Distinguishing postpartum and antepartum depressive trajectories in a large population-based cohort: the impact of exposure to adversity and offspring gender.

BACKGROUND: Distinguishing temporal patterns of depressive symptoms during pregnancy and after childbirth has important clinical implications for diagnosis, treatment, and maternal and child outcomes. The primary aim of the present study was to distinguish patterns of chronically elevated levels of depressive symptoms v. trajectories that are either elevated during pregnancy but then remit after childbirth, v. patterns that increase after childbirth. METHODS: The report uses latent growth mixture modeling in a large, population-based cohort (N = 12 121) to investigate temporal patterns of depressive symptoms. We examined theoretically relevant sociodemographic factors, exposure to adversity, and offspring gender as predictors. RESULTS: Four distinct trajectories emerged, including resilient (74.3%), improving (9.2%), emergent (4.0%), and chronic (11.5%). Lower maternal and paternal education distinguished chronic from resilient depressive trajectories, whereas higher maternal and partner education, and female offspring gender, distinguished the emergent trajectory from the chronic trajectory. Younger maternal age distinguished the improving group from the resilient group. Exposure to medical, interpersonal, financial, and housing adversity predicted membership in the chronic, emergent, and improving trajectories compared with the resilient trajectory. Finally, exposure to medical, interpersonal, and financial adversity was associated with the chronic v. improving group, and inversely related to the emergent class relative to the improving group. CONCLUSIONS: There are distinct temporal patterns of depressive symptoms during pregnancy, after childbirth, and beyond. Most women show stable low levels of depressive symptoms, while emergent and chronic depression patterns are separable with distinct correlates, most notably maternal age, education levels, adversity exposure, and child gender.

Integrative Science Approach to Resilience: The Notre Dame Study of Health & Well-being (NDHWB).

Although many studies have unequivocally demonstrated the promise of understanding resilience to adversity and characterizing the consequences if stress is unabated, needed are dynamic theories and methods to enhance the rigor and interpretation of these assessments. From a dynamic systems perspective, the focus is not whether an individual possesses some fixed ability or unchangeable trait, but rather to understand the flexibility and responsiveness of stress regulation systems to daily hassles and adverse life events. A renewed interest in individual variability allows researchers to see trajectories of change over both short- and long-time scales to understand the developmental course. As a result, it is possible to answer questions, such as, how does the dysregulation in emotion caused by stress, to both within and between daily affect processes, relate to longitudinal trajectories (over time-scales of years) of dysfunction and disease? The overarching goal of the Notre Dame Study of Health & Well-being is to detail the types and qualities of contextual influences, in conjunction with dynamic psychobiological systems, to assess the precursors, concomitant influences and consequences of stress and resilience in the face of adversity on cognitive, health and well-being outcomes.

Diagnostic criteria for complicated grief disorder.

OBJECTIVE: Some prolonged and turbulent grief reactions include symptoms that differ from the DSM-IV criteria for major depressive disorder. The authors investigated a new diagnosis that would include these symptoms. METHOD: They developed observer-based definitions of 30 symptoms noted clinically in previous longitudinal interviews of bereaved persons and then designed a plan to investigate whether any combination of these would serve as criteria for a possible new diagnosis of complicated grief disorder. Using a structured diagnostic interview, they assessed 70 subjects whose spouses had died. Latent class model analyses and signal detection procedures were used to calibrate the data against global clinical ratings and self-report measures of grief-specific distress. RESULTS: Complicated grief disorder was found to be characterized by a smaller set of the assessed symptoms. Subjects elected by an algorithm for these symptoms patterns did not significantly overlap with subjects who received a diagnosis of major depressive disorder. CONCLUSIONS: A new diagnosis of complicated grief disorder may be indicated. Its criteria would include the current experience (more than a year after a loss) of intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep disturbances, and maladaptive levels of loss of interest in personal activities.

The crucial importance of empirical evidence in the development of bereavement theory: reply to Archer (2001).

In his commentary, J. Archer (2001a) argued that G. A. Bonanno and S. Kaltman's (1999) review and integration of the bereavement literature failed to consider evolutionary theory or other approaches to the origins of grief. Archer also argued that Bonanno and Kaltman had merely replaced the traditional grief work perspective with cognitive restructuring, thereby ignoring the processes related to avoidance and distancing from the loss. In this reply, the author first explains that although it was compelling to do so, Bonanno and Kaltman did not emphasize an evolutionary approach to the origins of grief reactions because in their current form these theories lack empirical and theoretical clarity. Second, the author shows that, contrary to Archer's reading, Bonanno and Kaltman's article viewed cognitive restructuring as a mechanism used primarily by extremely grieved persons and only in some cognitive domains. Last, the author shows that Bonanno and Kaltman have championed rather than ignored avoidant or distancing processes.

Toward an integrative perspective on bereavement.

For nearly a century, bereavement theorists have assumed that recovery from loss requires a period of grief work in which the ultimate goal is the severing of the attachment bond to the deceased. Reviews appearing in the 1980s noted a surprising absence of empirical support for this view, thus leaving the bereavement field without a guiding theoretical base. In this article, the authors consider alternative perspectives on bereavement that are based on cognitive stress theory, attachment theory, the social-functional account of emotion, and trauma theory. They then elaborate on the most promising features of each theory in an attempt to develop an integrative framework to guide future research. The authors elucidate 4 fundamental components of the grieving process--context, meaning, representations of the lost relationship, and coping and emotion-regulation processes--and suggest ways in which these components may interact over the course of bereavement.

The varieties of grief experience.

The bereavement literature has yet to show consensus on a clear definition of normal and abnormal or complicated grief reactions. According to DSM-IV, bereavement is a stressor event that warrants a clinical diagnosis only in extreme cases when other DSM categories of psychopathology (e.g., Major Depression) are evident. In contrast, bereavement theorists have proposed a number of different types of abnormal grief reactions, including those in which grief is masked or delayed. In this article, we review empirical evidence on the longitudinal course, phenomenological features, and possible diagnostic relevance of grief reactions. This evidence was generally consistent with the DSM-IV's view of bereavement and provided little support for more complicated taxonomies. Most bereaved individuals showed moderate disruptions in functioning during the first year after a loss, while more chronic symptoms were evidenced by a relatively small minority. Further, those individuals showing chronic grief reactions can be relatively easily accommodated by existing diagnostic categories. Finally, we found no evidence to support the proposed delayed grief category. We close by suggesting directions for subsequent research.

Interpersonal ambivalence, perceived relationship adjustment, and conjugal loss.

Ambivalence is widely assumed to prolong grief. To examine this hypothesis, the authors developed a measure of ambivalence based on an algorithmic combination of separate positive and negative evaluations of one's spouse. Preliminary construct validity was evidenced in relation to emotional difficulties and to facial expressions of emotion. Bereaved participants, relative to a nonbereaved comparison sample, recollected their relationships as better adjusted but were more ambivalent. Ambivalence about spouses was generally associated with increased distress and poorer perceived health but did not predict long-term grief outcome once initial outcome was controlled. In contrast, initial grief and distress predicted increased ambivalence and decreased Dyadic Adjustment Scale scores at 14 months postloss, regardless of initial scores on these measures. Limitations and implications of the findings are discussed.

Facial expressions of emotion and the course of conjugal bereavement.

The common assumption that emotional expression mediates the course of bereavement is tested. Competing hypotheses about the direction of mediation were formulated from the grief work and social-functional accounts of emotional expression. Facial expressions of emotion in conjugally bereaved adults were coded at 6 months post-loss as they described their relationship with the deceased; grief and perceived health were measured at 6, 14, and 25 months. Facial expressions of negative emotion, in particular anger, predicted increased grief at 14 months and poorer perceived health through 25 months. Facial expressions of positive emotion predicted decreased grief through 25 months and a positive but nonsignificant relation to perceived health. Predictive relations between negative and positive emotional expression persisted when initial levels of self-reported emotion, grief, and health were statistically controlled, demonstrating the mediating role of facial expressions of emotion in adjustment to conjugal loss. Theoretical and clinical implications are discussed.

A study of laughter and dissociation: distinct correlates of laughter and smiling during bereavement.

Laughter facilitates the adaptive response to stress by increasing the psychological distance from distress and by enhancing social relations. To test these hypotheses, the authors related measures of bereaved adults' laughter and smiling 6 months postloss to measures of their (a) subjective emotion and dissociation from distress, (b) social relations, and (c) responses they evoked in others. Duchenne laughter, which involves orbicularis oculi muscle action, related to self-reports of reduced anger and increased enjoyment, the dissociation of distress, better social relations, and positive responses from strangers, whereas non-Duchenne laughter did not. Lending credence to speculations in the ethological literature, Duchenne laughter correlated with different intrapersonal and interpersonal responses than Duchenne smiles. Discussion focuses on the relevance of these findings to theories of positive emotion.

When avoiding unpleasant emotions might not be such a bad thing: verbal-autonomic response dissociation and midlife conjugal bereavement.

It has been widely assumed that emotional avoidance during bereavement leads to either prolonged grief, delayed grief, or delayed somatic symptoms. To test this view, as well as a contrasting adaptive hypothesis, emotional avoidance was measured 6 months after a conjugal loss as negative verbal-autonomic response dissociation (low self-rated negative emotion coupled with heightened cardiovascular activity) and compared with grief measured at 6 and 14 months. The negative dissociation score evidenced reliability and validity but did not evidence the assumed link to severe grief. Rather, consistent with the adaptive hypothesis, negative dissociation at 6 months was associated with minimal grief symptoms across 14 months. Negative dissociation scores were also linked to initially high levels of somatic symptoms, which dropped to a low level by 14 months. Possible explanations for the initial cost and long-term adaptive quality of emotional avoidance during bereavement, as well as implications and limitations of the findings, are discussed.

Preference, familiarity, and recognition after repeated brief exposures to random geometric shapes.

Repeated one-millisecond exposures to random polygon targets have been shown to result in preference for the target shapes over similar distractor shapes in the absence of recognition (Knust-Wilson & Zajonc, 1980). Seamon, Brody, and Kauff (1983a) interpreted this preference-without-recognition effect in terms of a two-process model of recognition memory. The present set of experiments tested three predictions of the two-process model: Target discrimination equal to that found in the preference task should also occur when subjects make familiarity judgments; recognition performance should improve if the target stimuli are presented and tested with an easily encodable visual context; and both preference and familiarity judgments should be unaffected by manipulations of context. The results supported all three predictions. The implications of the results for a competing model proposed by Zajonc (1980) are also discussed.

Familial social support predicts a reduced cortisol response to stress in sexual minority young adults.

Social support has been repeatedly associated with mental and physical health outcomes, with hypothalamic-pituitary-adrenocortical (HPA) axis activity posited as a potential mechanism. The influence of social bonds appears particularly important in the face of stigma-related stress; however, there is a dearth of research examining social support and HPA axis response among members of a stigmatized group. To address this gap in the literature, we tested in a sample of 70 lesbian, gay, and bisexual (LGB) young adults whether family support or peer support differentially predict cortisol reactivity in response to a laboratory stressor, the Trier Social Stress Test. While greater levels of family support were associated with reduced cortisol reactivity, neither peer support nor overall support satisfaction was associated with cortisol response. These findings suggest that the association between social support and neuroendocrine functioning differs according to the source of support among members of one stigmatized group.

Doing and being well (for the most part): adaptive patterns of narrative self-evaluation during bereavement.

Narrative self-evaluation patterns were studied in relation to longitudinal measures of adaptation to the death of a spouse in midlife. Narrative self-evaluations, identified in open-ended interview transcripts at 6 months post-loss, were coded as either positive or negative and as either doing-based (evaluations of "what one does") or being-based (evaluations of "what one is"). These narrative variables were then compared with separate, clinical-interview measures of grief at 6, 14, and 25 months post-loss. Results confirmed 3 predictions. First, participants who made an optimal proportion of positive to negative self-evaluations (approximately a 5:1 positive-to-negative ratio) had lower grief levels over time than did those who made either higher or lower proportions. Second, the tendency to focus on evaluations of what one does rather than what one is predicted lower grief levels over time. Third, participants who directly integrated doing-based and being-based self-evaluations had lower grief levels over time than those who did not link the 2 evaluations. Implications for the narrative construction of personal meaning and identity in relation to adaptation are discussed.

Pathological grief: diagnosis and explanation.

Pathological grief deserves a place in the diagnostic nomenclature. Because posttraumatic stress disorder requires an event beyond the range of usual experience and bereavement is virtually a universal experience, a new diagnosis of signs and symptoms precipitated by a loss event is needed. Many varieties of pathological grief have been noted in clinical research studies, and multiple diagnoses of pathological grief would make research difficult. The authors advance a solution in a personality-based explanation of abnormal responses to loss events; this allows for a single diagnosis of pathological grief. The authors also present a predictive model to partially explain pathological grief by antecedent trait combinations. The hypothesis is that persons with a preloss combination of both contradictions in relational schemas about the deceased and tendencies toward excessive control to stifle unwanted affect will tend to have unsuccessful processes of mourning. Types of contradictions and overcontrol may vary, yielding personality-based varieties of response within a single diagnostic category.

"It was never that bad": biased recall of grief and long-term adjustment to the death of a spouse.

At 6 months following the death of their spouse, 37 participants reported their grief-related symptoms and thoughts, and then, approximately 4.5 years later, they attempted to recall how they felt at the time of the 6-month report. Although participants were far less distressed at recall than initially, they recalled their 6-month grief rather accurately. Participants did however overestimate prior grief-related intrusive ideation. Participant's current level of grief predicted what they recalled slightly better than the actual initial grief. Conversely, what they recalled predicted current levels of grief across various measures. Participants whose grief diminished relatively little over time tended to overestimate prior grief more. The retrospective reappraisal that one's past grief was not severe may indicate effective coping.

Prediction of complicated grief by positive and negative themes in narratives.

A narrative coding system was employed to investigate the thematic parameters of complicated grief among participants who had recently experienced spousal loss. Two goals guided the research. First, we investigated the prevalence of and interrelationship between positive and negative themes in a narrative interview conducted 6 months into bereavement. The coding system was modeled after Erikson's (1982) scheme of crises solutions across the life span. Second, we examined the relationship of these themes to various symptom measures obtained at 6- and 14 months postloss. Results revealed no systematic relationship between corresponding positive and negative themes. Aggregated positive and negative themes showed significant correlations with 6-month measures of intrusion and avoidance and, as predicted, with various 14-month symptom levels. Regression analyses revealed that positive themes explained significant portions of 14-month symptom variance, even when 6-month symptom scores were controlled. Findings are discussed with regard to conceptualizations of grief as a stress response syndrome, where intrusive processes (e.g., in narration) are of importance.

When children tell their friends they have AIDS: possible consequences for psychological well-being and disease progression.

OBJECTIVE: Past research has demonstrated that self-disclosure of traumatic or secretive information produces observable health benefits. Self-disclosure has also been linked, albeit less consistently, to improved psychological health. The present study examined the physiological and psychological consequences of children's self-disclosure of their HIV/AIDS status to friends. METHODS: Data were collected twice, one year apart, from 64 caregiver-child dyads in which all of the children were infected with HIV. Dependent variables included the child's CD4%, self-concept, and level of behavioral problems. RESULTS: Children who had disclosed their HIV+ diagnosis to friends during the 1-year course of the study had a significantly larger increase in CD4% than children who had told their friends before the study or those children who had not yet disclosed their HIV+ diagnosis to friends. This effect remained significant when the child's age and level of medication (protease inhibitors) were statistically controlled. Self-disclosure to friends did not impact the child's behavior or self-concept. CONCLUSIONS: This is the first study to investigate the effect of self-disclosure in children. The results were consistent with previous studies showing the positive health consequences of self-disclosure in adults, and suggest potentially important implications for professional and familial care givers of HIV/AIDS individuals.