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.

Do insecure attachment styles predict prolonged grief symptoms? Significant null findings.

Insecure attachment is proposed to be a risk factor in the development and persistence of severe grief. Although prior research demonstrates positive cross-sectional and longitudinal correlations between attachment styles and prolonged grief symptoms, controlled longitudinal analyses yield fewer convincing results. Therefore, we sought to further clarify the concurrent and longitudinal associations between these constructs. A sample of 225 bereaved Dutch adults (87% women; Mean age: 48.86 years) participated in a three-wave longitudinal survey including measures of attachment anxiety and attachment avoidance at baseline and prolonged grief symptoms at baseline and 6- and 12-month follow-up. Attachment anxiety and attachment avoidance were significantly positively correlated with prolonged grief symptoms at all time-points. However, multiple regressions, controlling for baseline symptoms, showed that attachment anxiety, attachment avoidance, and their interaction did not predict residual change in prolonged grief symptoms. These findings cast doubt on the proposed role of insecure attachment styles in prolonged grief.

A systematic review of loneliness in bereavement: Current research and future directions.

Bereaved people suffer from loneliness and loneliness is associated with poor mental health. In this study, this topic is reviewed. An agenda is suggested for future research. Research that is theory-driven, addresses measurement consistency, correlates of loneliness in bereaved and non-bereaved, and treatment is necessary for prevention and intervention.

Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal.

Kübler-Ross's stage model of grief, while still extremely popular and frequently accepted, has also elicited significant criticisms against its adoption as a guideline for grieving. Inaccurate portrayal of the model may lead to bereaved individuals feeling that they are grieving incorrectly. This may also result in ineffectual support from loved ones and healthcare professionals. These harmful consequences make the presentation of the five stages model an important area of concern. The Internet provides ample resources for accessing information about grief, raising questions about portrayal of the stages model on digital resources. We therefore conducted a systematic narrative review using Google to examine how Kübler-Ross's five stages model is presented on the internet. We specifically examined the prominence of the model, whether warnings, limitations and criticisms are provided, and how positively the model is endorsed. A total of 72 websites were eligible for inclusion in the sample. Our analyses showed that 44 of these (61.1%) addressed the model, indicating its continued popularity. Evaluation scores were calculated to provide quantitative assessments of the extent to which the websites criticized and/or endorsed the model. Results indicated low criticalness of the model, with sites often neglecting evaluative commentary and including definitive statements of endorsement. We conclude that such presentation is misleading; a definitive and uncritical portrayal of the model may give the impression that experiencing the stages is the only way to grieve. This may have harmful consequences for bereaved persons. It may alienate those who do not relate to the model. Presentation of the model should be limited to acknowledging its historical significance, should include critical appraisal, and present contemporary alternative models which better-represent processes of grief and grieving.

Loneliness in Bereavement: Measurement Matters.

The role of loneliness in the bereavement experience has been reported as substantial, with the death of a close person leaving a considerable void in the life of the bereaved. Yet, there is lack of agreement about its precise role and, notably, whether loneliness should be included as a core symptom for diagnosis of grief complications. The ongoing threat of heightened social isolation due to the COVID-19 pandemic underlines the need to understand the impact of loneliness, and to accurately chart its prevalence, intensity, duration, and associated difficulties in the context of bereavement. Assessment issues are central to this endeavor. In this article, we review the scientific literature to examine how loneliness after bereavement has been operationalized and measured. Sixty-three articles analyzing 51 independent datasets were reviewed. Results show major disparities: approximately half of the projects assessed loneliness by means of one of two validated scales (spanning different versions); the remainder included only single- or few-item measures. Diverse instructions, content and answer categories were used. While one size does not fit all, awareness of assessment options and dis/advantages may aid selection of the most appropriate measure, to suit the goals of a particular study and the specific groups under investigation. Our conclusion is that, in selecting a loneliness measure, health care professionals should come to their own well-informed decision, aided by the information provided in our review.

Upward and Downward Counterfactual Thought After Loss: A Multiwave Controlled Longitudinal Study.

Counterfactual thoughts, mental simulations about how a situation may have turned out differently (i.e., "if only …, then …"), can reduce mental health after stressful life-events. However, how specific counterfactual thought types relate to post-loss mental health problems is unclear. We hypothesized that self-referenced upward counterfactuals (i.e., "If only I had done …, then the current situation would be better") may serve as cognitive avoidance, thereby perpetuating loss-related distress. Conversely, downward counterfactuals (i.e., "If … had happened, then the current situation could have been [even] worse") may facilitate benefit finding, thereby reducing distress. In a longitudinal survey, self-referent, other-referent, and nonreferent upward counterfactuals, and nonreferent downward counterfactuals were assessed at baseline. Prolonged grief and depression symptoms were assessed at baseline, and 6- and 12-month follow-ups. Multiple regression analyses assessed associations between counterfactual thoughts and symptom levels in 65 recently bereaved people who generated counterfactual thoughts about the loss-event. Moderator analyses assessed the unicity of significant effects in the previous step, by comparing these effects in 59 people generating loss-related counterfactuals with those in 59 propensity-score matched participants generating counterfactuals about other negative life-events. Multivariate analyses showed that nonreferent upward counterfactuals were uniquely strongly positively associated with prolonged grief and depression symptoms concurrently. Self-referent upward counterfactuals were uniquely positively associated with prolonged grief and depression symptoms longitudinally. Moderator analyses confirmed that thinking about how one's (in)actions could prevent a death uniquely exacerbated prolonged grief and depression severity. Prolonged grief treatment may be improved by targeting self-blame and guilt.

Bereavement in Times of COVID-19: A Review and Theoretical Framework.

A review of the literature on adaptation to bereavement during the COVID-19 pandemic was conducted to assess the current state of knowledge. Scopus, Web of Science and Google Scholar databases were searched for studies published during the first 6 months of the COVID-19 outbreak. 44 articles were included in the review. Narrative synthesis showed that knowledge was largely based on expert assessments of prior bereavement research and professional experience; there is so far absence of empirical evidence linking features of COVID-19 bereavement situations to health outcomes. Severe negative consequences have been consistently predicted by authors. There is still relatively little consideration of positive or compensatory processes or the possibility that these could alleviate the effect of the shocking, traumatic circumstances. With two notable exceptions, there has been lack of attention to the role of theoretical models for guiding research and practice. A theoretical perspective (the Dual Process Model, DPM) was applied to the information derived from the available articles. Two features of the DPM framework illustrated its relevance: 1. It enables systematic assessment of the range of loss- and restoration-related challenges for the bereaved; 2. It speaks for extension of psychotherapeutic intervention to manage secondary, restoration- as well as primary, loss-oriented stressors; studies have demonstrated that this may increase the effectiveness of intervention. Directions for future research and DPM application are suggested.

Does pre-event lack of emotional support increase the risk of post-event PTSD, anxiety, depression symptoms and lack of support? A comparative population-based study among victims of threat and violence.

Our knowledge about the effects of perceived emotional support on PTSD, anxiety and depressive symptoms after serious threat and violence is primarily based on post-event studies. Very little is known about the extent to which (1) victims lacking pre-event emotional support are more at risk of post-event symptoms and lack of post-event support than victims with pre-event emotional support, and (2) victims with pre-event emotional support and victims lacking emotional support are more at risk of post-event anxiety and depressive symptoms than nonvictims with similar pre-event support levels. For this purpose, we conducted a 2-wave prospective study (VICTIMS) using the Dutch population-based longitudinal LISS panel. Multivariate logistic regression analyses were conducted, controlling for pre-event demographics, symptoms, and physical, work-related and financial problems. As hypothesized, victims (Nvictims total = 187) lacking pre-event support more often had high post-event PTSD, anxiety and depressive symptoms than victims with pre-event support. No significant differences were found between victims and nonvictims with pre-event emotional support (Nnonvictims total = 2,828, not exposed to any event). Since victims and nonvictims with pre-event support did not differ in post-event symptoms and support, the findings offer strong evidence for the buffering hypothesis of emotional support.

Cremation and Grief: Are Ways of Commemorating the Dead Related to Adjustment Over Time?

Funeral services are known to serve multiple functions for bereaved persons. There is also a common, intuitively reasonable assumption of positive associations between engaging in funeral activities and adjustment to bereavement. We examined whether restricting ceremonial cremation arrangements to a minimum has a negative association with grief over time. Bereaved persons in the United Kingdom completed questionnaires 2 to 5 months postloss and again a year later (N = 233 with complete data; dropout = 11.4%). Neither type nor elaborateness of the cremation service, nor satisfaction with arrangements (typically high), emerged as significantly related to grief; no major subgroup differences (e.g., according to income level) were found. Results suggested that it does not matter to grief whether a more minimalistic or elaborate funeral ceremony was observed. We concluded that the funeral industry represented in this investigation is offering bereaved people the range of choices regarding cremation arrangements to meet their needs. Limits to generalizability are discussed.

Which groups affected by Potentially Traumatic Events (PTEs) are most at risk for a lack of social support? A prospective population-based study on the 12-month prevalence of PTEs and risk factors for a lack of post-event social support.

OBJECTIVES: Little is known about the 12-month prevalence of potentially traumatic events (PTEs) and to what extent the type of PTE is a risk factor for post-event lack of social support. In addition, it is largely unknown if pre-event mental health problems and loneliness, and demographics are risk factors for a lack of support. Aim of the present prospective study is to fill these gaps in evidence-based knowledge. METHODS: A survey was conducted among a large random sample of the Dutch adult population (i.e. the longitudinal LISS panel) in March-April 2018, and linked with pre-event mental health and loneliness data from surveys conducted in 2016 (n = 5,879). We distinguished four forms of perceived social support: emotional and esteem support, and social recognition and general disapproval. RESULTS: Loss of a significant other and/or colleague (28%) was the most prevalent 12-month PTE. The 12-month prevalence of violence, accidents and/or, and theft-related events was 13%. Multivariate logistic regression analyses revealed no differences in lack of emotional and esteem support, or in lack of recognition across non-death PTEs and death-related PTEs. However, victims of threat and physical (sexual) violence more often faced disapproval than those affected by burglary and accidents. Results furthermore showed that pre-event mental health problems, pre-event loneliness and stress during the PTE were important independent predictors of forms of support and acknowledgment. Affected individuals with a non-Western background more often lacked support and acknowledgment. CONCLUSIONS: Many adults are confronted with a PTE during a year. In general, pre-event factors and stress during the event are better predictors of a perceived lack of support and acknowledgment than type of event. Early screening programs should especially assess pre-event mental health and loneliness, besides levels of stress during the event, to identify affected people who are at risk for a lack of social support and acknowledgment.

Bereavement or breakup: Differences in networks of depression.

BACKGROUND: Prior network analyses demonstrated that the death of a loved one potentially precedes specific depression symptoms, primarily loneliness, which in turn links to other depressive symptoms. In this study, we extend prior research by comparing depression symptom network structures following two types of marital disruption: bereavement versus separation. METHODS: We fitted two Gaussian Graphical Models to cross-sectional data from a Swiss survey of older persons (145 bereaved, 217 separated, and 362 married controls), and compared symptom levels across bereaved and separated individuals. RESULTS: Separated compared to widowed individuals were more likely to perceive an unfriendly environment and oneself as a failure. Both types of marital disruption were strongly linked to loneliness, from where different relations emerged to other depressive symptoms. Amongst others, loneliness had a stronger connection to perceiving oneself as a failure in separated compared to widowed individuals. Conversely, loneliness had a stronger connection to getting going in widowed individuals. LIMITATIONS: Analyses are based on cross-sectional between-subjects data, and conclusions regarding dynamic processes on the within-subjects level remain putative. Further, some of the estimated parameters in the network exhibited overlapping confidence intervals and their order needs to be interpreted with care. Replications should thus aim for studies with multiple time points and larger samples. CONCLUSIONS: The findings of this study add to a growing body of literature indicating that depressive symptom patterns depend on contextual factors. If replicated on the within-subjects level, such findings have implications for setting up patient-tailored treatment approaches in dependence of contextual factors.

Homesickness in social context: An ecological momentary assessment study among 1st-year university students.

Homesickness is common among university students and associated with mental health problems. Most previous studies assessed homesickness as a summary of the past weeks. However, there may be significant fluctuations across situations. At the current residence, homesickness may especially be triggered during (phone) interactions with attachment figures. Dutch and international 1st-year students (n = 92) completed the Utrecht Homesickness Scale and subsequently used a smartphone application to record social interactions for 14 days (ecological momentary assessment [EMA]). For each interaction they reported the social context (e.g. location, contact type) and their affective state, including homesickness. Homesickness in the past weeks and momentary homesickness were both higher in international students than in Dutch students. Feeling homesick was highest at participants' current residency, when interacting with parents, or when using video-chat. When participants felt more homesick, they reported less pleasant and more unpleasant affect. In conclusion, EMA provided insight in cross-situational variations in homesickness.

No pain, no gain: cross-lagged analyses of posttraumatic growth and anxiety, depression, posttraumatic stress and prolonged grief symptoms after loss.

BACKGROUND AND OBJECTIVES: Major negative life-events including bereavement can precipitate perceived positive life-changes, termed posttraumatic growth (PTG). While traditionally considered an adaptive phenomenon, it has been suggested that PTG represents a maladaptive coping response similar to cognitive avoidance. To clarify the function of PTG, it is crucial to establish concurrent and longitudinal associations of PTG with post-event mental health problems. Yet, longitudinal studies on this topic are scarce. The present study fills this gap in knowledge. DESIGN: A two-wave longitudinal survey was conducted. METHODS: Four-hundred and twelve bereaved adults (87.6% women) filled out scales assessing PTG and symptoms of depression, anxiety, prolonged grief, and posttraumatic stress at baseline and 6 months later. RESULTS: The baseline concurrent relationships between all symptom levels and PTG were curvilinear (inverted U-shape). Cross-lagged analyses demonstrated that symptom levels did not predict levels of PTG 6 months later, or vice versa. CONCLUSIONS: Findings suggest PTG after loss has no substantive negative or positive effects on mental health. Development of specific treatments to increase PTG after bereavement therefore appears premature.

Community-based counseling reaches and helps bereaved people living in low-income households.

OBJECTIVE: Poverty is related to increased grief-related mental health problems, leading some to suggest bereavement counseling should be tailored to income. However, information about accessibility and effectiveness of such counseling programs serving low-income households is scarce. This longitudinal study therefore investigated the association between poverty and complicated grief (CG), and the effectiveness of a community-based bereavement counseling program in serving low-income households. METHODS: Two hundred eighty-eight participants (75% female) were enrolled. Loss-related and demographic variables were assessed at baseline. Regression analyses were used to investigate household income as a predictor of CG, and examine bereavement counseling effectiveness by comparing CG symptom change across three household income categories across three time-points: baseline (T1), T1 + 12 months (T2), and T1 + 18 months (T3). RESULTS: Of all participants, 35.8% reported below poverty-threshold income, twice the general population's rate. Multiple regression analysis indicated poverty-threshold income was a predictor of CG symptoms over and above demographic and loss-related characteristics. Three-way interaction analysis detected a significant treatment effect for study condition across time, but no differences in treatment effects across income. CONCLUSION: Lower household income was associated with higher CG symptoms. Since income did not predict differential treatment response, community-based bereavement counseling appeared no less efficacious for members of low-income households. Clinical or methodological significance of this article: While previous research has indicated low income may be a risk factor for mental health problems after bereavement, and it has therefore been suggested bereavement counseling should be tailored to income, no study to date has investigated the need for such tailoring. This controlled, longitudinal treatment study fills this gap in knowledge. Main findings are that low income is a key predictor of complicated grief symptoms. The study also shows that the effectiveness of one-to-one bereavement counseling does not appear to differ according to income level.

Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial.

This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling model for adults on reducing complicated grief (CG) symptoms. Participants (N = 344; 79% female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was hypothesized that participants who received intervention would experience a greater decline in CG levels immediately following the intervention compared to the control participants, but the difference would diminish at follow-up (due to relapse). Data were collected via postal questionnaire at 3 time points: baseline (T), post-intervention (T + 12 months), and follow-up (T + 18 months). CG, post-traumatic stress, and general psychological distress were assessed at all time points. Multilevel analyses controlling for relevant covariates were conducted to examine group differences in symptom levels over time. A stepwise, serial gatekeeping procedure was used to correct for multiple hypothesis testing. A main finding was that, contrary to expectations, counselling intervention and control group participants experienced a similar reduction in CG symptoms at postmeasure. However, intervention participants demonstrated a greater reduction in symptom levels at follow-up (M = 53.64; d = .33) compared to the control group (M = 62.00). Results suggest community-based bereavement counselling may have long-term beneficial effects. Further longitudinal treatment effect investigations with extensive study intervals are needed.

Meaning and coping orientation of bereaved parents: Individual and dyadic processes.

The present study aimed to examine whether bereaved parents "meaning-made"-defined as results of attempts to reduce discrepancies between the meaning assigned to the death of the child and self and world-views-was influenced by their own and their partner's coping orientations. Coping orientations were conceptualized within the Dual Process Model, which entails loss coping orientation (LO; focus on the loss itself), restoration coping orientations (RO; focus on stressors that come about as an indirect consequence of the bereavement), and a flexible oscillation between both coping orientations. The sample consisted of 227 couples identified through obituary notices in local and national newspapers, who provided data at 6, 13, and 20 months after the death of their child. At all three points of measurement, both partners independently completed the Dual Coping Inventory (DCI) and a scale developed by the authors about meaning-made from the loss. Data were analyzed using a multi-level Actor-Partner Interdependence Model. Results show that the combination of parents' own LO and RO (operationalized through the interaction effect between LO and RO) have a positive effect in parents' meaning-made. Partners' LO have a negative effect in parents' meaning-made. These results highlight the importance of, in the context of parental bereavement, being flexible by using both coping orientations, and of acknowledging the interdependence between partners, namely, the interpersonal process by which partner's coping affect one's meaning-made.

Cautioning Health-Care Professionals.

Science and practice seem deeply stuck in the so-called stage theory of grief. Health-care professionals continue to "prescribe" stages. Basically, this perspective endorses the idea that bereaved people go through a set pattern of specific reactions over time following the death of a loved one. It has frequently been interpreted prescriptively, as a progression that bereaved persons must follow in order to adapt to loss. It is of paramount importance to assess stage theory, not least in view of the current status of the maladaptive "persistent complex bereavement-related disorder" as a category for further research in DSM-5. We therefore review the status and value of this approach. It has remained hugely influential among researchers as well as practitioners across recent decades, but there has also been forceful opposition. Major concerns include the absence of sound empirical evidence, conceptual clarity, or explanatory potential. It lacks practical utility for the design or allocation of treatment services, and it does not help identification of those at risk or with complications in the grieving process. Most disturbingly, the expectation that bereaved persons will, even should, go through stages of grieving can be harmful to those who do not. Following such lines of reasoning, we argue that stage theory should be discarded by all concerned (including bereaved persons themselves); at best, it should be relegated to the realms of history. There are alternative models that better represent grieving processes. We develop guidelines to enhance such a move beyond the stage approach in both theory and practice.

Does worry affect adjustment to bereavement? A longitudinal investigation.

BACKGROUND AND OBJECTIVES: Repetitive thought is a trans-diagnostic risk-factor for development of psychopathology. Research on repetitive thought in bereaved individuals has focused primarily on clarifying the role of rumination, repetitive thinking about past negative events and/or negative emotions. While detrimental effects of rumination have been demonstrated following bereavement, surprisingly few studies have aimed to clarify the role of worry, repetitive thinking about potential future negative events, in adjustment to loss. This study sought to fill this gap in knowledge. METHODS/DESIGN: One hundred eighty-three bereaved individuals (85.3% women) filled out questionnaires on sociodemographic and loss-related characteristics, worry, and symptom measures of depression, anxiety, and prolonged grief. After six months, 155 participants completed worry and symptom measures again. Using multiple regression analyses, concurrent and longitudinal associations between loss-related variables, worry, and symptoms of psychopathology were examined. RESULTS: Main results were that worry was strongly positively associated with symptoms of anxiety, depression and prolonged grief concurrently and also predicted higher levels of anxiety, depression and prolonged grief longitudinally. CONCLUSIONS: Findings suggest that worry influences adjustment to bereavement negatively and may be a potential target in grief therapy, especially when aiming to reduce anxiety.