ICD-11 Prolonged Grief Disorder Criteria: Turning Challenges Into Opportunities With Multiverse Analyses

Validity of the TGI-SR+ in Francophone populations: Insights from Quebec and Belgium

The loss of a significant person can lead to a broad spectrum of responses. While most individuals gradually recover within a year, a minority develop Prolonged Grief Disorder (PGD). The Traumatic Grief Inventory Self-Report Plus (TGI-SR+) was recently developed to ensure that the original scale (TGI-SR) still accurately assesses PGD in line with the latest diagnostic standards of the DSM-5-TR and ICD-11. This study aimed to validate the TGI-SR+ within two French-speaking cohorts: 276 French-Canadian and 469 Belgian participants. Data were collected through an online survey in 2022. Confirmatory factor analysis resulted in a 4-factor model for the TGI-SR+ total scale, but high inter-item correlations favored a 1-factor solution. A 1-factor model was found for the DSM-5-TR and ICD-11 PGD scores. Convergent validity with mental health disorder, depression, and post-traumatic growth, and known-group validity were confirmed. The findings endorse the TGI-SR+ as a valid tool for detecting potential PGD.

A comprehensive investigation of comorbidities of prolonged grief disorder in a bereaved inpatient psychiatric sample

Prolonged Grief Disorder (PGD) was recently added to ICD-11 and DSM-5-TR. Depression and Posttraumatic Stress Disorder (PTSD) are frequent comorbidities, but findings regarding comorbid somatoform disorder and personality disorders remain mixed and studies with severely impaired patients are scarce. It was therefore the objective of the present study to examine comorbidities of PGD in a bereaved inpatient psychiatric sample. We assessed N = 101 bereaved inpatients in a psychiatric hospital with clinical interviews and self-report questionnaires. We calculated differences between patients with and without a PGD-diagnosis in number and type of comorbid disorders as well as associations between the severity of PGD and comorbid disorders. On average, patients had 2.53 comorbid psychiatric diagnoses. Patients with and without a PGD-diagnosis did not differ in their number of comorbid diagnoses, and there was no association between number of comorbid diagnoses and PGD-severity. However, patients with PGD, had significantly more comorbid diagnoses belonging to neurotic-, stress-related and somatoform disorders of the ICD-10. Patients with PGDICD-11 also had significantly higher scores in self-reported depressive, PTSD-, and somatoform symptoms, as well as the negative affectivity personality domain than those without a PGD diagnosis. To the best of our knowledge, this is the first study to provide insights into comorbidities of PGD in a bereaved inpatient psychiatric sample. It highlights the importance of considering PGD symptoms as part of the complaints of bereaved patients to achieve a tailored treatment approach. Future longitudinal studies are needed to unveil relationships between pre-existing mental disorders and PGD.

Psychometric Evaluation of the Traumatic Grief Inventory-Self Report Plus (TGI-SR+) in Chinese Bereaved People

OBJECTIVE

The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) measures the most recent prolonged grief disorder (PGD) symptom sets defined in the 11th edition of the International Statistical of Diseases and Related Health Problems (ICD-11) and the text revision of the fifth edition of the Diagnostical and Statistical Manual of Mental Disorders (DSM-5-TR). However, the TGI-SR+ has not yet been translated and validated in Chinese. This study aims to evaluate the psychometric properties of the Chinese translation of the TGI-SR+.

METHODS

We examined the Chinese TGI-SR+'s factor structure, internal consistency, convergent validity, discriminant validity, known-groups validity, and optimal clinical cut-off scores in 443 Chinese bereaved adults.

RESULTS

Confirmatory factor analyses showed that the two-factor models showed the best fit for the Chinese TGI-SR+ items assessing ICD-11 and DSM-5-TR prolonged grief symptoms. Items assessing ICD-11 and DSM-5-TR prolonged grief symptoms demonstrated good internal consistency. Associations of TGI-SR+ scores with symptom levels of prolonged grief (assessed by the International Prolonged Grief Disorder Scale), posttraumatic stress, anxiety, and depression supported convergent and discriminant validity. Associations with background/loss-related variables provided evidence for known-groups validity. Cut-off points for probable ICD-11 PGD (liberal scoring rule), probable ICD-11 PGD (conservative scoring rule), and probable DSM-5-TR PGD were ≥67, ≥75, and ≥68, respectively.

DISCUSSION

The Chinese TGI-SR+ appears to be a reliable and valid measure to assess prolonged grief symptoms per ICD-11 and DSM-5-TR among Chinese bereaved adults.

Prevalence and correlates of ICD-11-based prolonged grief disorder in a representative Slovakian sample of recently bereaved adults

Background: Prolonged Grief Disorder (PGD) has recently been included in both the ICD-11 and DSM-5-TR diagnostic manuals. Studying its prevalence and correlates across cultures is vital for more effective identification, treatment, and prevention.Objective: This study aimed to examine prevalence rates of ICD-11-based PGD, in a representative Slovakian sample in response to deaths of loved ones occurring during the previous year. Further aims were to examine the factor structure of PGD symptoms and correlates of summed PGD item scores and PGD 'caseness'.Method: Self-reported data on PGD, depression, anxiety, alcohol use, and descriptive characteristics were gathered from a representative sample of the Slovak population (N = 319).Results: Data were gathered from N = 1853 people; 319 participants (17.2%) reported a loss in the past year. The prevalence of probable PGD among these bereaved participants was 1.99% for recent losses (<6 months, n = 151) and 7.75% for more distant losses (6-12 months, n = 130). The most frequently endorsed symptoms included longing/yearning for the deceased, sadness, denial/unrealness, and difficulty accepting the death. PGD symptoms had a unitary factor structure which was consistent for subsamples bereaved 1-5 and 6-12 months. The severity of PGD varied with kinship. Depression and anxiety, but not alcohol misuse, were associated with PGD severity and PGD caseness.Conclusions: These findings underscore that a significant group of people develop PGD between 6-12 months following a loss. This emphasises the need for targeted psychological interventions.

Perceived social support and symptoms of prolonged grief after a drug-related death

Social network support can be important when adjusting to life after the death of a close family member or friend. However, research has yielded inconclusive results regarding the relationship between social support and complicated grief reactions. Persons bereaved after a drug-related death (DRD) are a group of people who are at high risk of developing bereavement complications. Based on a Norwegian study on DRD bereaved close family members and friends (n = 250), this study examines the association between perceived social support, societal stigma, own social withdrawal, and prolonged grief symptoms (PGS). Own social withdrawal predicts the most variance in PGS symptoms: 8%, perceived social support: 3%, and societal stigma: 1%. Together the three focal variables explain 17.5% of variations in PGS. Results from the study point to the importance of social network support, which could reduce bereavement complications after a DRD.

The Grief Debate, the DSM, and Clinical Practice

There has been an ongoing debate regarding grief, whether it may be at times pathological, and whether it is different from depression. This article addresses those questions by tracking the changing course of the Diagnostic and Statistical Manuals of Mental Disorders (DSMs) since DSM-III and by reviewing the debate concerning grief and depression. At the time when DSM-III was being prepared in the late 1970s (it was published in 1980), there was a concern that normal bereavement (or grief) was being diagnosed as major depression. To address this concern, the editors of DSM-III added a category of "uncomplicated bereavement." The fourth edition of the DSM (DSM-IV), published in 1994, then followed by a minor change. However, the editors of DSM-5 decided to eliminate the bereavement exclusion entirely. Their concern was simply whether the individual did or did not suffer from major depression. Since an individual might not warrant a diagnosis of major depression but might still be experiencing grief, the DSM discussion leads directly into the question of whether grief-later called prolonged grief disorder-and depression are separate conditions. Advocates for prolonged grief disorder maintained that grief is different from depression but that patients may present with a mix of grief and depressive symptoms that are clinically difficult to distinguish. Advocates of separate conditions have in fact developed an inventory of symptoms that identify prolonged grief disorder. However, inasmuch as a typical grief presentation will include depressive symptoms, the clinical challenge is to distinguish prolonged grief disorder and major depression, as well as to distinguish both from normal grief. Given the temporal limits of an average consultation, this article argues that making the required distinctions is an unrealistic expectation. Finally, researchers have developed specific treatment programs for prolonged grief disorder, but a conflict between the 2 primary researchers involved and the generalities in which the programs are phrased have led to the suggestion of a different approach to treatment that replaces generalities with a person-centered approach.

Prolonged grief disorder in an inpatient psychiatric sample: psychometric properties of a new clinical interview and preliminary prevalence

BACKGROUND

Prolonged Grief Disorder (PGD) was newly included in the ICD-11 and DSM-5-TR. It is not yet part of the standard assessments in many healthcare systems, including psychiatric wards. Because disordered grief is associated with suicidality, sleep problems and substance use disorders, an investigation into PGD in psychiatric inpatients is warranted.

METHOD

We interviewed N = 101 psychiatric inpatients who were admitted to the open psychiatric wards and the day hospital of a German psychiatric hospital and who had lost a person close to them. Assessments comprised clinical interviews and self-report instruments covering PGD and other mental disorders. We specifically developed the International Interview for Prolonged Grief Disorder according to ICD-11 (I-PGD-11) for the study and examined its psychometric properties.

RESULTS

The prevalence rate of PGD among bereaved patients according to ICD-11 was 16.83% and according to DSM-5-TR 10.89%. The I-PGD-11 showed good psychometric properties (Mc Donald's ω = 0.89, ICC = 0.985). Being female, having lost a child or spouse, and unnatural or surprising circumstances of the death were associated with higher PGD scores.

TRIAL REGISTRATION

Approval was obtained by the ethics committee of the of the Goethe University Frankfurt (2021-62, 2023-17) and the Chamber of Hessian Physicians (2021-2730-evBO). The study was preregistered ( https://doi.org/10.17605/OSF.IO/K98MF ).

LIMITATIONS

We only assessed inpatients of one psychiatric clinic in Germany, limiting the generalizability of our findings.

CONCLUSION

The present study underlines the importance of exploring loss and grief in psychiatric inpatients and including PGD in the assessments. Given that a significant minority of psychiatric inpatients has prolonged grief symptoms, more research into inpatient treatment programs is needed.

Prolonged grief disorder symptomology in three African countries: A network analysis and comparison

Background

Bereavement is a globally prevalent life stressor, but in some instances, it may be followed by a persistent condition of grief and distress, codified within the 11th edition of the International Classification of Diseases (ICD-11) as prolonged grief disorder (PGD). Network analysis provides a valuable framework for understanding psychological disorders at a nuanced symptom-based level.

Aim

This study novelly explores the network structure of ICD-11 PGD symptomology in a non-Western sample and assesses the replication of this across three African country sub-samples in these data.

Methodology

Network models were estimated using the "Inventory of Complicated Grief-Revised" in a sample of trauma-exposed individuals who experienced bereavement throughout life (N = 1,554) from three African countries (Ghana, n = 290; Kenya, n = 619; Nigeria, n = 645). These networks were statistically evaluated using the network comparison test.

Results

It was found that "Feelings of Loss" and "Difficulty moving on" were the most central symptoms in the combined sample network. These findings were largely consistent for the Ghana and Nigeria sub-samples, however, network structure differences were noted in the Kenya sub-sample.

Conclusion

The identified PGD network highlights particular indicators and associations across three African samples. Implications for the assessment and treatment of PGD in these cultural contexts warrant consideration.

Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria

Background

Prolonged grief disorder (PGD) was recently included as a disorder in the ICD-11 and DSM-5-TR. Although both classification systems use the same name, the criteria content, and diagnostic approach vary. This study aimed to estimate the respective prevalence of PGDICD-11 and PGDDSM-5-TR and examine the diagnostic agreement while varying the diagnostic algorithm of PGDICD-11 (bereavement vs. symptom period; varying number of accessory symptoms).

Methods

A representative sample of the German general population (N = 2,509) was investigated, of which n=1,071 reported the loss of a close person. PGD symptoms were assessed with the Traumatic Grief Inventory - Self Report Plus (TGI-SR+).

Results

The point prevalence of PGD among the bereaved varied between 4.7%-6.8%, depending on the criteria and diagnostic algorithm. The prevalence of PGDDSM-5-TR was significantly lower than the prevalence of PGDICD-11. The diagnostic agreement between both criteria sets was substantial and increased after the number of accessory symptoms for PGDICD-11 was increased from one to three. The most common symptoms were intrusive thoughts/images related to the deceased person, longing for the deceased person, and difficulty accepting the loss.

Conclusion

The results demonstrate that the prevalence of PGD significantly varies depending on the application of the diagnostic algorithm and criteria. PGD affects a substantial proportion of the general population and should be addressed by healthcare providers. However, applying the minimum ICD-11 criteria could lead overestimating the prevalence. Therefore, further harmonizing the ICD-11 and DSM-5-TR criteria and diagnostic algorithm for PGD seems appropriate.

Psychometric properties of the PG-13-R scale to assess prolonged grief disorder among bereaved Iranian adults

OBJECTIVES

The PG-13-Revised (PG-13-R) is a self-report measure to assess prolonged grief disorder (PGD) in terms of Diagnostic and Statistical Manual of Mental Disorders, fifth revision, Text Revision. This measure has been shown to yield good psychometric properties in Western samples. This study aimed to evaluate the psychometric properties of the Persian PG-13-R.

METHODS

Three hundred forty-seven individuals (209 women and 138 men) fully completed the scales. The participants were recruited using convenience sampling. The confirmatory factor analysis (CFA), convergent and divergent validity, and reliability of the Persian version of the PG-13-R were evaluated.

RESULTS

CFA results of a unidimensional model support the construct validity of this version of the PG-13-R. The results of this study demonstrated that this version of the PG-13-R has internal consistency reliability (omega coefficient of 0.93), and the test-retest reliability with an interval of 6 weeks was 0.89. The convergent and divergent validity was shown with significant correlations between the PG-13-R and measures of depression, PTSD, functional impairment, and hope.

SIGNIFICANCE OF RESULTS

Overall, the Persian version of the PG-13-R showed good psychometric properties in the Iranian population.

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

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

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

ABSTRACT

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

Operationalization, implications and correlates of the cultural deviance criterion for ICD-11 and DSM-5 prolonged grief disorder

Prolonged Grief Disorder (PGD) is included in ICD-11 and DSM-5-TR and includes a requirement of cultural deviance. This study examined endorsement rates and factors associated with endorsement of this criterion among Danish bereaved spouses (n = 425) and their adult children (n = 159) four years post-loss. In total, 7.5% (n = 44) participants endorsed this criterion. Both including and excluding the criterion, the prevalence rates for probable DSM-5-TR PGD were 1.4% (n = 8) and 1.7% (n = 10), respectively and for probable ICD-11 PGD were 1.4% (n = 8) and 2.2% (n = 13), respectively. Age and gender of the deceased, age of the bereaved, greater grief severity, and comorbid psychopathology were positively associated with endorsement of the criterion. Findings demonstrate low endorsement of the cultural deviation criterion, that its inclusion excludes several potential PGD cases, and unanticipated associations with several factors raise questions about the criterion's validity.

Psychometric evaluation of the Swedish Traumatic Grief Inventory Self-Report Plus (TGI-SR+) in bereaved parents

The International Classification of Diseases Eleventh Edition (ICD-11), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), now include prolonged grief disorder (PGD). Since criteria for PGD in both classification systems differ from prior proposed grief disorders and each other, the validation of a single instrument to screen for prolonged grief (PG) symptoms of both new diagnoses is critical for bereavement research and care. Therefore, we evaluated the psychometric properties of the Swedish version of the Traumatic Grief Inventory Self-Report Plus (TGI-SR+). Two-hundred and forty-eight bereaved parents completed questions about sociodemographic and loss-related variables, the TGI-SR+, and symptom measures of post-traumatic stress (PTS), depression and an older measure of PG symptoms, the Prolonged Grief Disorder-13 (PG-13). Confirmatory factor analyses showed that a one-factor model best fit DSM-5-TR and ICD-11 PG symptoms and the analyses of the internal consistency and inter-item correlations showed that these symptoms could be reliably assessed. In support of convergent validity, DSM-5-TR and ICD-11 PG symptoms correlated with symptoms of PTS, depression and PG assessed with the PG-13. In support of known-groups validity, DSM-5-TR and ICD-11 PG symptoms were higher among lower educated (vs. higher educated) participants and related negatively to time since loss. ROC analyses showed optimal cut-off score of ≥71 and ≥72 to determine probable caseness for DSM-5-TR and ICD-11 PGD, respectively. Results support the reliability and validity of the Swedish TGI-SR+ as a screening instrument for PG in research and bereavement care.

Grief in family carers of people living with dementia: A systematic review

OBJECTIVES

Grief research in family carers of people with dementia has increased. We aimed to report the prevalence of pre-death and post-death grief and to synthesize associated factors and the relationship between pre-death factors and post-death grief and services used to manage grief.

DESIGN

(Prospero protocol: CRD42020165071) We systematically reviewed literature from PsycINFO, MEDLINE, CINAHL, and ASSIA until April 2020. Effectiveness of intervention data and studies not written in English were excluded; qualitative studies were additionally excluded during study selection. Study quality was assessed using the Mixed Methods Appraisal Tool. Evidence was narratively summarized.

PARTICIPANTS

Family non-paid carers of somebody with any dementia type.

MEASUREMENTS

Validated measures of pre-death and/or post-death grief.

RESULTS

We included quantitative data from 55 studies (44 rated as high quality). Most included solely spouse or adult child carers. Forty-one studies reported pre-death grief, 12 post-death grief, and 6 service use; eight were longitudinal. 17% met the Prolonged Grief Disorder criteria pre-death (n = 1) and 6-26% (n = 4) of participants met the Complicated Grief criteria post-death. Being a spouse, less educated, caring for somebody with advanced dementia, and greater burden and depression were associated with higher pre-death grief. Lower education level and depression were predictive of higher post-death grief. Pre-death factors found to influence post-death grief were grief and depression. Limited service use evidence was reported.

CONCLUSION

Awareness of characteristics which increase the likelihood of higher grief can help identify those in need of support. Future research should focus on what supports or services are beneficial to grief experiences.

Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies

Prolonged grief disorder has recently been added to the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders 5, Text Revision. This historical development is often presented as a linear process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. The present contribution provides an overview of work contradicting this dominant narrative. First, I show that the developmental history of prolonged grief disorder has been nonlinear and that this yields questions on generalizability and problems with measurement of the newest criteria sets. Second, I highlight an important gap in the validity evidence: the distinction of prolonged grief disorder from normal grief. Third, I discuss concerns relating to the societal effects of the inclusion of prolonged grief disorder in diagnostic handbooks, including the medicalization of grief, development and adverse effects of pharmacotherapy and stigmatization. A more realistic, balanced view on the history, validity and societal impact of prolonged grief disorder appears appropriate. I recommend stringent validation of assessment instruments for prolonged grief disorder, convergence of criteria-sets, closing gaps in validity evidence and developing strategies to mitigate the negative effects of grief diagnoses.

Prolonged Grief Disorder: Recognition and Provision of Care Along the Bereavement Journey

ABSTRACT

Prolonged grief disorder (PGD), sometimes called complicated grief, can impair a person's ability to function in daily life and elevate the risk for physical and mental decompensation. In 2022, PGD was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), increasing the potential for treatment with interpersonal therapy and medication. Nurses with knowledge of the signs and risk factors of PGD can identify people experiencing extended, unresolving grief and can offer care and referrals for therapy and support.

Factors Associated with Complicated Grief Following a Railway Tragedy

On July 6, 2013, a train with 72 crude oil tank cars derailed in the heart of Lac-Mégantic, a small municipality of 6,000 inhabitants located in Québec (Canada). This tragedy killed 47 people. Technological disasters are rarely studied in bereavement research, and train derailments even less. The goal of this article is to increase our understanding of the bereavement consequences of technological disasters. Specifically, we aim to identify the factors that lead to the experience complicated grief and distinguish from the protective factors. A representative population-based survey was conducted among 268 bereaved people, three and a half years after the train accident. Of these, 71 people (26.5%) experienced complicated grief. People with complicated grief (CG) differ significantly from those without CG in terms of psychological health, perception of physical health, alcohol use and medication, as well as social and professional relationships. Hierarchical logistic regression analysis identified four predictive factors for CG: level of exposure to the disaster, having a negative perception of the event, as well as having a paid job and low-income increase the risk of CG. The importance of having health and social practitioners pay attention to these factors of CG are discussed along with future directions for research.

The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study's conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

Predictors of Prolonged Grief Disorder in a German Representative Population Sample: Unexpectedness of Bereavement Contributes to Grief Severity and Prolonged Grief Disorder

Most people adapt to bereavement over time. For a minority, the grief persists and may lead to a prolonged grief disorder (PGD). Identifying grievers at risk of PGD may enable specific prevention measures. The present study examined the extent to which the subjective unexpectedness of the death predicted grief outcomes above and beyond known sociodemographic and objective loss-related variables in a sample drawn from a population-representative investigation. In our sample (n = 2,531), 811 participants (M _age 55.1 ± 17.8 years, 59.2% women) had experienced the loss of a significant person six or more months ago. Participants provided demographic and loss-related information, perceptions of the unexpectedness of the death and completed the Prolonged Grief Disorder-13 + 9 (PG-13 + 9). The PG-13 + 9 was used to determine PGD caseness. A binary logistic regression investigated predictors of PGD caseness, and a linear regression predictors of grief severity. ANCOVAs compared PGD symptoms between the groups who had experienced an "expected" vs. "unexpected" loss, while controlling for the relationship to the deceased and time since loss. The loss of a child (OR = 23.66; 95%CI, 6.03-68.28), or a partner (OR = 5.32; 95%CI, 1.79-15.83), the time since loss (OR = 0.99; 95%CI, 0.99-1.00) and the unexpectedness of the death (OR = 3.58; 95%CI, 1.70-7.69) were significant predictors of PGD caseness (Nagelkerke's R² = 0.25) and grief severity. Participants who had experienced the loss as unexpected (vs. expected) reported higher scores on all PGD symptoms. Unexpectedness of the death emerged as significant risk factor for PGD, even after controlling for demographic and other loss-related variables. While our findings replicate previous research on the importance of the relationship to the deceased as a risk factor for PGD, they also highlight the importance of assessing the subjective unexpectedness of a death and may help to identify risk groups who can profit from preventive interventions.

Content overlap analyses of ICD-11 and DSM-5 prolonged grief disorder and prior criteria-sets

BACKGROUND

The International Classification of Diseases eleventh edition (ICD-11) has recently included prolonged grief disorder (PGD), a diagnosis characterized by severe, persistent, and disabling grief. The text revision of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5-TR) is scheduled to include a similar but distinct diagnosis, also termed PGD. Concerns have been raised that these new diagnoses are qualitatively different from both prior proposed diagnoses for pathological grief and each other, which may affect the generalizability of findings obtained with different criteria sets.

OBJECTIVE

We conducted a content overlap analysis of PGD_ICD-11, PGD_DSM-5-TR, and previous proposals for pathological grief diagnoses (i.e. PGD 2009; complicated grief (CG), PGD ICD-11 beta draft, persistent complex bereavement disorder (PCBD) per DSM-5).

METHODS

Using the Jaccard's Index, we established the degree of content overlap between core and accessory symptoms of PGD_ICD-11, PGD_DSM-5-TR, and prior proposals for pathological grief diagnoses.

RESULTS

Main findings are that PGD_ICD-11 and PGD_DSM-5-TR showed moderate content overlap with each other and with most prior proposed diagnoses for pathological grief. PGD_ICD-11 and PGD_DSM-5-TR showed the strongest content overlap with their direct predecessors, PGD_{ICD-11 beta draft} and PCBD, respectively.

CONCLUSIONS

Limited content overlap between PGD_ICD-11 and PGD_DSM-5-TR and preceding criteria sets may threaten generalizability of past research on phenomenological characteristics of pathological grief to current criteria sets. Similarly, findings obtained with instruments to assess PGD_ICD-11 may not generalize to PGD_DSM-5-TR and vice versa. Researchers should aim to determine under which circumstances criteria sets for PGD yield similar or distinct characteristics. Convergence of criteria sets for PGD remains an important goal for the future.

Valid measurement of DSM-5 persistent complex bereavement disorder and DSM-5-TR and ICD-11 prolonged grief disorder: The Traumatic Grief Inventory-Self Report Plus (TGI-SR+)

INTRODUCTION

When grief reactions after bereavement are so intense that they impair daily functioning, a diagnosis of disturbed grief may apply. Slightly differing criteria-sets for disturbed grief are included in the ICD-11, the DSM-5, and its forthcoming text revision, DSM-5-TR. We examined psychometric properties of a new self-report measure, the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+), that assesses these criteria sets for Persistent Complex Bereavement Disorder (PCBD) as per DSM-5, and Prolonged Grief Disorder (PGD) as defined in ICD-11 and DSM-5-TR.

MATERIAL AND METHODS

We examined the: i) factor structure, ii) internal consistency, iii) temporal stability, iv) convergent validity, v) known-groups validity, vi) probable caseness, and vii) optimal clinical cut-off scores in two Dutch bereaved samples. Sample 1 consisted of 278 adults, bereaved by various causes. Sample 2 included 270 adults who lost loved ones in a traffic accident.

RESULTS

We found support for a 3-factor PCBD model, 1-factor DSM-5-TR model, and 1-factor ICD-11 PGD model. The DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD items demonstrated good internal consistency and temporal stability. Associations between disturbed grief symptoms and posttraumatic stress and depression levels supported convergent validity. Associations between demographic/loss-related variables and disturbed grief symptoms supported known-groups validity. Optimal clinical cut-offs for the TGI-SR+ total score were ≥ 75, ≥71, and ≥ 75 for probable caseness of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD, respectively.

DISCUSSION

While replication of our findings in diverse bereaved samples is needed, we conclude that the TGI-SR+ is a reliable and valid measure to assess symptoms of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD.

Review of Grief Therapies for Older Adults

Purpose of Review

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

Findings

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Summary

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Emotional processing during the therapy for complicated grief

OBJECTIVE

Prior research, mainly conducted on depression, observed that clients' improved capability to process their emotions predicted better therapeutic outcomes. The current comparative study aimed to investigate whether emotional processing was related to therapeutic change in complicated grief.

METHOD

We analyzed two contrasting cases (good or poor outcome) treated with grief constructivist therapy. In both cases we investigated the association of emotional processing (Experiencing Scale) to (1) therapeutic outcome (Inventory of Complicated Grief), and (2) change in the type of grief-related emotions (Emotions Episodes).

RESULTS

The session-by-session growth of clients' emotional processing and the change of grief-related emotions were qualitatively explored throughout both cases. Compared with the poor outcome case, the good outcome case achieved more improvement in the ability to process emotions. Such improvement occurred alongside a deeper change in the type of grief-related emotions aroused, from maladaptive to more adaptive responses.

CONCLUSION

Our findings suggest that a higher emotional processing capability may be associated with the transformation of grief-related maladaptive emotions and with the improvement of complicated grief condition.

What Ever Happened to Nostalgia (the Diagnosis)?

ABSTRACT

Nostalgia and homesickness are not currently regarded as mental disorders. The psychic pain associated with longing to return home had been considered a mental disorder for centuries, especially in Europe, where it was a sign of moral weakness between nations. Nostalgia's effects on American Civil War soldiers-anxiety, depression, and sleep and appetite disturbances, for example-were described by clinicians and linked to significant morbidity and mortality. Since then, although these effects of combat have been of interest, focus has shifted to psychic trauma, relegating the concept of nostalgia to an unclassified but commonly encountered condition. Besides wartime trauma, symptomatic conditions related to nostalgia have been described among displaced persons and refugees living in the diaspora longing for their homelands (e.g., social displacement syndrome). More recently, nostalgia has pervaded culture as a benign pastime, with no implications for psychopathology. Finally, the longing for return to an idyllic or imagined lifestyle has returned amid worldwide quarantining and isolation during the COVID-19 pandemic. In this new sense, nostalgia has become a remedy rather than a disease. We identify four major iterations of nostalgia: the medical condition of homesickness, the condition studied in wartime, the application to migration and social displacement, and as a remedy for existential anxiety. We conclude that nostalgia per se is neither pathological nor normative, but a consistent phenomenon in human existence that should not be overlooked in cultural assessment and psychotherapy.

Prevalence of prolonged grief disorder

BACKGROUND

Prolonged grief is a disorder (PGD) characterized by severe and disabling grief reactions for an extended period of time after the loss of a significant person. ICD-11 and DSM-5-TR differ substantially in individual criteria.

OBJECTIVE

Estimation of the respective prevalence of PGD_ICD-11 and PGD_DSM-5-TR and the frequency with which single symptoms of prolonged grief occur in the general population.

METHODS

Out of a representative sample of the German general population (N=2498), n = 914 reported a significant loss and prolonged grief symptoms based on the extended version of the self-reported Prolonged Grief Disorder-13+9 (PG13+9). Sociodemographic and loss-related characteristics were collected.

RESULTS

The probable prevalence of PGD_ICD-11 was 1.5% and that of PGD_DSM-5-TR was 1.2% in the general sample. Among bereaved persons (n=914), the prevalence of developing PGD_ICD-11 was 4.2% and that of PGD_DSM-5-TR was 3.3%. Diagnostic agreement between the two criteria-sets was very high and did not increase after heightening the accessory symptom threshold for PGD_ICD-11. Difficulties accepting the loss was the most frequent single symptom (14-25%) and grief-related impairment was common (10-16%). Over 60% of participants with a probable PGD diagnosis utilized health care services.

LIMITATIONS

Results are based on self-reported data. The PG13+9 was not designed to assess grief symptoms according to ICD-11 and DSM-5-TR diagnostic criteria.

CONCLUSIONS

Prolonged grief according to ICD-11 and DSM-5-TR is a notable disorder in the general population. Among bereaved persons, single symptoms of prolonged grief are relatively frequent and cause substantial degrees of impairment.

Evaluation of the performance of instruments to diagnose grief disorders: A diagnostic meta-analysis

BACKGROUND

Prolonged or complicated grief disorder occurs in 9.8% of bereaved adults and can progress into adverse health effects if left unresolved. Evidence on the appropriate and specific diagnostic instrument for the assessment of prolonged or complicated grief disorders is lacking.

OBJECTIVE

The purpose of this study was to evaluate the performance of the most widely used instruments to diagnose grief disorders, including The Inventory of Complicated Grief, The Inventory of Complicated Grief - Revised, and the Prolonged Grief Disorder-13.

DESIGN

Diagnostic meta-analysis.

DATA SOURCES

PubMed, EMBASE, CINAHL, Medline, Scopus, Web of Science, and Cochrane were searched up to July 1, 2020.

METHODS

We included studies evaluating the sensitivity and specificity of grief disorders diagnostic tools against the comparator tests in individuals who experienced the loss of a family member. A diagnostic meta-analysis of pooled sensitivity and specificity, likelihood ratios, and area under curve were performed with a random-effect and hierarchical model.

RESULTS

In the current study, 3540 participants were involved. The six studies of the Inventory of Complicated Grief had pooled sensitivity of 0.93 (95% confidence interval: 0.87 to 0.97) and specificity of 0.96 (95% confidence interval: 0.92 to 0.98). The positive likelihood ratio was 23.4 (95% confidence interval: 11.2 to 49.0) and the negative likelihood ratio was 0.07 (95% confidence interval: 0.04 to 0.14) with area under curve value at 0.96 (95% confidence interval: 0.97 to 0.99). For Prolonged Grief Disorder-13, the three included studies' pooled sensitivity was 0.51 (95% confidence interval: 0.42 to 0.60), and the pooled specificity was 0.96 (95% confidence interval: 0.93 to 0.98). The Inventory of Complicated Grief-Revised evaluation could not be performed as only two articles from the same study were identified in this meta-analysis.

CONCLUSIONS

The Inventory of Complicated Grief is a highly recommend instrument to differentiate the case of grief disorders. Nurses and health care professionals can use the Inventory of Complicated Grief in the diagnosis of prolonged or complicated grief disorders due to its high sensitivity and specificity values. Further evaluations are needed for the use of Prolonged Grief Disorder-13 and Inventory of Complicated Grief-Revised.

REGISTRATION

The study is registered with the Open Science Framework (https://osf.io/bs8n6/?view_only=109e76e59efb4d7699153f62564f57ed). Tweetable abstract: Inventory of Complicated Grief is a highly recommend instrument with high sensitivity and specificity for diagnosing grief disorders.

Validation of a German Version of the Grief Cognitions Questionnaire and Establishment of a Short Form

Background

Whereas the majority of bereaved persons recover from their grief without professional assistance, a minority develops pathological grief reactions. Etiological models postulate that dysfunctional cognitions may perpetuate such reactions. The Grief Cognitions Questionnaire (GCQ) assesses thoughts after bereavement in nine interrelated domains. A short form (GCQ-SF) with four domains is often used. However, an evaluation of the psychometric properties of the GCQ-SF and its utility compared to the GCQ is lacking and these instruments have not been validated in German.

Method

German bereaved persons (time since loss 35.3 ± 34.6 months) responded to an online survey containing the GCQ, measures of grief severity, grief rumination, symptoms of depression and anxiety, and optimism and pessimism. 585 participants (18–78 years, 88% women) were included. Item analyses and confirmatory factor analyses were conducted. Correlations between the GCQ and GCQ-SF and grief rumination, optimism and pessimism assessed construct validity. Criterion-related validity was assessed by comparing whether the correlation of the GCQ (and the GCQ-SF) with grief severity was higher than with anxious and depressive symptoms. Logistic regression and receiver-operator characteristics (ROC) compared the questionnaires on their ability to predict probable prolonged grief ‘caseness’ (ICG ≥ 25, time since loss ≥6 months).

Results

Internal consistencies for both questionnaires were identical and excellent (α = 0.96). Confirmatory factor analyses obtained a satisfactory fit for models with nine and four correlated subscales and respective higher-order factor models. The GCQ and the GCQ-SF correlated higher with grief severity than with other measures of psychopathology. The logistic regression showed a significant association between the GCQ-SF and prolonged grief ‘caseness’. Of the remaining subscales of the GCQ, only one subscale (‘Others’) contributed to the prediction. The ROC analyses showed nearly identical areas under the curve.

Conclusion

The translated GCQ and GCQ-SF demonstrated very good psychometric properties. The correlations with grief severity highlight the questionnaires’ clinical relevance. The questionnaires possessed identical diagnostic specificity and sensitivity. Whenever a timesaving assessment of the most typical grief-specific cognitions is important, the GCQ-SF represents an alternative to the GCQ. The original GCQ may still be superior when a more detailed description of a bereaved person’s cognitions is desirable.

End of Life Intervention Program During COVID-19 in Vall d'Hebron University Hospital

Introduction: The coronavirus disease 19 (COVID-19) and its consequences have placed our societies and healthcare systems under pressure. Also, a major impact on the individual and societal experience of death, dying, and bereavement has been observed. Factors such as social distancing, unexpected death or not being able to say goodbye, which might predict Prolonged Grief Disorder (PGD), are taking place. Moreover, hospitals have become a habitual place for End of Life (EOL) situations but not in the usual conditions because, for example, mitigation measures prevent families from being together with hospitalized relatives. Therefore, we implemented an EOL program with a multidisciplinary team involving health social workers (HSW) and clinical psychologists (CP) in coordination with the medical teams and nursing staff. Objectives: We aim to describe an EOL intervention program implemented during COVID-19 in the Vall d'Hebron University Hospital (HUVH). We present its structure, circuit, and functions. Descriptive analyses of the sample and the interventions that required psychological and social attention are reported. Material and methods: The total sample consists of 359 relatives of 219 EOL patients. Inclusion criteria were families cared for during the COVID-19 pandemic with family patients admitted to the HUVH in an EOL situation regardless of whether or not the patient was diagnosed with COVID-19. Results: Our program is based on family EOL care perceptions and the COVID-19 context features that hinder EOL situations. The program attended 219 families, of which 55.3% were COVID-19 patients and 44.7% had other pathologies. The EOL intervention program was activated in most of the EOL situations, specifically, in 85% of cases, and 78% of relatives were able to come and say goodbye to their loved ones. An emotional impact on the EOL team was reported. It is necessary to dignify the EOL situation in the COVID-19 pandemic, and appropriate psychosocial attention is needed to try to minimize future complications in grief processes and mitigate PGD.