The associations of grief-related rumination with prolonged grief and posttraumatic stress symptoms: A longitudinal study of bereaved after the 2011 terror attack in Norway.

After the sudden and violent death of a loved one, many bereaved experience symptoms of prolonged grief (PG) and posttraumatic stress (PTS). The present study investigated the cross-sectional and longitudinal associations of grief-related rumination with PG and PTS symptoms among bereaved parents and siblings after the Utøya terror attack in Norway on 22 July 2011 (N = 110, Mage = 43.2 years, 59.1% female). Participants' responses on the Rumination Scale, the Inventory of Complicated Grief and the Impact of Event Scale-Revised 28, 40 and 102 months after the loss were analysed. Cross-sectionally and longitudinally, grief-related rumination was positively and strongly linked with PG and PTS symptoms. When controlling for the baseline levels of PG and PTS symptoms and demographics of the sample, grief-related rumination predicted PG symptoms after 12 months but not after 74 months. Further, grief-related rumination predicted significantly the PTS symptoms of avoidance after 12 and 74 months and hyperarousal after 74 months beyond sample demographics and baseline symptoms. The results suggest that grief-related rumination is an important factor in PG and PTS symptoms after traumatic bereavement.

Somatic symptoms and insomnia among bereaved parents and siblings eight years after the Utøya terror attack.

Background: Levels of prolonged grief symptoms (PGS) and post-traumatic stress symptoms (PTSS) can be high, many years following bereavement after terror, but knowledge concerning somatic health is scarce. Terrorism is a serious public health challenge, and increased knowledge about long-term somatic symptoms and insomnia is essential for establishing follow-up interventions after terrorism bereavement.Objective: To study the prevalence of somatic symptoms and insomnia and their association with PGS, PTSS, and functional impairment among terrorism-bereaved parents and siblings.Methods: A cross-sectional quantitative study included 122 bereaved individuals from the Utøya terror attack in Norway in 2011. The sample comprised 88 parents and 34 siblings aged 19 years and above (Mage = 49.7 years, SDage = 13.8 years, 59.8% females). The participants completed questionnaires 8 years after the attack assessing somatic symptoms (Children's Somatic Symptoms Inventory) and insomnia (Bergen Insomnia Scale) along with measures of PGS (Inventory of Complicated Grief), PTSS (Impact of Event Scale-Revised), and functional impairment (Work and Social Adjustment Scale).Results: Fatigue was the most frequently reported somatic symptom (88% of females and 65% of males). Females reported statistically significantly more somatic symptoms than males. In total, 68% of the bereaved individuals scored above the cut-off for insomnia. There were no statistically significant gender differences for insomnia. Female gender, intrusion, and arousal were associated with somatic symptoms. Intrusion and somatic symptoms were associated with insomnia. Somatic symptoms, avoidance, and hyperarousal were associated with functional impairment.Conclusion: Many bereaved parents and siblings report somatic symptoms and insomnia eight years after the terror attack. Somatic symptoms are associated with functional impairment. Long-term follow-up and support after traumatic bereavement should focus on somatic symptoms and insomnia.

Many bereaved individuals, especially females, reported insomnia and somatic symptoms, including fatigue, pain, and other related symptoms.Somatic symptoms, avoidance, and hyperarousal were identified as being associated with functional impairment among the bereaved.Post-traumatic stress symptoms played a more significant role than prolonged grief symptoms in explaining the reduced physical health experienced by the bereaved.

Grief trajectories among bereaved parents after the 2011 Utøya terror attack: A qualitative analysis.

This study took a qualitative approach to explore terror-bereaved parents' long-term experiences with grief. Data were drawn from a larger, longitudinal study, and interviews with 10 bereaved parents were selected based on their reported change in scores on Inventory of Complicated Grief (ICG) over a period of 6.5 years, including the five parents with the largest change (group 1) and the five parents with the least change (group 2). Reflexive thematic analysis of the interview transcripts resulted in four main themes: "I felt completely lost and helpless, like I was stuck in a whirlwind" and "I have been fighting to get back to my everyday life", which both groups contributed to. Participants in group 1 contributed to the theme "I have found a way to a new life," while participants in group 2 contributed to the theme "I cannot seem to find a way to a new life." Findings suggest that sense of control, acceptance, and social support enhanced experienced coping following terror-related bereavement, while comorbid mental health problems, difficulties with acceptance, and repetitive thoughts about the death was experienced as contributing to long-term struggles following terror-related bereavement.

Paths to positive growth in parents bereaved by drug-related death: A mixed-method study.

Introduction: Drug-related deaths (DRDs) are a major public health challenge. Losing a child to a DRD can be a very stressful life event, which places parents at risk of mental and physical health problems. However, traumatic experiences like losing a child to DRD can paradoxically also lead to positive psychological changes. A mixed-method approach was used to understand the complexity of the phenomenon of post-traumatic growth experienced by parents following a DRD. Method: By combining data from a survey (n = 89) and interviews (n = 14), we explored positive growth experiences among Norwegian parents. We conducted descriptive analyses of the sample's demographic characteristics and mean scores for Post-traumatic Growth Inventory (PTGI-SF) items. Hierarchical multiple regression was used to examine the influence of the ability to perform daily activities (WSAS), self-efficacy (GSE-SF), social support (CSS), and symptoms of prolonged grief (PG-13) on the outcome variable of post-traumatic growth (PTGI-SF). Reflexive thematic analysis was applied to analyze the qualitative data. Finally, we integrated the results of the survey and the interviews. Results: For items measuring post-traumatic growth, parents scored highest on the item "I discovered that I'm stronger than I thought I was" and lowest on the item "I am able to do better things with my life." Self-efficacy and social support had a statistically significant relation with post-traumatic growth. Two themes were generated from the interviews: (I) new perspectives on life and (II) new paths in life. Even though the "New Possibilities" subscale had the lowest mean score for the PTGI-SF, new paths in life were important for many of the interviewed parents. Discussion: Parents described traumatic stressors associated with having a child who uses narcotics and hence experienced positive changes even before losing their child. We argue that on an individual level, the consequences of spillover stigma, low self-efficacy, and intrusive rumination can hinder potential post-traumatic growth. On a group level, enhancing network support may increase post-traumatic growth experiences. Hence, parents who have experienced a DRD can benefit from help to activate their social networks and strengthen their self-efficacy.

Delayed post-traumatic stress and memory inflation of life-threatening events following a natural disaster: prospective study.

BACKGROUND: The causes of delayed post-traumatic stress disorder (PTSD) are debated, and the validity of late-onset PTSD has been questioned. AIMS: We aimed to examine predictors of delayed PTSD in a community sample of survivors of a natural disaster. METHOD: Norwegian survivors of the 2004 Indian Ocean tsunami (n = 532) responded to a questionnaire at 6 and 24 months post-disaster. The questionnaire measured PTSD symptoms, recalled exposure and immediate stress responses to the disaster, recalled perceived life threat, personality dimensions, social support and other subsequent adverse life events. RESULTS: When dichotomising PTSD symptom scores, 331 participants had low and 194 had high PTSD scores (early-onset PTSD) at 6 months. Of those with initially low scores, 43 (13.0%) had high symptom scores (delayed PTSD) at 24 months. The delayed PTSD group had a lower degree of initially assessed threat and witness experiences of death or suffering, lower immediate stress response and higher degree of memory inflation of perceived threat than the early-onset PTSD group. Among those with low PTSD scores at 6 months, onset of delayed PTSD was associated with neuroticism and memory inflation of life threat, but not with the degree of initially assessed disaster exposure or reports of subsequent adverse life events. CONCLUSIONS: Lack of association between trauma exposure and delayed onset of PTSD symptoms casts doubt on whether the traumatic event is actually the primary causative factor for delayed PTSD. Our findings suggest that delayed PTSD may be a manifestation of personality factors and memory inflation of the severity of an event.

Different Trajectories of Prolonged Grief in Bereaved Family Members After Terror.

Introduction: The loss of a loved one in a terror incident is associated with elevated risk for mental health disorders such as prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD), but the long- term adaptation after such losses are not well understood. This study aims to explore the trajectories of PGD among parents and siblings (n = 129) after the 2011 terror attack on Utøya Island, Norway. Methods: The 19-item Inventory of Complicated grief (ICG) was used to measure PGD at 18, 28, and 40 months post-loss. Latent class growth analysis (LCGA) was used to identify trajectories of grief and a multinomial regression analysis was conducted to examine predictors of class membership. Results: The analysis identified three grief trajectories; moderate/decreasing class (23%), high/slow decreasing class (64%), and a high/chronic class (13%). Predictors of high/slow recovery or chronic grief was female gender, previous depressive symptoms, and intrusion and avoidance symptoms. Conclusion: The findings highlights the difficult grief process and slow recovery that characterizes the majority of close family members bereaved by a terror-incident. Community mental health programs should strive for both early outreach and long-term follow-up after such incidents.

Early intervention for bereaved children: What mental health professionals think.

People rarely specify what "early intervention" following bereavement means, so we explored the views of experienced professionals working primarily with bereaved children. In an anonymous online survey, 84 mental health professionals answered questions about the content and timeframe of early intervention. The types of interventions varied, but conversation and support were most frequent. Most considered early intervention to mean before or during the first month following the loss. Although meta-analyses show little benefit of early intervention, professionals disagree and see the need to tailor interventions to the type of death, the situation of the family, and the intensity of reactions.

A Relational Perspective on Social Support Between Bereaved and Their Networks After Terror: A Qualitative Study.

The aim of this study is to increase the understanding of social network support after traumatic deaths and, by demonstrating the complexities of such encounters, to highlight whether such support may be totally beneficial. A phenomenological dynamic and relational perspective was applied to 22 in-depth interviews with parents bereaved as a result of the 2011 terror attack in Norway. Three main themes were identified in respect of interactional support processes: (a) valued support, (b) stressful experiences, and (c) interactive barriers. As well as describing the value of experienced support, the article also elaborates on the effect of lacking, avoidant, and inept support. The findings show that insecure communication and a nonmatching understanding of time and emotional overload can form interactive barriers between the bereaved and their networks. By better understanding the relational regulation processes inherent in social support we may provide informed advice to both the bereaved and their networks to maximize recovery.

Can visiting the site of death be beneficial for bereaved families after terror? A qualitative study of parents' and siblings' experiences of visiting Utøya Island after the 2011 Norway terror attack.

Background. After the 2011 terror attack on Utøya Island, a collective visit was organized for bereaved families. There is limited knowledge whether bereaved families can benefit from such visits after terror. Objective. This study aims to explore how bereaved families experienced visiting the site of death after the 2011 terror attack. Method. As part of in-depth interviews, 22 parents and 16 siblings were asked whether they had visited Utøya and, if so, how they experienced the visit. Participants' responses were analysed using thematic analysis. Results. The results showed that for the majority of the bereaved, visiting Utøya had been important in processing their loss. Three key themes emerged as to what they considered important with the visit: 'seeing the actual place of death', 'seeking factual information', and 'learning to know the island'. These factors were associated both with beneficial reactions (e.g. accepting the reality of the loss increased cognitive clarity) and with distressing reactions (e.g. intrusive thoughts, re-enactment images), but the benefits had outweighed the distress. Having the opportunity for multiple visits seemed to optimize the benefits. Conclusion. Bereaved families should be offered the opportunity to visit the site of death after terror.

Planteamiento. Después del ataque terrorista de 2011 en la isla de Utøya, se organizó una visita colectiva para las familias en duelo. Existe un conocimiento limitado de si las familias en duelo pueden beneficiarse de tales visitas después del hecho aterrador.Objetivo. Este estudio tiene como objetivo explorar cómo las familias en duelo experimentaron la visita el sitio de la muerte después del ataque terrorista de 2011.Método. Como parte de las entrevistas en profundidad, se les preguntó a 22 padres y 16 hermanos si habían visitado Utøya, y en caso afirmativo, cómo experimentaron la visita. Las respuestas de los participantes se analizaron mediante análisis temáticos.Resultados. Para la mayoría de los familiares en duelo, visitar Utøya había sido importante para procesar su pérdida. Aparecieron tres temas clave sobre lo que consideraban importante de la visita; 'Ver el lugar real de la muerte', 'buscar información objetiva' y 'aprender a conocer la isla'. Estos factores se asociaron tanto con reacciones beneficiosas (por ejemplo, aceptar la realidad de la pérdida), como con reacciones dolorosas o angustiantes (p. ej.,pensamientos intrusivos, imágenes de reescenificación). Tener la oportunidad de realizar varias visitas pareció optimizar los beneficios.Conclusión. Las familias en duelo deberían tener la oportunidad de visitar el lugar de la muerte después de un hecho aterrador.

Optimizing Visits to the Site of Death for Bereaved Families After Disasters and Terrorist Events.

In recent years it has been common after disasters and terrorist events to offer bereaved families the opportunity to visit the place where their loved ones died. Many report that such visits are beneficial in processing their loss. Various factors, both cognitive (eg, counteracting disbelief) and existential or emotional (eg, achieving a sense of closeness to the deceased), are associated with the experienced benefit. Nonetheless, exacerbations of trauma and grief reactions (eg, re-enactment fantasies) are common, with some of the bereaved also reporting adverse reactions after the visit. Subsequently, proper preparations are a prerequisite before such visits take place. This article describes how to optimize collective visits to the site of death after disasters or terrorist events for bereaved families. Important questions-for example, concerning those who should be responsible for organizing a visit and those who should be invited, the timing of the visit, what can be done at the site, the need for support personnel, and other practical issues-are discussed and general guidelines are recommended. (Disaster Med Public Health Preparedness. 2018;12:523-527).

Early Interventions Following the Death of a Parent: Protocol of a Mixed Methods Systematic Review.

BACKGROUND: Previous meta-analyses examined the effectiveness of interventions for bereaved children showing small to moderate effect sizes. However, no mixed methods systematic review was conducted on bereavement interventions following the loss of a parent focusing on the time since death in regard to the prevention of grief complications. OBJECTIVE: The overall purpose of the review is to provide a rigorous synthesis of early intervention after parental death in childhood. Specifically, the aims are twofold: (1) to determine the rationales, contents, timeframes, and outcomes of early bereavement care interventions for children and/or their parents and (2) to assess the quality of current early intervention studies. METHODS: Quantitative, qualitative, and mixed methods intervention studies that start intervention with parentally bereaved children (and/or their parents) up to 6 months postloss will be included in the review. The search strategy was based on the Population, Interventions, Comparator, Outcomes, and Study Designs (PICOS) approach, and it was devised together with a university librarian. The literature searches will be carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, Excerpta Medica Database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The Mixed Methods Appraisal Tool will be used to appraise the quality of eligible studies. All data will be narratively synthetized following the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. RESULTS: The systematic review is ongoing and the data search has started. The review is expected to be completed by the end of 2017. Findings will be submitted to leading journals for publication. CONCLUSIONS: In accordance with the current diagnostic criteria for prolonged grief as well as the users' perspectives literature, this systematic review outlines a possible sensitive period for early intervention following the death of a parent. The hereby presented protocol ensures the groundwork and transparency for the process of conducting the systematic review. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017064077; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017064077 (Archived by WebCite at http://www.webcitation.org/6rMq6F0fv).

What distinguishes prolonged grief disorder from depression? / Hva skiller forlenget sorg-forstyrrelse fra depresjon?

Prolonged grief disorder, which is proposed as a new diagnosis in ICD-11, and depression have some similarities but also several key differences. In order to provide the correct help and treatment, it is important for doctors to be able to ascertain whether a person is struggling with prolonged grief or has become depressed following the loss of a loved one.

Media exposure and prolonged grief: A study of bereaved parents and siblings after the 2011 Utøya Island terror attack.

BACKGROUND: After terror attacks, the media coverage can be a potential secondary stressor for bereaved families. In the present study, we aimed to examine the level of prolonged grief (PG), and to explore the association between media exposure and PG in parents and siblings of individuals who were killed in a terror attack. METHOD: Parents and siblings (n = 103) from 42 different families bereaved by the 2011 Utøya Island mass shooting participated in a survey 18 months after the attack. The survey measured the amount of media exposure experienced by the bereaved during the first month after the attack. PG was self-reported using the Inventory of Complicated Grief (ICG). Data was analyzed with multilevel methods with mixed effects models. RESULTS: Of the total sample of participants, 78.6% (n = 81/103) had sum scores higher than the designated cutoff >25 on ICG, indicating a probable prolonged grief disorder (PGD). Multilevel analysis showed significantly higher level of PG among those who reported high exposure to the media coverage (>4 hours daily) the first month after the attack, among females, and among those who were in contact with their son/daughter/brother/sister by telephone during the attack. LIMITATIONS: With the cross-sectional design, caution should be taken about making interpretations about causal effects. CONCLUSION: Media exposure may trigger or maintain prolonged grief reactions. (PsycINFO Database Record

Grief and Traumatic Grief in Children in the Context of Mass Trauma.

Children who have had someone close die as a result of a mass trauma event such as war, armed conflict, acts of terror, political violence, torture, mass accidents, and natural disasters are at risk for biopsychosocial problems. Research on how to classify when grief becomes complicated or traumatic in children is scarce, and while functioning level may provide a good indication, assessing functioning may be difficult in mass trauma environments where routines and structure are often lacking. There are promising trauma- and grief-focused interventions for children post-mass trauma, which are mostly provided in school settings. However, more advanced multi-method interventions are needed that address grief and trauma in the context of the child's overall mental health, parent/caregiver role in assisting the child, family system issues, ways to provide safe caring environments amidst chaos and change, and interventions that take into account local consumer perspectives, including the voices of children.

Prevalence of psychiatric disorders and functional impairment after loss of a family member: a longitudinal study after the 2004 Tsunami.

BACKGROUND: Bereavement following disasters is a devastating experience for family members. The aim of this study was to examine the long-term mental health effects of losing a loved one in a natural disaster. METHODS: Ninety-four Norwegians aged 18-80 years who lost close family members in the 2004 Southeast Asian tsunami were evaluated 2 and 6 years after the disaster. The participants were either staying in an affected area at the time of the disaster (i.e., directly exposed) or not (i.e., not directly exposed). The prevalence of psychiatric disorders was assessed by the MINI International Neuropsychiatric Interview (M.I.N.I). Prolonged grief disorder (PGD) was self-reported using the Inventory of Complicated Grief (ICG), and functional impairment was self-reported using the Work and Social Adjustment Scale (WSAS). RESULTS: We did not identify a significant decrease in the prevalence of PGD, posttraumatic stress disorder (PTSD), or major depressive disorder (MDD) from 2 to 6 years. Approximately, one-third of the bereaved (36%) had a psychiatric disorder 6 years after the tsunami. The most common disorder was PGD (12%) followed by general anxiety disorder (GAD, 11%), agoraphobia (11%), and MDD (10%). The prevalence of PTSD and MDD was higher among family members who were directly exposed to the disaster compared to those who were not (21 vs. 0%, and 25 vs. 3%). PGD was associated with functional impairment independent of other disorders. CONCLUSIONS: Loss of a close family member in a natural disaster can have a substantial adverse long-term effect on mental health and everyday functioning.

Bereavement and mental health after sudden and violent losses: a review.

This paper reviews the literature on the psychological consequences of sudden and violent losses, including disaster and military losses. It also reviews risk and resilience factors for grief and mental health and describes the effects and possible benefit of psychosocial interventions. The review shows gaps in the literature on grief and bereavement after sudden and violent deaths. Still, some preliminary conclusions can be made. Several studies show that a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved. The prevalence of mental disorders such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD, also termed complicated grief) varies widely, however, from study to study. Also, mental health disorders are more elevated after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seems to be slower. Several factors related to the circumstances of the loss may put the bereaved at heightened risk for mental distress. These factors may be differentially related to different outcomes; some increase the risk for PTSD, others for PGD. Given the special circumstances, bereavement following sudden and violent death may require different interventions than for loss from natural death. Recommendations for future research and clinical implications are discussed.

Parental mental health after the accidental death of a son during military service: 23-year follow-up study.

We prospectively studied parental mental health after suddenly losing a son in a military training accident. Parents (N = 32) were interviewed at 1, 2 and 23 years after the death of their son. The General Health Questionnaire and Expanded Texas Inventory of Grief were self-reported at 1, 2, 5, and 23 years; the Inventory of Complicated Grief was self-reported at 23 years. We observed a high prevalence of psychiatric disorders at 1- and 2-year follow-ups (57% and 45%, respectively), particularly major depression (43% and 31%, respectively). Only one mental disorder was diagnosed at the 23-year follow-up. Grief and psychological distress were highest at 1- and 2-year follow-ups. Spouses exhibited a high concordance of psychological distress. Mothers reported more intense grief reactions than did fathers. The loss of a son during military service may have a substantial impact on parental mental health particularly during the first 2 years after death. Spouses' grief can be interrelated and may contribute to their psychological distress.

Visiting the site of death: experiences of the bereaved after the 2004 Southeast Asian Tsunami.

The authors examined how many bereaved relatives of Norwegian tourists who perished in the 2004 Southeast Asian Tsunami had visited the site of death and the most important outcome from the visit. We conducted in-depth interviews (n = 110) and used self-report questionnaires (Impact of Event Scale-Revised, Inventory of Complicated Grief and General Health Questionnaire) in a total of 130 first-degree family members 2 years post-disaster. Results showed that the majority of participants (n = 113; 87%) had visited the site of death. The most important outcome was gaining an increased understanding of what occurred (61%) and a feeling of closeness to the deceased (27%). Those who had visited the site of death reported lower avoidance behavior and higher degree of acceptance of the loss than non-visitors. Although this could be a cause as well as a consequence of the visit, visiting the site of death may be an important part of the support offered to bereaved families after experiencing a disaster loss.