REVIEW

There is increasing recognition that a minority of bereaved persons experiences persistent and disabling grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment research within a cognitive behavioral treatment framework, and establish a novel and systematic research agenda for complicated grief treatment.

RECENT FINDINGS

Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to definitions of complicated grief may threaten generalizability and clinical application of research findings. Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in targeting complicated grief. However, little is known about what, how, and for whom treatment works best.

SUMMARY

In light of these findings, we recommend systematic investigation of: what works best in complicated grief treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling studies; how it works, by conducting investigations on therapeutic theories and examining mediators of therapeutic change; and for whom it works, by examining potential moderators of treatment effects.

Visual function in autism spectrum disorders: a critical review

Studies have shown considerable evidence of visual dysfunction in autism spectrum disorders. Anomalies in visual information processing can have a major effect on the life quality of individuals with autism spectrum disorders. We summarise the hypotheses and theories underlying neural aetiologies and genetic factors that cause these disorders, as well as the possible influences of unusual sensory processing on the communications and behaviour characterised by the autistics. In particular, we review the impact of these dysfunctions on visual performance.

Cognitive behavioural therapy for psychopathology in relatives of missing persons: study protocol for a pilot randomised controlled trial

BACKGROUND

It is hypothesized that the grieving process of relatives of missing persons is complicated by having to deal with uncertainty about the fate of their loved one. We developed a cognitive behavioural therapy (CBT) with mindfulness that focuses on dealing with this uncertainty. In this article, we elucidate the rationale of a pilot randomised controlled trial (RCT) for testing the feasibility and potential effectiveness of this CBT for reducing symptoms of psychopathology in relatives of missing persons.

METHODS

A pilot RCT comparing participants of the CBT condition (n = 15) with waiting list controls (n = 15) will be executed. Individuals suffering from psychopathology related to the long-term disappearance of a loved one are eligible to participate. The treatment consists of eight individual sessions. Questionnaires tapping psychological constructs will be administered before, during, and after the treatment. The feasibility of the treatment will be evaluated using descriptive statistics (e.g., attrition rate). The primary analysis consists of a within-group analysis of changes in mean scores of persistent complex bereavement disorder from baseline to immediately post-treatment and follow-up (12 and 24 weeks post-treatment).

DISCUSSION

A significant number of people experience the disappearance of a loved one. Surprisingly, an RCT to evaluate a treatment for psychopathology among relatives of missing persons has never been conducted. Knowledge about treatment effects is needed to improve treatment options for those in need of help. The strengths of this study are the development of a tailored treatment for relatives of missing persons and the use of a pilot design before exposing a large sample to a treatment that has yet to be evaluated. Future research could benefit from the results of this study.

TRIAL REGISTRATION

NTR4732 (The Netherlands National Trial Register (NTR)).

Assessment of Emotional Experience and Emotional Recognition in Complicated Grief

There is substantial evidence of bias in the processing of emotion in people with complicated grief (CG). Previous studies have tended to assess the expression of emotion in CG, but other aspects of emotion (mainly emotion recognition, and the subjective aspects of emotion) have not been addressed, despite their importance for practicing clinicians. A quasi-experimental design with two matched groups (Complicated Grief, N = 24 and Non-Complicated Grief, N = 20) was carried out. The Facial Expression of Emotion Test (emotion recognition), a set of pictures from the International Affective Picture System (subjective experience of emotion) and the Symptom Checklist 90 Revised (psychopathology) were employed. The CG group showed lower scores on the dimension of valence for specific conditions on the IAPS, related to the subjective experience of emotion. In addition, they presented higher values of psychopathology. In contrast, statistically significant results were not found for the recognition of emotion. In conclusion, from a neuropsychological point of view, the subjective aspects of emotion and psychopathology seem central in explaining the experience of those with CG. These results are clinically significant for psychotherapists and psychoanalysts working in the field of grief and loss.

Efficacy of an integrative CBT for prolonged grief disorder: A long-term follow-up

BACKGROUND

While some intervention trials have demonstrated efficacy in treating prolonged grief disorder (PGD), data on long-term treatment effects are scarce.

METHODS

Fifty-one outpatients with clinically relevant prolonged grief symptoms, who had participated in a randomized controlled trial (RCT), were followed up, on average, 1.5 years after integrative cognitive behavioral therapy for PGD (PG-CBT). Initial assessment procedures were repeated, with PGD symptom severity as the main outcome and general mental health symptoms as secondary outcomes. As results in the immediate and delayed treatment groups (former wait list) were similar, the follow-up data were pooled.

RESULTS

Overall, 80% of the original ITT sample could be reached, that is 89% of the 37 treated participants, as well as 8 out of 14 participants who had dropped out of the RCT. The considerable short-term treatment success of PG-CBT was stable; pre to follow-up Cohen׳s d was large, with 1.24 in the ITT analysis and 2.22 for completers. The pre to post-improvement in overall mental health was maintained.

LIMITATIONS

Since the RCT wait list group had been treated after their waiting period as well, no controlled long-term outcomes are available.

CONCLUSIONS

PG-CBT proved to be effective in the longer run. In comparison to other RCTs on prolonged grief this is the largest sample followed up for this long.

The Medicalization of Bereavement: (Ab)normal Grief in the DSM-5

This article examines the recently published changes to eliminate the bereavement exclusion (BE) from the criteria for the diagnosis of major depression in the fifth edition of the Diagnostic and Statistical Manual (DSM-5). Numerous scholars and critics have expressed concerns by calling these changes a "medicalization" of grief. This article first considers the removal of the BE and then examines the macrolevel and microlevel consequences of this medicalization of grief, including overdiagnosis and overtreatment, a potential expanded market for pharmaceutical companies, and the loss of traditional and cultural methods of adapting to the loss of a loved one.

Insecure Attachment Styles and Complicated Grief Severity

A growing body of evidence supports links between attachment style, complicated grief (CG), and coping mechanisms in bereavement. In general, adults with insecure attachment styles are at an increased risk for developing CG when faced with the death of a loved one. However, much remains unknown regarding this complex interaction. This article provides a comprehensive synthesis of this literature base, offering future directions for attachment-informed CG research, clinical assessment, and treatment. The clear risk posed by an insecure attachment style on CG highlights the need for a proper and thorough assessment of attachment style as part of standard practice in grief-related treatment as well as the importance of meeting the unique clinical needs of the bereaved in consideration of one's attachment style. Further emphasis also should be placed on the mediating impacts of sociocultural variables, any of which could help to mitigate one's return to a level of preloss functioning.

Prolonged grief: setting the research agenda

BACKGROUND

Prolonged grief disorder is proposed for the International Classification of Diseases (ICD-11), though it was rejected as a diagnosis for DSM-5.

OBJECTIVE

This review outlines findings and defines important areas for future research viewed from a lifespan perspective.

RESULTS

The development and psychometric evaluation of measures for the new diagnosis is paramount, specifically for children and adolescents. Treatments need to be adapted for specific subgroups and research findings have to be disseminated into various professional settings.

[Trauma and stressor-related disorders: diagnostic conceptualization in DSM-5]

The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) includes a distinct diagnostic group of trauma and stressor-related disorders that has been set apart from anxiety disorders. From a perspective of adult psychiatry this new disorder category includes posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders. The PTSD is based on narrower trauma criteria that focus on acute life-threatening situations, serious injury, or sexual violence by way of direct confrontation, witnessing or indirect confrontation. Indirect confrontation, however, is reserved only for violent or accidental events that occurred to close family members or friends. The former A2 criterion of an intense emotional reaction to trauma has been removed. A deliberately broad approach to clinical PTSD phenomenology has created an empirically driven new cluster of persistent negative alterations in cognition and mood due to experiencing traumatic events. The ASD has been reconceptualized as an intense stress syndrome with a clear need of acute treatment during the early course after traumatic exposure. Adjustment disorders continue to emphasize maladaptive emotional and behavioral responses to unspecific, non-traumatic stressors in an intensity that is beyond social or cultural norms. Neither complex PTSD nor prolonged grief disorders have received an independent diagnostic status within DSM-5. With respect to stress-related disorders major divergences between DSM-5 and the future International Classification of Diseases 11 (ICD-11) are to be expected.

Treatment of complicated grief in elderly persons: a randomized clinical trial

IMPORTANCE

Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population.

OBJECTIVE

To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline.

INTERVENTIONS

Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly.

MAIN OUTCOMES AND MEASURES

Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale.

RESULTS

Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age.

CONCLUSIONS AND RELEVANCE

Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01244295.