Nightmare Disorder, Psychopathology Levels, and Coping in a Diverse Psychiatric Sample.

OBJECTIVE: Nightmares are associated with psychopathology and impaired coping in the general population. However, little is known about this association in a psychiatric population. In this study, we investigate whether patients with diverse psychiatric disorders have increased symptomatology and different coping styles if they suffer from comorbid nightmare disorder. METHOD: Participants were 498 patients with diverse moderate to severe psychiatric disorders. As part of a standard assessment procedure, they filled out questionnaires regarding nightmares, psychopathology, personality pathology, and coping. RESULTS: A multivariate analysis of covariance and post hoc tests showed that patients with nightmare disorder scored higher on psychopathology (ηp2 = .03; p = .001) and personality pathology (ηp2 = .01-.03; p < .05). No significant differences were found with regards to coping strategies. CONCLUSION: Nightmare disorder is associated with higher levels of psychopathology and personality pathology in a sample of patients with diverse psychiatric disorders.

Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial.

This study examined the effectiveness and feasibility of therapist-guided Internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N=18), BA (N=17), or a waiting-list (N=12). Treatment groups received 6 homework assignments over 6 to 8weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination, and brooding levels relative to the control group at posttreatment (d=0.7-1.2). BA lowered complicated grief, posttraumatic stress, and grief rumination levels at posttreatment (d=0.8-0.9). At 3-month follow-up, effects of EX were maintained on complicated grief and grief rumination (d=0.6-1.2), and for BA on complicated grief, posttraumatic stress, and grief rumination (d=0.8-0.9). EX reduced depression more strongly than BA (d=0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.

Imagery rehearsal therapy in addition to treatment as usual for patients with diverse psychiatric diagnoses suffering from nightmares: a randomized controlled trial.

OBJECTIVE: Nightmares are associated with psychopathology and daily distress. They are highly prevalent in a psychiatric population (30%). Currently, imagery rehearsal therapy (IRT) is the treatment of choice for nightmares. With IRT, the script of the nightmare is changed into a new dream, which is imagined during the day. However, the effects of IRT in a psychiatric population remain unknown. The aim of this study was to determine the effectiveness of IRT in a heterogeneous psychiatric population. METHOD: Between January 2006 and July 2010, 90 patients with psychiatric disorders (DSM-IV-TR) were randomized to IRT or treatment-as-usual conditions. IRT consisted of 6 individual sessions added to the treatment as usual. Nightmare frequency was assessed using daily nightmare logs and the Nightmare Frequency Questionnaire. Nightmare distress was assessed using the Nightmare Distress Questionnaire and the Nightmare Effects Survey. General psychiatric symptoms were assessed using the Symptom Checklist-90 and a PTSD symptom questionnaire. Assessments were administered at the start of the trial, after the IRT and at follow-up 3 months later. RESULTS: IRT showed a moderate effect (Cohen d = 0.5-0.7, P < .05) on nightmare frequency, nightmare distress, and psychopathology measures compared with treatment as usual. These effects were largely sustained at the 3-month follow-up (Cohen d = 0.4-0.6, P < .10). CONCLUSIONS: IRT is an effective treatment for nightmares among patients with comorbid psychiatric disorders and can be employed in addition to the on-going treatment. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00291031.

Adaptive and maladaptive rumination after loss: A three-wave longitudinal study.

OBJECTIVES: Rumination is a risk factor after bereavement, predicting higher concurrent and prospective symptom levels of complicated grief and depression in mourners. Research has shown that rumination may consist of adaptive and maladaptive subtypes, but there has been a paucity of research in this topic in the bereavement area. Therefore, we aimed to clarify whether functional and dysfunctional forms of rumination can be distinguished after loss. DESIGN: Two-hundred and forty-two adults, who lost a first-degree family member on average 10 months previously, filled out questionnaires at three time points with 6 months between each time point. METHODS: Multiple regression analyses, controlled for loss-related variables, neuroticism, and baseline symptoms, were run to examine associations of subtypes of depressive rumination (brooding, reflection) and grief rumination (rumination about injustice, meaning, reactions, relationships and counterfactual thinking) with concurrent and prospective symptom levels of complicated grief and depression. RESULTS: Overall, grief rumination explained more variance in symptom levels than depressive rumination. Other major findings were that grief rumination about injustice predicted higher concurrent and prospective symptom levels of complicated grief and higher prospective symptom levels of depression. In contrast, grief rumination about emotional reactions was related to prospective reductions in symptoms of complicated grief. Reflection was also associated with prospective reductions of complicated grief and depressive symptom levels. CONCLUSIONS: Results indicate that adaptive and maladaptive forms of ruminative thinking can be distinguished in bereaved individuals. Therapeutic interventions for complicated grief could potentially be improved by including techniques aimed at reducing maladaptive rumination and increasing adaptive rumination. PRACTITIONER POINTS: Clinical implications: Adaptive and maladaptive components of rumination after loss can be distinguished. They are differentially associated with concurrent and prospective symptom levels of complicated grief and depression in mourners. Adaptive rumination after bereavement is characterized by repetitive, self-focused thinking aimed at understanding one's depressive and loss-related emotional reactions. Maladaptive rumination is characterized by repetitive, self-focused thinking about injustice to the self and making passive comparisons between the current situation (in which one has experienced a loss) and unrealized alternatives. Psychological interventions for complicated grief may be improved by adding therapeutic techniques aimed at reducing maladaptive rumination and increasing adaptive rumination. Cautions and limitations: This investigation relied exclusively on self-report measures. Conjugally bereaved women were overrepresented in the current sample. Complicated grief and depression levels in the current sample ranged from non-clinical to clinical. Effects may be more pronounced in a clinical sample.

Rumination and implicit avoidance following bereavement: an approach avoidance task investigation.

BACKGROUND AND OBJECTIVES: Rumination, a risk factor in adjustment to bereavement, has often been considered a confrontation process. However, building on research on worry in generalized anxiety disorder (GAD) and rumination in post-traumatic stress disorder (PTSD), researchers recently developed the Rumination as Avoidance Hypothesis (RAH), which states that rumination after bereavement serves to avoid the reality of the loss. In the present study, RAH was tested by investigating if rumination is associated with implicit loss avoidance. METHODS: An Approach Avoidance Task (AAT) was used to assess automatic behavior tendencies. Using a joystick, 71 persons who recently lost a first-degree relative (90.1% women), pulled stimuli toward themselves or pushed them away from themselves. Stimuli represented the loss (picture deceased + loss word), were loss-related but ambiguous (picture deceased + neutral word; picture stranger + loss word), or were non-loss-related (picture stranger + neutral word; puzzle picture + X's). RESULTS: Participants who ruminated more were relatively faster in pushing loss stimuli away from themselves and slower in pulling loss stimuli towards themselves, implying more rumination was associated with stronger implicit loss avoidance. Effects were maintained after controlling for depressive or post-traumatic stress symptom levels, but not when controlling for prolonged grief symptom levels. LIMITATIONS: Conjugally bereaved women were overrepresented in the sample, which limits generalizability of results. The study was correlational, precluding causal inferences. CONCLUSIONS: In line with RAH, rumination was positively associated with loss avoidance. This may indicate that the application of exposure-based techniques can reduce rumination and loss-related psychopathology.

Is rumination after bereavement linked with loss avoidance? Evidence from eye-tracking.

Rumination is a risk factor in adjustment to bereavement. It is associated with and predicts psychopathology after loss. Yet, the function of rumination in bereavement remains unclear. In the past, researchers often assumed rumination to be a maladaptive confrontation process. However, based on cognitive avoidance theories of worry in generalised anxiety disorder (GAD) and rumination after post-traumatic stress disorder (PTSD), others have suggested that rumination may serve to avoid painful aspects of the loss, thereby contributing to complicated grief. To examine if rumination is linked with loss avoidance, an eye-tracking study was conducted with 54 bereaved individuals (27 high and 27 low ruminators). On 24 trials, participants looked for 10 seconds at a picture of the deceased and a picture of a stranger, randomly combined with negative, neutral or loss-related words. High ruminators were expected to show initial vigilance followed by subsequent disengagement for loss stimuli (i.e., picture deceased with a loss word) in the first 1500 ms. Additionally, we expected high ruminators to avoid these loss stimuli and to show attentional preference for non-loss-related negative stimuli (i.e., picture stranger with a negative word) on longer exposure durations (1500-10000 ms). Contrary to expectations, we found no evidence for an effect of rumination on vigilance and disengagement of loss stimuli in the first 1500 ms. However, in the 1500-10000 ms interval, high ruminators showed shorter gaze times for loss stimuli and longer gaze times for negative (and neutral) non-loss-related stimuli, even when controlling for depression and complicated grief symptom levels. Effects of rumination on average fixation times mirrored these findings. This suggests that rumination and loss avoidance are closely associated. A potential clinical implication is that rumination and grief complications after bereavement may be reduced through the use of exposure and acceptance-based therapeutic techniques.

The effect of support on internet-delivered treatment for insomnia: does baseline depression severity matter?

Internet-delivered cognitive-behavioral treatment is effective for insomnia. However, little is known about the beneficial effects of support. Recently we demonstrated that motivational support moderately improved the effects of Internet-delivered treatment for insomnia. In the present study, we tested whether depressive symptoms at baseline moderate the effect of support on Internet-delivered treatment for insomnia. We performed a multilevel intention-to-treat analysis on 262 participants in a randomized controlled trial. We found that baseline depressive symptoms moderated the effect of support on sleep efficiency, total sleep time, and sleep onset latency (but not on wake after sleep onset, number of nightly awakenings, or the Insomnia Severity Index). This means that for these variables, people with high levels of depressive symptoms benefit from support, whereas people with low levels of depressive symptoms improve regardless of support. The data show that baseline depression severity plays an important role in the way Internet treatments need to be delivered. These findings open up opportunities to personalize the support offered in Internet-delivered treatments.

Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss.

Ruminative coping has been associated with negative outcomes in bereavement. Rather than assuming it to be a problematic confrontation process, researchers have recently suggested rumination to be maladaptive through its links with avoidance processes. The main aim of this study was to examine, for the first time, whether the relationship between ruminative coping and symptoms of complicated grief and depression is mediated by avoidance processes (suppression, memory/experiential avoidance, behavioral avoidance, loss-reality avoidance). A sample of 282 adults (88% female, 12% male), bereaved on average 18 months previously, filled out three questionnaires at 6-month intervals. We assessed symptom levels, grief rumination, and trait rumination at baseline; avoidance processes after 6 months; and symptom levels after 12 months. When controlling for initial symptom levels, experiential avoidance mediated the link between grief rumination and complicated grief, and experiential avoidance and behavioral avoidance mediated the link between grief rumination and depression. Post hoc analyses showed suppression may also mediate the link between grief rumination and symptoms of complicated grief, but not depression. Loss-reality avoidance was no significant mediator of these relationships. This study provides initial evidence that rumination during bereavement increases and perpetuates symptoms of psychopathology, because it is linked with specific avoidance processes. Bereaved individuals with problematic grief and (chronic) rumination may benefit from therapy focused on countering avoidance tendencies.

The effectiveness of Grief-Help, a cognitive behavioural treatment for prolonged grief in children: study protocol for a randomised controlled trial.

BACKGROUND: There is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). PGD is mostly studied in adults, but clinically significant PGD symptoms have also been observed in children and adolescents. Yet, to date no effective treatment for childhood PGD exists. The aims of this study are: (1) to investigate the effectiveness of Grief-Help, a nine-session cognitive-behavioural treatment for childhood PGD, combined with five sessions of parental counselling, immediately after the treatment and at three, six and twelve months follow-up; (2) to examine tentative mediators of the effects of Grief-Help, (i.e., maladaptive cognitions and behaviours and positive parenting), and (3) to determine whether demographic variables, child personality, as well as symptoms of PGD, anxiety, and depression in parents moderate the treatment effectiveness. METHODS/DESIGN: We will conduct a Randomised Controlled Trial (RCT) in which 160 children and adolescents aged 8-18 years are randomly allocated to cognitive behavioural Grief-Help or to a supportive counselling intervention; both treatments are combined with five sessions of parental counselling. We will recruit participants from clinics for mental health in the Netherlands. The primary outcome measure will be the severity of Prolonged Grief Disorder symptoms according to the Inventory of Prolonged Grief for Children (IPG-C). Secondary outcomes will include PTSD, depression and parent-rated internalizing and externalizing problems. Mediators like positive parenting and maladaptive cognitions and behaviours will be identified. We will also examine possible moderators including demographic variables (e.g. time since loss, cause of death), psychopathology symptoms in parents (PGD, anxiety and depression) and child personality. Assessments will take place in both groups at baseline, after the treatment-phase and three, six and twelve months after the post-treatment assessment. DISCUSSION: We aim to contribute to the improvement of mental health care for children and adolescents suffering from loss. By comparing Grief-Help with supportive counselling, and by investigating mediators and moderators of its effectiveness we hope to provide new insights in the effects of interventions for bereaved children, and their mechanisms of change. TRIAL REGISTRATION: Netherlands Trial Register NTR3854.

Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: a randomized trial.

Internet-delivered treatment is effective for insomnia, but little is known about the beneficial effects of support. The aim of the current study was to investigate the additional effects of low-intensity support to an internet-delivered treatment for insomnia. Two hundred and sixty-two participants were randomized to an internet-delivered intervention for insomnia with (n = 129) or without support (n = 133). All participants received an internet-delivered cognitive behavioral treatment for insomnia. In addition, the participants in the support condition received weekly emails. Assessments were at baseline, post-treatment, and 6-month follow-up. Both groups effectively ameliorated insomnia complaints. Adding support led to significantly higher effects on most sleep measures (d = 0.3-0.5; p < 0.05), self-reported insomnia severity (d = 0.4; p < 0.001), anxiety, and depressive symptoms (d = 0.4; p < 0.01). At the 6-month follow-up, these effects remained significant for sleep efficiency, sleep onset latency, insomnia symptoms, and depressive symptoms (d = 0.3-0.5; p < 0.05). Providing support significantly enhances the benefits of internet-delivered treatment for insomnia on several variables. It appears that motivational feedback increases the effect of the intervention and encourages more participants to complete the intervention, which in turn improves its effectiveness.

Partner-oriented self-regulation among bereaved parents: the costs of holding in grief for the partner's sake.

Bereavement research has focused on individual rather than interdependent processes in coping with loss. Yet bereavement takes place in a social context, and relationship partners are likely to influence each other's grieving process. We examined the impact of a dynamic, interpersonal phenomenon, partner-oriented self-regulation (POSR): the avoidance of talking about loss and remaining strong in the partner's presence to protect the partner. Two hundred nineteen couples who had lost a child participated 6, 13, and 20 months after their loss. Consistent with predictions, results showed that one partner's POSR was associated not only with an increase in his or her own grief, but also with an increase in the other partner's grief. These relationships persisted over time: Self-reported and partner-reported POSR predicted later grief. These results are paradoxical: Although parents try to protect their partners through POSR, this effort has the opposite of the desired outcome. These findings underline the importance of further investigating interpersonal dynamics of coping with bereavement.

Baseline depression levels do not affect efficacy of cognitive-behavioral self-help treatment for insomnia.

BACKGROUND: Cognitive-behavioral therapy can effectively treat insomnia (CBT-I). Randomized controlled trials have shown efficacy of self-help CBT-I, but unclear is whether excluding depressive patients boosted treatment effects. METHOD: We administered unsupported self-help CBT-I to insomnia patients with low and high depression levels. Based on the validated Centre of Epidemiological Studies-Depression (CES-D) scale, the internet-recruited sample (N = 479) was divided into three groups: low depression scores (n = 198), mild depression scores (n = 182), and high depression scores (n = 99). Follow-ups were 4 and 18 weeks after completion of the treatment. RESULTS: At 4-week follow-up, all groups had a similar amelioration on the primary sleep measures (d = 0.1-0.7; P < 0.05) and the secondary insomnia ratings (d = 1.2; P < 0.001). The only difference was that the high/mild depression groups had a steeper reduction in depression (d = 1.0-1.1; P < 0.001) and anxiety scores (d = 0.7-0.8; P < 0.001) than the low depression group (depression and anxiety: d = 0.3; P < 0.01), possibly due to floor effects in the latter group. The observed effects were sustained at the 18-week follow-up. CONCLUSIONS: This study showed that CBT-I is effective regardless of baseline depression levels. Treating the combination of insomnia and depression is an extra challenge since it is associated with increased sleep problems. These data may help us understand the relationship between insomnia and depression and indicate that self-help CBT-I may be a promising addition to regular depression treatment.

Internet-delivered or mailed self-help treatment for insomnia?: a randomized waiting-list controlled trial.

Cognitive Behavioral Therapy (CBT) is effective in reducing insomnia complaints, but the effects of self-help CBT have been inconsistent. The aim of this study was to determine the effectiveness of self-help for insomnia delivered in either electronic or paper-and-pencil format compared to a waiting-list. Participants kept a diary and filled out questionnaires before they were randomized into electronic (n = 216), paper-and-pencil (n = 205), or waiting-list (n = 202) groups. The intervention consisted of 6 weeks of unsupported self-help CBT, and post-tests were 4, 18, and 48 weeks after intervention. At 4-week follow-up, electronic and paper-and-pencil conditions were superior (p < .01) compared to the waiting-list condition on most daily sleep measures (Δd = 0.29-0.64), global insomnia symptoms (Δd = 0.90-1.00), depression (Δd = 0.36-0.41), and anxiety symptoms (Δd = 0.33-0.40). The electronic and paper-and-pencil groups demonstrated equal effectiveness 4 weeks after treatment (Δd = 0.00-0.22; p > .05). Effects were sustained at 48-week follow-up. This large-scale unsupported self-help study shows moderate to large effects on sleep measures that were still present after 48 weeks. Unsupported self-help CBT for insomnia therefore appears to be a promising first option in a stepped care approach.

Factors associated with outcome of cognitive-behavioural therapy for complicated grief: a preliminary study.

Complicated grief (CG), also called prolonged grief disorder, is a debilitating condition that can develop following a loss. There is growing evidence that cognitive-behavioural interventions are efficacious in the treatment of CG. The present preliminary study used data from 43 patients with CG who were randomly assigned to cognitive-behavioural therapy in an earlier treatment trial to explore (a) predictors of outcome of cognitive-behavioural therapy for CG and (b) the relationship between symptom improvement and changes in loss-related negative cognitions and avoidance behaviours. Analyses showed that worse treatment outcome was associated with lower education attainment, loss of a partner/child (instead of some other relative), early treatment discontinuation, less patient motivation and more severe CG symptoms at pre-treatment. As predicted, stronger reduction in CG severity was significantly associated with stronger reductions in negative cognitions and avoidance. Implications of these findings are discussed.

Long-term effectiveness of cognitive-behavioural self-help intervention for nightmares.

Nightmares are a prevalent disorder leading to daily impairments. Two cognitive-behavioural self-help interventions--imagery rehearsal and exposure--recently showed short-term efficacy compared to a waiting-list and a group that recorded their nightmares. This paper reports the long-term results of the imagery rehearsal (n=103) and exposure (n=95) interventions. Participants were assigned randomly to a condition after completing baseline measurements; they received a 6-week self-help intervention and completed questionnaires 4, 16 and 42 weeks after end of treatment. Initial effects on nightmare measures were almost completely sustained after 42 weeks (d=0.50-0.70); no differences were found between exposure and imagery rehearsal therapy. These results suggest that nightmares should be targeted specifically and that an internet-delivered self-help intervention seems to be a good first option in a stepped-care model.

Cognitive-behavioral self-help treatment for nightmares: a randomized controlled trial.

BACKGROUND: Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary)--in a self-help format--with a waiting list. METHODS: Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline. RESULTS: Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25-0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20-0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19-0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording. CONCLUSIONS: IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.

Mediating processes in bereavement: the role of rumination, threatening grief interpretations, and deliberate grief avoidance.

Limited research so far has examined coping processes that mediate between risk factors and bereavement outcome. Knowledge of these pathways is important, since it helps establish why some bereaved persons are more vulnerable than others and suggests possibilities for intervention. In this international longitudinal study, three potentially critical mediators, namely rumination, threatening grief interpretations and deliberate grief avoidance, were examined in relationship to previously established risk factors (e.g., expectedness of the death, attachment style) and four major outcome variables (grief, depressive symptoms, emotional loneliness and positive mood). Individuals who were recently bereaved (maximum 3 years) filled in questionnaires at three points in time. Results showed that rumination and--to a somewhat lesser extent--threatening grief interpretations played an important role in mediating the effects of various risk factors on outcomes. However, the contribution of these two mediators was dependent on the specific risk factor and outcome measure under consideration. For example, whereas the effect of neuroticism on grief was mediated by both processes (to the extent of 73%), the effect of neuroticism on positive mood was only mediated by rumination and to a smaller extent (23%). A few risk factors, such as current financial situation and spirituality, were not mediated by either coping strategy. Implications of these findings are discussed.

A prospective examination of catastrophic misinterpretations and experiential avoidance in emotional distress following loss.

This prospective study examined the role of experiential avoidance and catastrophic misinterpretations of grief reactions in emotional distress following the death of a loved one. Eighty-two bereaved individuals completed measures of experiential avoidance, catastrophic misinterpretations, and symptom of prolonged grief disorder (PGD) and depression within the first half year of bereavement, and again completed measures assessing PGD and depression severity 1 year later. The findings showed that experiential avoidance was significantly correlated with endorsement of catastrophic misinterpretations of grief reactions. In addition, both constructs were correlated with concurrent and prospective symptom levels of PGD and depression. However, the associations between experiential avoidance and symptom levels were no longer significant, when controlling for catastrophic misinterpretations of grief reactions. Moreover, catastrophic misinterpretations but not experiential avoidance predicted PGD severity at follow-up, beyond baseline levels of PGD. Both constructs did not predict later depression beyond baseline depression. Theoretical and clinical implications of these findings are discussed.

Prolonged Grief Disorder, depression, and posttraumatic stress disorder are distinguishable syndromes.

BACKGROUND: This study examined the distinctiveness of symptoms of Prolonged Grief Disorder (PGD), depression, and posttraumatic stress disorder (PTSD). We compared the fit of a one-factor model with the fit of four hierarchical models in which symptoms formed three distinct correlated higher-order dimensions, and PTSD-items were modeled in different ways. METHODS: Self-reported data were available from two samples; 572 mourners recruited via the internet and 408 mourners recruited via healthcare workers. RESULTS: In Sample 1, the unitary model did not fit the data. The four hierarchical models all fit better. The model in which PTSD-items constituted four lower-order factors of reexperiencing, avoidance, dysphoria, and hyperarousal fit the data best. The fit was further improved, when one weak PGD-item and one weak PTSD-item were removed, and error-terms of similar items were allowed to correlate. Findings from Sample 1 were replicated in Sample 2. LIMITATIONS: This study relied on self-reported data. Not all PGD-criteria and depression-criteria were assessed. CONCLUSIONS: This is the first confirmatory factor analysis study showing that symptoms of PGD, depression, and PTSD represent distinguishable syndromes. PGD-symptoms should be addressed in the assessment and treatment of bereaved people seeking treatment.