A case report to understand the use of an evidence-based approach of prolonged grief therapy in Chinese culture.

Prolonged grief disorder (PGD) is a new diagnosis that may cause significant functional impairment. Prolonged grief therapy (PGT) is a manualized 16-session intervention, whose efficacy has been demonstrated in studies primarily from Western cultures. The current report aimed to present a case to illustrate the use of PGT in Chinese culture. The client was a bereaved adult suffering from PGD after the death of her mother ten years ago. Additionally, she lost her father three months ago. Questionnaires were completed before and after treatment. In-depth interview was conducted at a 3-month follow-up. The client's scores for grief, functional impairment, grief-related beliefs and avoidance, depression and insomnia all decreased substantially after treatment. The follow-up feedbacks indicated that the beneficial effects of PGT persisted in the client's life. This case report provides preliminary evidence that bereaved people in China could benefit greatly from PGT, with minimal cultural adaptation.

Latent class analysis of grief-related beliefs among recently bereaved adults.

Grief-related beliefs play an important role in bereavement adjustment. This study aimed to investigate the patterns and correlates of grief-related beliefs among recently bereaved adults (n = 311). Latent class analysis results suggested three meaningful grief belief classes could be identified: the High grief belief class (24.1%), Predominantly counterfactual thoughts class (42.4%), and Low belief class (33.4%). Members in the High grief belief class reported the highest levels of grief symptoms, depression and PTSD symptoms, loneliness, and functional impairment. Compared with the Low belief class, unmarried people, people in poor health, individuals who lost parents, partners, or children, and those who experienced violent or unexpected death were more likely to belong to the High grief belief class. Findings of this study support the importance of examining grief-related cognitions in research and clinical practice, especially counterfactual thoughts about the death, which may need to be specifically screened and targeted in treatment.

Grief-related beliefs in shidu parents with and without prolonged grief disorder: Psychometric properties of a Chinese version of the Typical Beliefs Questionnaire.

The Typical Beliefs Questionnaire (TBQ) assesses common grief-related cognitions, which demonstrated satisfactory psychometric properties in a treatment-seeking sample with prolonged grief disorder (PGD). Chinese shidu parents (bereaved parents over the age of 49 who have lost their only child) are at a high risk of PGD. The current study aimed to examine psychometric properties of the Chinese version of the TBQ (TBQ-C) in a community sample of shidu parents with and without PGD, to compare this to the original validation clinical sample in the United States bereaved of any close relationship and to consider its use as a clinical tool. We examined the rate of positive endorsement, factor structure, internal consistency and validity of the TBQ-C in 310 community-based shidu parents (including 102 who met the criteria for PGD). Results showed that the rate of positive endorsement for each item ranged from 7.2% to 48.6% among non-PGD participants and from 20.6% to 92.2% among PGD participants. Confirmatory factor analysis indicated that the original five-factor structure fit both the non-PGD and PGD shidu parents. The TBQ-C showed acceptable internal consistency and satisfactory convergent and concurrent validity in both groups. It had good discriminant validity and can be helpful in distinguishing shidu parents with and without PGD. The TBQ-C can be used to investigate common grief-related beliefs that may be problematic for both shidu parents with and without PGD.

Change in avoidance and negative grief-related cognitions mediates treatment outcome in older adults with prolonged grief disorder.

Objective: The present study investigated the role of the two theoretically derived mediators in the treatment of Prolonged Grief Disorder (PGD). Mediators were changes in avoidance and maladaptive cognitions. An additional hypothesis tested whether these candidate mediators are specific to CBT-based Complicated Grief Treatment (CGT) compared to Interpersonal Therapy (IPT). Method: We performed secondary analyses with assessment completers (n = 131) from a randomized-controlled trial with older adults with PGD. Patients received 16 sessions of CGT or IPT. Outcomes were treatment response and reductions in grief symptoms and grief-related related impairment. Results: Reductions in avoidance between baseline and week 16 mediated reductions in grief symptoms and grief-related impairment. Reductions in maladaptive grief-related cognitions over the same period mediated treatment response, reductions in grief symptoms and grief-related impairment. There were no significant treatment-mediator interactions. We could not establish that mediators changed before the outcomes. Conclusion: Results are consistent with theoretical models of PGD, including the CGT treatment model. Despite different therapeutic procedures, we found no significant interaction effect, but CGT produced larger effects. Future research needs to establish a timeline of change through the use of multiple measurements of mediators and outcomes.Trial registration: ClinicalTrials.gov identifier: NCT01244295.

Optimizing the clinical utility of four proposed criteria for a persistent and impairing grief disorder by emphasizing core, rather than associated symptoms.

BACKGROUND: Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated. METHODS: Participants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms. RESULTS: All four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86-96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47-82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly 'very good' (κ = 0.86-0.96). CONCLUSIONS: The four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.

Grief Before and After Bereavement in the Elderly: An Approach to Care.

Grief is the natural response to the death of a loved one and is encountered frequently in clinical practice with the elderly; it can also precede the death. Knowledge about four distinct forms of grief can aid clinicians with the conceptualization of grief, and the assessment and care of grievers. First, predeath grief is experienced by many caregivers of terminally ill patients. Second, acute grief arises immediately after the death of a loved one; and third, this normally evolves to a permanent state of integrated grief after a process of adaptation. Finally, failure of adaptation results in Prolonged Grief Disorder (PGD) which has been recently included in ICD-11. The hallmark feature of PGD is intense longing for the deceased or persistent preoccupation with the deceased that lasts longer than 6 months after the death. Validated instruments are available to assist practitioners with assessment of predeath grief and screening for PGD, thereby enabling identification of patients in need of additional support. Increased risks of morbidity and mortality following bereavement are important health issues for clinicians to be aware of. All grievers can benefit from support focused on understanding their grief, managing emotional pain, thinking about the future, strengthening their relationships, telling the story of the death, learning to live with reminders of the deceased, and connecting with memories. A short-term evidence-based intervention for PGD is based upon these seven themes and is efficacious in the elderly. Caregivers of the terminally ill benefit from psychological support that validates and normalizes their grief experiences and helps them recognize and accept their losses.

Changes in typical beliefs in response to complicated grief treatment.

BACKGROUND: Prolonged grief disorder (PGD) is a new diagnosis in the 11th edition of the International Classification of Diseases, estimated to affect 1 in 10 bereaved people and causing significant distress and impairment. Maladaptive thoughts play an important role in PGD. We have previously validated the typical beliefs questionnaire (TBQ), which contains five kinds of thinking commonly seen in PGD: protesting the death, negative thoughts about the world, needing the person, less grief is wrong, and grieving too much. The current paper examines the role of maladaptive cognition as measured by the TBQ in PGD and its change with treatment. METHODS: Among participants in a multisite clinical trial including 394 adults, we examined (a) the relationship between maladaptive thoughts at baseline and treatment outcomes, (b) the relationship between maladaptive thoughts and suicidality at baseline and posttreatment, and (c) the effect of treatment with and without complicated grief therapy (CGT) on maladaptive thinking. RESULTS: TBQ scores were associated with treatment outcomes and were strongly related to suicidal thinking before and after treatment. TBQ scores showed significantly greater reduction in participants who received CGT with citalopram versus citalopram alone (adjusted mean standard error [SE] difference, -2.45 [0.85]; p = .004) and those who received CGT with placebo versus placebo alone (adjusted mean [SE] difference, -3.44 [0.90]; p < .001). CONCLUSIONS: Maladaptive thoughts, as measured by the TBQ, have clinical and research significance for PGD and its treatment.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis.

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Impact of sleep on complicated grief severity and outcomes.

BACKGROUND: Complicated grief (CG) is characterized by persistent, impairing grief after losing a loved one. Little is known about sleep disturbance in CG. Baseline prevalence of subjective sleep disturbance, impact of treatment on sleep, and impact of mid-treatment sleep on CG and quality of life outcomes were examined in adults with CG in secondary analyses of a clinical trial. METHODS: Patients with CG (n = 395, mean age =53.0; 78% female) were randomized to CGT+placebo, CGT+citalopram (CIT), CIT, or placebo. Subjective sleep disturbance was assessed by a grief-anchored sleep item (Pittsburgh Sleep Quality Index: PSQI-1) and a four-item sleep subscale of the Quick Inventory of Depressive Symptomatology (QIDS-4). Sleep disturbance was quantified as at least one QIDS-4 item with severity ≥2 or grief-related sleep disturbance ≥3 days a week for PSQI-1. Outcomes included the Inventory of Complicated Grief (ICG), Work and Social Adjustment Scale (WSAS), and Clinical Global Impressions Scale. RESULTS: Baseline sleep disturbance prevalence was 91% on the QIDS-4 and 46% for the grief-anchored PSQI-1. Baseline CG severity was significantly associated with sleep disturbance (QIDS-4: p = .015; PSQI-1: p = .001) after controlling for comorbid depression and PTSD. Sleep improved with treatment; those receiving CGT+CIT versus CIT evidenced better endpoint sleep (p = .027). Mid-treatment QIDS-4 significantly predicted improvement on outcome measures (all p < .01), though only WSAS remained significant after adjustment for mid-treatment ICG (p = .02). CONCLUSIONS: Greater CG severity is associated with poorer sleep beyond PTSD and depression comorbidity. Additional research including objective sleep measurement is needed to optimally elucidate and address sleep impairment associated with CG.

Prolonged grief disorder: clinical utility of ICD-11 diagnostic guidelines.

BACKGROUND: The World Health Organization (WHO) International Classification of Disease (ICD-11) is expected to include a new diagnosis for prolonged grief disorder (ICD-11PGD). This study examines the validity and clinical utility of the ICD-11PGD guideline by testing its performance in a well-characterized clinical sample and contrasting it with a very different criteria set with the same name (PGDPLOS). METHODS: We examined data from 261 treatment-seeking participants in the National Institute of Mental Health (NIMH)-sponsored multicenter clinical trial to determine the rates of diagnosis using the ICD-11PGD guideline and compared these with diagnosis using PGDPLOS criteria. RESULTS: The ICD-11PGD guideline identified 95.8% [95% confidence interval (CI) 93.3-98.2%] of a treatment-responsive cohort of patients with distressing and impairing grief. PGDPLOS criteria identified only 59.0% (95% CI 53.0-65.0%) and were more likely to omit those who lost someone other than a spouse, were currently married, bereaved by violent means, or not diagnosed with co-occurring depression. Those not diagnosed by PGDPLOS criteria showed the same rate of treatment response as those who were diagnosed. CONCLUSIONS: The ICD-11PGD diagnostic guideline showed good performance characteristics in this sample, while PGDPLOS criteria did not. Limitations of the research sample used to derive PGDPLOS criteria may partly explain their poor performance in a more diverse clinical sample. Clinicians and researchers need to be aware of the important difference between these two identically named diagnostic methods.

Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics.

BACKGROUND: Complicated grief, a syndrome of persistent grief diagnosed >6 months following the loss of someone close is expected to be included in the 11th revision of the International Classification of Diseases as a new diagnosis called prolonged grief disorder. Complicated grief is associated with impaired functioning and health comorbidity and does not respond to treatments for depression. Individuals may seek help in primary care where providers need to be familiar with the syndrome. OBJECTIVE: This study examines the acceptability, feasibility and outcome of a screening programme for complicated grief among diverse adults receiving behavioural health services in integrated primary care. METHODS: Behavioural health providers (n = 14) administered the Brief Grief Questionnaire and the Inventory of Complicated Grief during routine assessment and completed an acceptability survey. Descriptive statistics described rates of complicated grief symptoms and sample demographics, health and service use. RESULTS: Most providers (71%) reported the Brief Grief Questionnaire to be a moderate to very useful assessment instrument and the Inventory of Complicated Grief moderate to very useful for developing a treatment plan (57%). Of the 2425 patients screened, 1015 reported a loss over 6 months ago. Of these 1015, 28% (n = 282) screened positive on the Brief Grief Questionnaire and 22% (n = 228) endorsed symptoms of complicated grief (Inventory of Complicated Grief score ≥25), considered at high risk for needing clinical care. CONCLUSIONS: A screening programme for identifying complicated grief was acceptable to providers, feasible to implement and useful in identifying complicated grief in integrated primary care clinics.

Measuring Maladaptive Cognitions in Complicated Grief: Introducing the Typical Beliefs Questionnaire.

OBJECTIVES: Maladaptive cognitions related to loss are thought to contribute to development of complicated grief and are crucial to address in treatment, but tools available to assess them are limited. This paper introduces the Typical Beliefs Questionnaire (TBQ), a 25-item self-report instrument to assess cognitions that interfere with adaptation to loss. DESIGN: Study participants completed an assessment battery during their initial evaluation and again after completing treatment at 20 weeks. Test-retest reliability was assessed on a subsample of the participants who did not show change in complicated grief severity after the first 4 weeks of treatment. To examine latent structure of the TBQ, an exploratory factor analysis (EFA) was performed. SETTING: Academic medical centers in Boston, New York, Pittsburgh, and San Diego from 2010-2014. PARTICIPANTS: 394 bereaved adults who met criteria for complicated grief. MEASUREMENTS: The TBQ along with assessments of complicated grief symptoms and related avoidance, depression symptoms, functional impairment, and perceived social support. RESULTS: The TBQ exhibited good internal consistency (α = 0.82) and test-retest reliability (N = 105; intraclass correlation coefficient = 0.74). EFA indicated a five-factor structure: "Protesting the Death," "Negative Thoughts About the World," "Needing the Person," "Less Grief is Wrong" and "Grieving Too Much." The total score and all factors showed sensitivity to change with treatment. CONCLUSIONS: This new tool allows a clinician to quickly and reliably ascertain presence of specific maladaptive cognitions related to complicated grief, and subsequently, to use the information to aid a diagnostic assessment, to structure the treatment, and to measure treatment outcomes.

Complicated grief after suicide bereavement and other causes of death.

The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.

THE STRUCTURED CLINICAL INTERVIEW FOR COMPLICATED GRIEF: RELIABILITY, VALIDITY, AND EXPLORATORY FACTOR ANALYSIS.

BACKGROUND: Complicated grief (CG) has been recently included in the DSM-5, under the term "persistent complex bereavement disorder," as a condition requiring further study. To our knowledge, no psychometric data on any structured clinical interview for CG (SCI-CG) is available to date. In this manuscript, we introduce the SCI-CG, a 31-item "SCID-like" clinician-administered instrument to assess the presence of CG symptoms. METHODS: Participants were 281 treatment-seeking adults with CG (77.9% [n = 219] women, mean age = 52.4, standard deviation [SD] = 17.8) who were assessed with the SCI-CG and measures of depression, posttraumatic stress, anxiety, functional impairment. RESULTS: The SCI-CG exhibited satisfactory internal consistency (α = .78), good test-retest reliability (interclass correlation [ICC] 0.68, 95% CI [0.60-0.75]), and excellent interrater reliability (ICC = 0.95, 95% CI [0.89-0.98]). Exploratory factor analyses revealed that a five-factor structure, explaining 50.3% of the total variance, was the best fit for the data. CONCLUSIONS: The clinician-rated SCI-CG demonstrates good internal consistency, reliability, and convergent validity in treatment-seeking individuals with CG and therefore can be a useful tool to assess CG. Although diagnostic criteria for CG have yet to be adequately validated, the SCI-CG may facilitate this process. The SCI-CG can now be used as a validated instrument in research and clinical practice.

Periloss dissociation, symptom severity, and treatment response in complicated grief.

BACKGROUND: Complicated grief (CG) is a bereavement-specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e., periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD-adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop-out rate. METHODS: PLD data collected as part of a randomized controlled trial of two loss-focused psychotherapy approaches for CG were examined. Treatment-seeking individuals with primary CG (n = 193) were assessed for PLD at the initial visit, 95 of whom were randomized and completed at least one treatment session. RESULTS: The PLD-adapted Peritraumatic Dissociative Experiences Questionnaire was found to be internally consistent (α = 0.91) with good convergent and divergent validity. After controlling for age, gender, time since loss, and current comorbid psychiatric diagnosis, self-reported PLD was associated with greater CG symptom severity (P < .01). However, contrary to our hypotheses, after controlling for age, baseline symptoms severity, psychiatric comorbidity, and treatment arm, PLD was predictive of better treatment response (P < .05) and lower study discontinuation (P < .01). CONCLUSIONS: PLD may be useful in identifying individuals at risk for CG and those who might respond to psychotherapy. Additional research should investigate the relationship of PLD with treatment outcome for different treatment approaches, and whether PLD prospectively predicts the development of CG.

A Web-Based Therapist Training Tutorial on Prolonged Grief Disorder Therapy: Pre-Post Assessment Study.

BACKGROUND: Prolonged grief disorder (PGD) is a newly recognized mental disorder characterized by pervasive intense grief that persists longer than cultural or social expectations and interferes with functioning. The COVID-19 epidemic has resulted in increased rates of PGD, and few clinicians feel confident in treating this condition. PGD therapy (PGDT) is a simple, short-term, and evidence-based treatment developed in tandem with the validation of the PGD diagnosis. To facilitate the dissemination of PGDT training, we developed a web-based therapist tutorial that includes didactic training on PGDT concepts and principles as well as web-based multimedia patient scenarios and examples of clinical implementation of PGDT. OBJECTIVE: We aimed to evaluate user satisfaction with the tutorial and whether the tutorial increased trainees' knowledge of PGDT principles and procedures. Moreover, we included a small number of pilot questions to evaluate the PGDT-related clinical skills. METHODS: This study evaluated tutorial learning using a pre- and poststudy design. Participants were recruited from professional organization mailing lists, announcements to graduates of the Columbia School of Social Work, and through word of mouth. After signing consent, participants completed a brief demographic survey, a 55-item multiple-choice prestudy test on the concepts and principles of PGD and PGDT covered in the tutorial, and a 4-item pilot web-based prestudy test to gauge PGD clinical implementation skills. The link to the course content was then activated, and participants were given 8 weeks to complete the 11-module tutorial containing information, web-based exercises, simulated patient and video examples, and self-tests. RESULTS: Overall, 406 clinicians signed consent, and 236 (58.1%) started the tutorial. Of these, 83.1% (196/236) completed all 11 modules. Trainee scores on our PDGT assessment improved substantially from pretraining to the postmodule assessment, with the total number of correct answers increasing from a mean of 29 (SD 5.5; 52.7% correct) to 36.7 (SD 5.2; 66.7% correct; t195=18.93; P<.001). In addition, the trainee's implementation scores on 4 clinical vignettes increased from 2.6 (SD 0.7) correct out of 4 to 3.1 (SD 0.4) out of 4 (t188=7.02; P<.001). Effect sizes (Cohen d) were 1.44 (95% CI 1.23-1.65) for PDGT assessment and 1.06 (95% CI 0.84-1.29) for implementation. Trainees found the tutorial interesting, enjoyable, clearly presented, and useful for professional development. They endorsed a mean score of 3.7 (SD 0.47) on a 1 to 4 scale of agreement with recommending the course to others and feeling satisfied with the tutorial, and a mean of 3.3 (SD 0.57) with feeling able to apply the skills with clients. CONCLUSIONS: This pilot study provides support for the usefulness of this web-based training for teaching clinicians how to administer PGDT. The addition of patient scenarios for clinical implementation strategies holds promise for increasing the effectiveness of PGDT training and other evidence-based treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT05121792; https://www.clinicaltrials.gov/ct2/show/NCT05121792.

A clinician-administered severity rating scale for illness anxiety: development, reliability, and validity of the H-YBOCS-M.

BACKGROUND: Clinician-administered measures to assess severity of illness anxiety and response to treatment are few. The authors evaluated a modified version of the hypochondriasis-Y-BOCS (H-YBOCS-M), a 19-item, semistructured, clinician-administered instrument designed to rate severity of illness-related thoughts, behaviors, and avoidance. METHODS: The scale was administered to 195 treatment-seeking adults with DSM-IV hypochondriasis. Test-retest reliability was assessed in a subsample of 20 patients. Interrater reliability was assessed by 27 interviews independently rated by four raters. Sensitivity to change was evaluated in a subsample of 149 patients. Convergent and discriminant validity was examined by comparing H-YBOCS-M scores to other measures administered. Item clustering was examined with confirmatory and exploratory factor analyses. RESULTS: The H-YBOCS-M demonstrated good internal consistency, interrater and test-retest reliability, and sensitivity to symptom change with treatment. Construct validity was supported by significant higher correlations with scores on other measures of hypochondriasis than with nonhypochondriacal measures. Improvement over time in response to treatment correlated with improvement both on measures of hypochondriasis and on measures of somatization, depression, anxiety, and functional status. Confirmatory factor analysis did not show adequate fit for a three-factor model. Exploratory factor analysis revealed a five-factor solution with the first two factors consistent with the separation of the H-YBOCS-M items into the subscales of illness-related avoidance and compulsions. CONCLUSIONS: H-YBOCS-M appears to be valid, reliable, and appropriate as an outcome measure for treatment studies of illness anxiety. Study results highlight "avoidance" as a key feature of illness anxiety-with potentially important nosologic and treatment implications.

Bereavement and anxiety.

Bereavement, one of life's most difficult experiences, usually triggers acute grief with yearning and longing for the deceased person that is often intense and preoccupying, along with frequent thoughts and memories of the person who died and relatively little interest in anything unrelated to the deceased loved one. Anxiety is a very common feature of grief that is often neglected. Anxiety is a natural response of the attachment system to separation from a loved one, seen in adults as well as children. Confrontation with one's own death is also a natural trigger of anxiety, though we usually protect ourselves from mortality salience using terror management strategies related to cultural values and self-esteem. In addition, loss of a loved one can trigger the onset of a DSM-IV anxiety disorder that, when present, can derail the mourning process and prolong acute grief. Bereavement-related anxiety disorders need to be recognized and treated.

Complicated grief and related bereavement issues for DSM-5.

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.

Posttraumatic Distress Symptoms and Their Response to Treatment in Adults With Prolonged Grief Disorder.

OBJECTIVE: Posttraumatic stress disorder and prolonged grief disorder (PGD) arise following major life stressors and may share some overlapping symptomatology. This study aimed to examine the presence and response to treatment of posttraumatic stress symptoms (PTSS) in bereaved adults with a primary diagnosis of PGD. METHODS: A randomized controlled trial of 395 adults with PGD (defined as an Inventory of Complicated Grief score ≥ 30 plus confirmation on structured clinical interview) randomly assigned participants to either complicated grief treatment (CGT) with citalopram, CGT plus placebo, citalopram, or placebo between March 2010 and September 2014. This secondary analysis examined the presence of PTSS (per the Davidson Trauma Scale) at baseline and change in PTSS with treatment using longitudinal mixed-effects regression and examined the role of violent compared to nonviolent deaths (loss type). RESULTS: High levels of PTSS were present at baseline, regardless of loss type, and were associated with increased functional impairment (P < .001). CGT with placebo demonstrated efficacy for PTSS compared to placebo in both threshold (OR = 2.71; 95% CI, 1.13-6.52; P = .026) and continuous (P < .001; effect size d = 0.47) analyses, and analyses were suggestive of a greater effect for CGT plus citalopram compared to citalopram alone (threshold analysis: OR = 2.84; 95% CI, 1.20-6.70; P = .017; continuous analysis: P = .053; d = 0.25). In contrast, citalopram did not differ from placebo, and CGT plus citalopram did not differ from CGT plus placebo. CONCLUSIONS: Bereavement-related PTSS are common in bereaved adults with PGD in the context of both violent and nonviolent death and are associated with poorer functioning. CGT shows efficacy for PTSS, while the antidepressant citalopram does not. TRIAL REGISTRATION: : ClinicalTrials.gov identifier: NCT01179568.