3 prolonged grief

Question 1

DSM criteria for PGD

Answer 1

at least 12 months in adults, 6 in children

at least one has been present:
- intense yearling/longing for the deceased
- preoccupation with thoughts or memories of the deceased person

at least 3 of the following have been present:
1. identity disruption (e.g., feeling as though part of oneself has died)
2. marked sense of disbelief about the death
3. avoidance of reminders that the person is dead
4. intense emotional pain (e.g., anger, bitterness, sorrow)
5. difficulty reintegrating into one’s relationships and activities
6. emotional numbness
7. feeling that life is meaningless
8. intense loneliness

the disturbance causes clinically significant distress

the duration and severity of the bereavement reaction exceeds expected social, cultural or religious norms

the symptoms are not better explained by other conditions

Question 2

the cognitive-behavioral model of prolonged grief

Answer 2

3 core processes in development of PG
1. poor integration of the separation with existing autobiographical knowledge
2. neg global beliefs & misinterpretations of grief reaction
3. anxious and depressive avoidance strategies

processes are offered to account for the occurrence of CG symptoms, whereas the interaction among these processes is postulated to be critical to symptoms becoming marked and persistent.

model recognizes that background variables influence CG:
- individual vulnerability factors
- characteristics of the loss event
- characteristics of the loss sequelae

Question 3

divergent reactions to conjugal loss

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 3

chronic grief : estimates of chronic depression and distress have ranged from 10-20% BUT the lack of pre loss data leaves unanswered many important questions
- one question involves the relation between chronic grief and pre existing psychopathology
- a pos relation between pre and post bereavement depression has been observed

absence of grief : usually thought that a lack of grief was due to denial or inhibition, and that it was maladaptive in the long run
- BUT now this view is being challenged
- argued that some people may not show overt sign of distress because of quick adjustment following expected loss, or due to personality factors that promote an inherent resilience to loss

delayed grief & improved functioning during bereavement : from a traditional perspective, the absence of overt signs of grieving only means that depression will eventually be manifested as a delayed reaction
- however, studies have shown that the % of respondents showing this pattern was extremely low
- maybe some individuals do actually show improved psychological health after the death of their spouse

Question 4

method & hypothesis

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 4

Categorized participants into low and high preloss depression - considered changes in depression for each group

Hypotheses - expected 3 basic bereavement patterns: common grief, chronic grief, absent grief
No evidence for a delayed grief reaction

Question 5

Pre loss predictors of divergent reactions to conjugal loss

qualities of the conjugal relationship

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 5

One of the most widely held assumptions is that chronic grief results from conflict in the conjugal relation

A related assumption is that chronic grief arises out of ambivalence toward the spouse
Also linked chronic grief to excessive dependency - either as a feature of the relationship or as a personality trait

Attachment style has been related to dependency
- has been suggested that individuals with anxious/ambivalent or preoccupied attachment style tend to react to loss with intense and prolonged distress
- has also been linked to a lack of grief - researchers have suggested that bereaved individuals who fail to show overt grief were only superficially attached to their conjugal partner

Has also been suggested that those who show little grief tend to be emotionally distant

Question 6

Pre loss predictors of divergent reactions to conjugal loss

coping resources

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 6

Coping resources play a crucial role in moderating adjustment to stressful life events, including interpersonal loss

Personality traits have been associated with coping efficacy - emotional stability (low neuroticism) may buffer an individual from the destabilizing nature of conjugal loss

Religious involvement may also be thought of as a coping resource - can foster resilience during bereavement both by providing stable, shared belief system and by providing affiliation and social support from the religious community

Question 7

Pre loss predictors of divergent reactions to conjugal loss

meaning and world view

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 7

Many researchers maintain that finding meaning is a core component of the grieving process → BUT many bereaved individuals report being unable to find any meaning in a loss
- These individuals tend to have a more prolonged grief reaction than others

Those who report not actively searching for meaning following loss appear to adjust well to trauma or loss
- An explanation for this is that individuals hold a priori beliefs about themselves and the world that can more readily accommodate the possibility of loss, thus minimizing the need to search for an explanation for the loss

Question 8

Pre loss predictors of divergent reactions to conjugal loss

context

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 8

Losses occurring in the context of serious spousal illness could be experienced as a relief from chronic stress and, lead to improved psychological health during grief

Another contextual factor is supportive resources - 2 types of support have been examined:
- Perceived social support (friends and relatives)
- Instrumental support (financial resources, help in the maintenance of home and familial responsibilities)

Question 9

2 predictions - relation of pre loss factors & bereavement patterns

first set of predictions

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 9

chronic grievers = relatively maladjusted individuals with few coping resources

resilient individuals = relatively healthy with more abundant coping resources

SO, compared with resilient individuals, chronic grievers at pre loss would have:
- A poorer quality relation with their spouse
- Fewer coping resources
- A more vulnerable world view
- A less favorable pre loss context

Question 10

2 predictions - relation of pre loss factors & bereavement patterns

second set of predictions

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 10

the traditional view that bereaved individuals who do not show overt signs of grieving are not resilient but rather lack interpersonal warmth and skill, are unable to form mature attachments, and have poor quality marriages

Groups labeled as resilient would:
- Report greater conflict
- Show an avoidant/dismissive attachment style
- Be rated by interviewers as having less interpersonal skills compared with common and chronic grievers

Question 11

results / discussion

(Bonanno et al, 2002)

Resilience to Loss and Chronic Grief: A Prospective Study From Preloss to 18-Months Postloss

Answer 11

main findings:
- Chronic grief could be distinguished from enduring, chronic depression
- Chronic grievers could be distinguished by their elevated depression and grief at 6 months post-loss → appears that PGD can be distinguished even in the early months of bereavement
- The most frequent pattern was resilience, not common grief
- A sizable minority showed a depressed-improvement pattern - not documented previously
- No evidence for a delayed grief pattern

moderator variables:
- Excessive dependency was the clearest predictor - both on the spouse and on general
- Variables hypothesized to underlie chronic grief were strongly related to chronic depression

Resilience: the high prevalence of this bereavement pattern underscores the fact that, contrary to popular belief, it is not abnormal to no experience intense grief following the loss of a close one
- This group was not ‘avoidant/distant’ - rather showed well-adjusted mental patterns and had adequate coping resources
- The maladaptive profile associated with absent grief was instead associated with the depressed-improved group

Question 12

proposals for PGD

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 12

This article proposes that the arguments given in the proposal for PGD being a mental disorder are not valid

Dangers of making a diagnosis - too inclusive criteria:
- Pathologize millions of normally suffering grieving individuals
- Create a target for drug development

Question 13

DSM-5 proposed grief-related changes to adjustment disorders

The DSM-5 proposal to eliminate the adjustment disorder bereavement exclusion

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 13

The DSM anxiety work group proposes eliminating the adjustment disorder (AD) bereavement exclusion

This will allow subsyndromal depressive symptoms during grief to qualify as AD
= without the bereavement exclusion, AD can be diagnosed during bereavement even on the basis of transient, minimal depressive symptoms

BUT, symptoms such as sadness, tearfulness, and insomnia are extremely common during normal grief → SO, the elimination of the exclusion constitutes a pathologization of virtually all normal grief

Question 14

DSM-5 proposed grief-related changes to adjustment disorders

DSM-5 proposal for an AD related to grief

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 14

The work group proposed adding a new category of AD related to bereavement to DSM-5

The new criteria would allow non-depressive grief symptoms to constitute adjustment disorders

These criteria are weaker with respect to any other PGD criteria set studied by researchers → they require the same sorts of symptoms, but with a lower threshold

Question 15

4 empirically based arguments for PGD to be a disorder

PGD as categorically different: the distinctive symptom argument

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 15

The distinctive symptom argument: PGDs symptoms are qualitatively different from those of normal grief in a way that suggests pathology

BUT, this hypothesis does not fit the facts since there is no clear qualitative difference between PGD symptoms and normal grief → all proposed PGD criteria regularly occur in intense normal grief

Only persistence of symptoms could differentiate normal grief from pathology

Question 16

4 empirically based arguments for PGD to be a disorder

PGD as distinctively severe grief

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 16

Researchers often define PGD simply as grief that is statistically extreme in severity of symptoms at some durational cut-point

BUT sheer statistical deviation in severity is invalid as an indicator of a disorder

Defining PGD in terms of some arbitrarily chosen symptom severity level leaves with the question of: when does intense normal grief become disorder grief?

Question 17

4 empirically based arguments for PGD to be a disorder

PGD as derailed grief: the interminability argument

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 17

argued that those with lengthy or more intense grieving processes may simply experience a longer grieving process, rather than suffering from a dysfunction

PGD proponents counterattack this by arguing that as a matter of empirical fact, once grief goes on for the specified 6-12 month duration, it then goes on more or less indefinitely (interminability hypothesis)
- if symptoms last longer, then something has gone wrong and grieving processes are derailed and will not proceed to resolution

the interminability hypothesis is clearly and repeatedly unsupported by the data PGD proponents cite

Question 18

4 empirically based arguments for PGD to be a disorder

PGD as risk factor: the predictive validity argument

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 18

Argument: the symptoms of PGD are predictive of substantial morbidity, adverse health behaviors, and quality of life impairments → SO the symptoms are indicative of pathology

Conceptual problems with the predictive validity argument: statistically heightened later negative outcomes do not necessarily imply earlier pathology
- it is questionable whether pathologizing an entire group is justified by the negative outcomes of a small minority
- E.g. coughing is associated with an increased likelihood of tuberculosis, but we don’t pathologize everyone who coughs because most coughing is normal

Question 19

4 empirically based arguments for PGD to be a disorder

conclusion

(Wakefield, 2021)

Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder

Answer 19

4 empirical arguments have been put forward to support PGDs conceptual validity as a disorder:
1. PGD has distinctive, pathognomonic symptoms separating it from normal grief
2. PGD has distinctively high levels of symptom severity
3. PGD represents a chronic pathological derailment of the normal process of grieving
4. PGD predicts negative outcomes that suggest it is a disorder

Close examination revealed serious empirical and conceptual deficiencies in these arguments

The data suggest that the DSM Work Group should reconsider these evidentially unsupported and overly inclusive new grief disorder categories

Question 20

stage theory

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 20

Posits that people go through five stages of grieving:
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Question 21

Criticism & assessment of stage theory

lack of theoretical depth/explanation

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 21

Kubler-Ross’s stages were not derived from theoretical principles

Fails to answer: what is the function of grief?

Stage theory doesn’t help identify those at risk or with complications in the grieving process

Question 22

Criticism & assessment of stage theory

Conceptual confusion and misrepresentation of grief and grieving

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 22

it is unclear what the sequential stages are and what they represent

Some denote affective states (e.g., anger, depression), others cognitive processes (e.g., denial, bargaining, acceptance)

Misrepresentation of grief in the Kubler-Ross’s stage theory:
- over simplicity
- passive model
- complex nature of coping - doesn’t argue in any way for the order
- inclusion of poorly defined concepts
- implies smooth progression
- prescriptive statements/interpetation
- neglets social/cultural context of grieving

Question 23

Criticism & assessment of stage theory

lack of empirical evidence

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 23

While there is empirical evidence that people experience (some of) the emotional and cognitive reactions some of the time, there is little to support the sequential development of these in stages

Question 24

Criticism & assessment of stage theory

the availability of alternative models

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 24

The stages approach has been supplanted by finer grained, sometimes theoretically based, more-representative-of-the-grieving-process models of grief and grieving

The alternative models have received no acknowledgement or discussion by Kubler-Ross and Kessler

Question 25

Criticism & assessment of stage theory

the neg consequences of using stage theory

(Stroebe et al, 2017)

Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief

Answer 25

Using this to support the bereaved may raise undue expectations, even presumptions about the course that grief should take

The consequences (what happens if one doesn’t follow the stages):
- Guilt for ‘not grieving appropriately and/or enough’
- Unhelpful and potentially harmful responses by health-care personnel
- Ineffective support from one’s social network

The stages were meant to be descriptive, but have taken to be prescriptive

Question 26

grief tasks model

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 26

Proposes that normal grief is the successful achievement of grief tasks, whereas complications in managing tasks reflect disturbed grief

No specific, linear order imposed

Grief tasks include:
- To accept the reality of the loss
- To process the associated pain
- To adjust to a world without the deceased
- To fund an enduring connection w/ the deceased in the midst of embarking on a new life

Question 27

PGD vs PCBD

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 27

Prolonged grief disorder - ICD11
Persistant complex bereavement disorder - DSM5

Similarities: in terms of symptomatology, empirical basis, and psychometric properties the two are essentially the same

PCBD - can be diagnosed 12 months after loss
PGD - can be diagnosed 6 months after loss (according to ICD)

Question 28

PGD comorbidity

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 28

Associated with an elevated risk of poor physical health, suicidality, reduced quality of life, and functional impairment

Frequently coincides with MDD, PTSD, GAD, and adult separation anxiety disorder

Question 29

PGD risk factors

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 29

There is evidence of elevated risk of PGD among women and people with lower levels of education

Personality traits: insecure attachment and neuroticism

The nature of the relation with the deceased is important → the death of a partner or child is associated with PGD

More severe grief is associated with unnatural and violent loss

Question 30

psychological interventions in preventing PGD

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 30

Universal or primary interventions in those with no risk factors is largely ineffective

Indicated or secondary prevention in those with high risk are more effective

Family focused therapy for high risk families of advanced cancer patients was found to reduced statistically significantly the risk that people developed PGD

Question 31

psychological interventions in treating PGD

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 31

There are relatively few controlled studies examining psychological treatments for PGD - some recommended psychological therapies:
- Complicated grief treatment → encompassing elements of exposure, cognitive restructuring, and interpersonal therapy
- CBT → combining exposure and cognitive interventions
- Therapist assisted online CBT → exposure, cognitive interventions, and behavioral activation applied using written assignments

Promising interventions tested in single controlled studies include: behavioral activation, cognitive narrative therapy, and integrated CBT

Question 32

pharmacological interventions in treating PGD

(Boelen, 2017)

Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder

Answer 32

limited support

Studies provide evidence for the efficacy and safety of antidepressant medications, including SSRIs and tricyclic antidepressants
- In most studies however, drugs were used to target depression rather than PGD - BUT beneficial effects for both might be expected since both share underlying mechanisms (e.g. negative cognitions, reduced activity)

Found that citalopram augmented the effects of the treatment on depression but not on PGD, and it did not substantially reduce depression

Question 33

support for PGD in ICD11 & DSM-5-TR

(Eisma, 2023)

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

Answer 33

Some studies have revealed the clinical relevance of PGD → a study found that grief-specific therapy was more effective in treating PGD than a depression focused therapy

Positive consequences of inclusion of PGD for patients: making PGD a diagnosis provides an impetus to investigate risk and protective factors, maintaining mechanisms and care for severe grief reactions

Question 34

challenges & controversies of PGD in ICD11 & DSM-5-TR

Non-linear history of PGD

(Eisma, 2023)

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

Answer 34

An assumption between the empirical research that was used to validate making PGD a diagnosis is that research on prior proposals directly informs the validity of current PGD criteria sets

However past proposals did not systematically build on each other to logically culminate in current diagnoses → instead, they show substantial differences in symptom count and content, time since loss criteria, and diagnostic algorithms compared to the current PGD criteria

Consequently, measures for prolonged grief symptoms do not comprehensively assess PGD per ICD-11 or DSM-5

Question 35

challenges & controversies of PGD in ICD11 & DSM-5-TR

Potential negative societal consequences

(Eisma, 2023)

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

Answer 35

Medicalization of normal grief: some argue that the introduction of PGD may lead to overdiagnosis and medicalization of normal grief
- for some groups of bereaved adults, severe and persistent grief appears a normal response to an abnormal life-event
- = diagnosing them with PGD would imply labeling normal grief variations as a medical disorder

Risks of pharmacotherapy: some are concerned that the establishment of PGD will lead to the development and application of medication

Stigmatization: this can have major negative consequences like increases in depression and suicidality, reduced help seeking, and premature termination of mental health treatments