Bereavement issues and prolonged grief disorder: A global perspective.

The death of a loved one - bereavement - is a universal experience that marks the human mental health condition. Grief - the cognitive, emotional, and behavioral responses to bereavement - is thus experienced by virtually everyone at some point in life, while mourning is a process through which grievers come to terms with the loss envisioning life without the deceased. Although distress subsides over time among most bereaved individuals, a minority will develop a condition recently identified as prolonged grief disorder (PGD). The present review provides a global perspective on bereavement, grief reactions, and PGD. Although the loss of a loved one and grief reactions are in general experienced consistently across different cultures, differences and variations in their expression may exist across cultures. Especially within specific populations that may be more at risk for PGD, possibly due to risk factors associated with the mechanisms of loss (e.g., refugees, migrants, and conflict survivors). The diagnostic criteria for PGD are mostly based on Western grieving populations, and cultural adaptations of PGD treatments are limited. Therefore, cross-cultural development and validation of PGD screening/assessment is critical to support future research on grief reactions and PGD, especially in non-Western contexts, and concerning the potential future global changes and challenges that appear to have a major impact on PGD. More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems.

The course of symptoms in the first 27 months following bereavement: A latent trajectory analysis of prolonged grief, posttraumatic stress, and depression.

BACKGROUND: Much remains unknown about the course of grief in the early months following bereavement, including the prevalence and timing of a recovery trajectory, whether specific symptoms mark a failure to recover, and the co-occurrence of chronic prolonged grief (PG), posttraumatic stress (PTS) and depression symptoms. METHODS: Two hundred fifty-nine participants completed PG, PTS and depression questionnaires up to eleven times every six weeks during the two years post-bereavement. We used Latent Class Growth Mixture Modeling (LCGMM) to identify subgroups of bereaved individuals sharing similar trajectories for each disorder. We used repeated measures ANOVA to evaluate differences in individual symptoms between trajectories. Finally, we investigated to what extent chronic trajectories of these three disorders co-occurred. RESULTS: Three trajectories of PG symptoms emerged: resilient (66.4%), chronic (25.1%) and acute recovery (8.4%). The overall severity and symptom profile of the acute recovery group were indistinguishable from that of the chronic group through 6 months post-bereavement, followed by reduction in PG from 6 to 18 months post-bereavement. Chronic PTS in the first-year post-bereavement tended to co-occur with chronic PG and/or chronic depression. CONCLUSIONS: Twenty five percent of those with initial elevations in grief recovered in the period of 6 to 12 months post-bereavement. These findings highlight the clinical importance of severe grief in the initial months following loss, but also suggests caution in diagnosing a grief disorder within the first-year post-bereavement.

The causal systems approach to prolonged grief: Recent developments and future directions.

The network theory of prolonged grief posits that causal interactions among symptoms of prolonged grief play a significant role in their coherence and persistence as a syndrome. Drawing on recent developments in the broader network approach to psychopathology, we argue that advancing our understanding of the causal system that gives rise to prolonged grief will require that we (a) strengthen our assessment of each component of the grief syndrome, (b) investigate intra-individual relationships among grief components as they evolve over time within individuals, (c) incorporate biological and social components into network studies of grief, and (d) generate formal theories that posit precisely how these biological, psychological, and social components interact with one another to give rise to prolonged grief disorder.

Traumatic grief research and care in the aftermath of the COVID-19 pandemic.

BACKGROUND: A significant increase in the number of individuals suffering from prolonged grief disorder is expected in the aftermath of the COVID-19 pandemic for two main reasons. First, the number of excess deaths has contributed to an immense number of bereaved individuals. Second, recent literature has shown that circumstances associated with COVID-19 deaths may be contributing to increased risk for the development of prolonged grief disorder. OBJECTIVE: To best support those affected by loss during the COVID-19 pandemic, it is important to inform clinicians and researchers about the development, the nature and the treatment of prolonged grief disorder and employ sound research. METHOD: In this editorial, we discuss important themes regarding prolonged grief disorder in the aftermath of the COVID-19 pandemic, to gather and present useful information for clinicians and researchers. RESULTS: The following themes were addressed: 1. Harmonization in the diagnosis of prolonged grief disorder. 2. Screening tools and interventions. 3. Pharmacotherapy. 4. Special attention for the elderly. 5. Special attention for children and adolescents. 6. A causal system perspective for understanding grief and prolonged grief disorder. CONCLUSIONS: If those involved in bereavement research and care manage to collaborate, the tragic consequences of COVID-19 might catalyse improvement of care for those most impaired following the loss of a loved one.

Antecedentes: Se espera un aumento significativo en el número de personas que padecen de un trastorno de duelo prolongado como consecuencia de la pandemia de COVID-19 por dos razones principales. Primero, el número de muertes en exceso ha contribuido a un inmenso número de personas en duelo. En segundo lugar, la literatura reciente ha demostrado que las circunstancias asociadas con las muertes por COVID-19 pueden estar contribuyendo a un mayor riesgo de desarrollar un trastorno de duelo prolongado.Objetivo: Para apoyar mejor a los afectados por la pérdida durante la pandemia de COVID-19, es importante informar a los médicos e investigadores sobre el desarrollo, la naturaleza y el tratamiento del trastorno de duelo prolongado y emplear investigaciones sólidas.Método: En este editorial, discutimos temas importantes relacionados con el trastorno de duelo prolongado después de la pandemia de COVID-19, para recopilar y presentar información útil para médicos e investigadores.Resultados: Se abordaron los siguientes temas: 1. Armonización en el diagnóstico del trastorno de duelo prolongado. 2. Herramientas de tamizaje e intervenciones. 3. Farmacoterapia. 4. Atención especial para adultos mayores. 5. Atención especial para niños y adolescentes. 6. Una perspectiva del sistema causal para comprender el duelo y el trastorno de duelo prolongado.Conclusiones: Si los involucrados en la investigación y el cuidado del duelo logran colaborar, las trágicas consecuencias del COVID-19 podrían catalizar la mejora de la atención para los más afectados después de la pérdida de un ser querido.

Peritraumatic distress predicts prolonged grief disorder symptom severity after the death of a parent in children and adolescents.

Background: In 2015 nearly 140 million children and adolescents under 18 had experienced the death of one or both parents. Parental death is often considered the most traumatic event that a child can experience in their lifetime. While parental loss may lead to the development of prolonged grief disorder (PGD), little is known about risk factors for such negative mental health outcome in children. Objective: The present study aims to examine peritraumatic reactions as predictors of PGD in children who lost a parent. Method: Thirty-four children (M age = 10.9, SD = 3.2, 67.6% females) who lost a parent (time since death = 4.6 months, SD = 2.3) were assessed for peritraumatic distress and peritraumatic dissociation experienced at the time of the loss, and for PGD symptom severity at three timepoints post-loss (<6 months; 6-12 months; >12 months). Results: PGD score was correlated with peritraumatic distress (.61; p < .01) but not with peritraumatic dissociation (.24; p = .3). Results from the mixed-model regression analysis identified peritraumatic distress as the only significant predictor of PGD symptom severity (B = 1.58, SE = .31; p < .0001), with no statistically significant effect of peritraumatic dissociation (B = - .43, SE = .36; p = .2), or time (B = - 3.84, SE = 2.99; p = .2). Conclusion: Our results suggest that peritraumatic distress might be useful to identify children at risk for developing PGD, and in need of further support. The development of early preventive strategies to prevent PGD in parentally bereaved children who experienced high peritraumatic distress is warranted.

Antecedentes: En el 2015 cerca de 140 millones de niños y adolescentes menores a 18 años experimentaron la muerte de uno o ambos padres. La muerte parental es considerada a menudo como el evento más traumático que un niño puede experimentar en su vida. Mientras que la pérdida parental puede conducir al desarrollo de Duelo Prolongado (PGD), poco se sabe respecto a los factores de riesgo para dicha consecuencia negativa en la salud mental de los niños.Objetivo: El presente estudio apunta a examinar reacciones peritraumáticas como predictores de PGD en niños que han perdido un padre o madre.Método: Treinta y cuatro niños (Edad promedio = 10.9, DE = 3.2, 67,6% mujeres) quienes perdieron su padre o madre (tiempo desde la muerte = 4.6 meses, DE=2.3) fueron evaluados en relación a angustia peritraumática y disociación peritraumática experimentados al momento de la pérdida, y en relación a severidad sintomática de PGD en tres momentos diferentes tras la pérdida (< 6 meses; 6-12 meses; > 12 meses).Resultados: El puntaje de PGD se correlacionó con angustia peritraumática (0.61; p < .01) pero no con disociación peritraumática (0.24; p = .3). Resultados del análisis de regresión de modelo mixto identificaron a la angustia peritraumática como el único predictor significativo para severidad sintomática de PGD (B = 1.58; p < .0001), sin efecto estadísticamente significativo de disociación peritraumática (B = ­ 0.43; p = .2) o según el tiempo (B = ­ 3.84; p = .2).Conclusión: Nuestros resultados sugieren que la angustia peritraumática puede ser útil para identificar niños en riesgo de desarrollar PGD, y en necesidad de mayor apoyo. Está justificado el desarrollo de estrategias preventivas tempranas para prevenir PGD en niños en duelo por pérdida parental que experimentan angustia peritraumática severa.

Prolonged grief disorder, posttraumatic stress disorder, and depression following traffic accidents among bereaved Balinese family members: Prevalence, latent classes and cultural correlates.

INTRODUCTION: Qualitative studies have described the rather unique styles of Balinese people to adjust to adversity. No quantitative research assessing psychopathology among bereaved individuals has been performed yet. This study estimated the prevalence of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD) and depression among bereaved individuals after traffic deaths in Bali and the relations between subgroups sharing the same symptoms and cultural, socio-demographic characteristics and posttraumatic growth (PTG). METHODS: In this cross-sectional study, 301 participants participated in questionnaire-interviews assessing PGD, PTSD, depression, PTG and cultural and socio-demographic characteristics. On average, the time since loss was 16 months. The purpose of the rituals was examined by a thematic qualitative analysis. We performed latent class analyses and subsequently calculated the odds ratios between membership of classes and characteristics with a multivariate 3step analysis. RESULTS: Prevalence rates of PGD (0%), PTSD (1%) and moderate depression (2%) were low. Most participants followed the bereavement rituals characteristic for Balinese culture. The purpose of these rituals was mainly the expression of caring for the deceased. We found a large resilient class (76%) and two smaller classes, one characterized by elevated PGD symptoms (11%) and one by elevated PTSD symptoms (13%). Loss of close kin was associated with membership of the PTSD class. CONCLUSIONS: Prevalence rates of PGD, PTSD and depression in the Balinese community were remarkably low. Participants appeared to be quite homogeneous in following religious and cultural habits. Aspects of the Balinese culture might protect bereaved individuals for developing mental health issues and could be used for an informed refinement of bereavement rituals in other cultures.

Post-Migration Stressors and Their Association With Symptom Reduction and Non-Completion During Treatment for Traumatic Grief in Refugees.

BACKGROUND: Resettled refugees exposed to trauma and loss are at risk to develop mental disorders such as posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder (PCBD). Post-migration stressors have been linked to poor mental health and smaller treatment effects. AIM: Our aim was to evaluate reductions in PTSD and PCBD symptoms and to explore the presence of post-migration stressors and their associations with symptom change and non-completion in a traumatic grief focused treatment in a cohort of refugees. METHODS: Paired sample t-tests were used to test the significance of the symptom reductions in PTSD and PCBD symptoms during treatment. The presence of post-migration stressors was derived from a qualitative analysis of the patient files. Associations between post-migration stressors and symptom reductions as well as non-completion were calculated. RESULTS: In this uncontrolled study, 81 files of consecutive patients were included. Significant reductions in both PCBD and PTSD symptomatology with medium effect sizes were found. Patients experienced a mean of three different post-migration stressors during the treatment. Undocumented asylum seekers were more likely to be non-completers. Ongoing conflict in the country of origin was associated with smaller PTSD symptom reductions and the total number of post-migration stressors was associated with smaller PCBD symptom reductions. CONCLUSIONS: Treatment for resettled refugees for traumatic grief coincides with alleviations in both PCBD and PTSD symptomatology. Specific post-migration stressors were associated with reduced treatment effects and increased non-completion. This is a first step towards well-informed improvements of mental health interventions for resettled refugees.

The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis.

BACKGROUND: Previous research has indicated that one out of ten naturally bereaved individuals develops prolonged grief disorder (PGD). Less is known about the prevalence of PGD following unnatural deaths, such as accidents, disasters, suicides, or homicides. The aim of this study was to compute the pooled prevalence of PGD and to determine possible causes of its varied estimates. METHODS: A literature search was conducted in PsycINFO, Ovid Medline, PILOTS, Embase, Web of Science, and CINAHL. A meta-analysis using random effects models was performed to calculate the pooled prevalence rate of PGD. Multivariate meta-regression was used to explore heterogeneity among the studies. RESULTS: Twenty-five articles met eligibility criteria. The random-effects pooled prevalence was 49%, 95% CI [33.6, 65.4]. Death of only child, violent killings and non-western study location were associated with a higher PGD prevalence. A longer time since loss and a loss in a natural disaster were associated with a lower PGD prevalence. LIMITATIONS: These findings should be interpreted with caution, because of the heterogeneity in study methodology. CONCLUSIONS: This first meta-analysis of PGD following unnatural losses indicated that nearly half of the bereaved adults experienced PGD. This illustrates the importance of assessing PGD in individuals affected by loss and trauma.

Symptomatology following loss and trauma: Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample.

BACKGROUND: Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population. METHOD: In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables. RESULTS: Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life. CONCLUSIONS: PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis.

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self-concept, which together are termed "disturbances in self-organization" (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO-only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tept complejo en pacientes expuestos a negligencia emocional y eventos traumáticos: un análisis de clases latentes TEPTC EN PACIENTES EXPUESTOS A NEGLIGENCIA: ACL El diagnóstico de trastorno de estrés postraumático complejo (TEPTC) propuesto en la 11' revisión de la Clasificación Internacional de Enfermedades refleja una evidencia creciente que un subgrupo de individuos con TEPT también sufre de problemas en la regulación emocional, habilidades interpersonales, y auto- concepto (conocido como "problemas en la auto-organización" [DSO], por sus siglas en inglés). Aunque se asume que el TEPTC es el resultado de la exposición a eventos traumáticos complejos, la negligencia emocional puede ser un contribuyente. Este estudio investigó la confirmación del TEPT y síntomas DSO (que juntos calificaban para TEPTC) en una muestra clínica de una generación post guerra. La muestra consistió en 218 pacientes que estuvieron expuestos a negligencia emocional en su infancia, un subgrupo que también había estado expuesto a potenciales eventos traumáticos. Usando los ítems del Cuestionario de Trauma de Harvard y el Inventario de Síntomas Abreviado, un análisis de clases latentes (ACL) reveló dos clases: alta confirmación de casi todos los síntomas de TEPTC (n=83; 38.1%) y baja confirmación de todos los síntomas de TEPTC (n=135; 61.9%). Contrario a nuestra hipótesis, no se encontró ninguna clase de sólo DSO. El método de pasos R3 mostró que el género y el número de eventos traumáticos son predictores significativos para la pertenencia a alguna clase. Comparado con la clase de baja probabilidad, los individuos de la clase TEPTC tenían más probabilidad de ser mujer, p = .013, y reportar un mayor número de experiencias traumáticas, p = .000. Se discute el rol intermediario potencial de la negligencia emocional en el desarrollo de DSO y TEPTC.

Further validation of the Traumatic Grief Inventory-Self Report (TGI-SR): A measure of persistent complex bereavement disorder and prolonged grief disorder.

The Traumatic Grief Inventory Self-Report version (TGI-SR) is an 18-item self-report measure. It was designed to assess symptoms of Persistent Complex Bereavement Disorder (PCBD) included in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 and Prolonged Grief Disorder (PGD) proposed by an international group of experts in grief. The research in this article used data from a bereaved patient sample and people who lost loved ones in the Ukrainian airplane crash in July 2014. Findings indicated that the TGI-SR is a reliable and valid tool to assess disturbed grief in research and to identify people needing a more comprehensive assessment of their grief in clinical settings.

Do prolonged grief disorder symptoms predict post-traumatic stress disorder symptoms following bereavement? A cross-lagged analysis.

BACKGROUND: Bereavement can precipitate different forms of psychopathology, including prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptoms. How these symptoms influence each other is unclear. The aim of this study was to examine the temporal relationship of symptoms of PGD and PTSD following bereavement. METHODS: We included 204 individuals, confronted with the loss of a loved one within the past year, who completed self-report measures of PGD and PTSD and again completed these measures one year later. We conducted a cross-lagged analysis to explore cross-lagged and autoregressive relationships. RESULTS: A significant cross-lagged relationship was found between PGD symptoms at time point 1 (T1) and PTSD symptoms at time point 2 (T2) (ß=0.270, p<0.001). Furthermore, PGD symptoms at T1 predicted PGD symptoms at T2 and PTSD symptoms at predicted PTSD symptoms at T2 (ß=0.617 and ß=0.458, ps<0.001, respectively). In addition, PGD and PTSD symptoms were significantly correlated on both time points. CONCLUSIONS: We found that PGD symptoms predict PTSD symptoms after a loss. Potentially, this could help to design new strategies and interventions for bereaved individuals. Additionally, PGD symptom levels predicted PGD symptom levels one year later, independently of the PTSD levels. This finding adds to the accumulating evidence that PGD is a distinct disorder.

Day patient treatment for traumatic grief: preliminary evaluation of a one-year treatment programme for patients with multiple and traumatic losses.

Background: Bereaved individuals who have lost a loved one under traumatic circumstances can develop symptoms of Persistent Complex Bereavement Disorder (PCBD) and/or Posttraumatic Stress Disorder (PTSD). This is particularly common in refugees, as they frequently have been confronted with multiple traumatic losses. For patients with severe PTSD and traumatic grief a treatment programme was developed, embedding individual traumatic grief focused therapy in a group-based multidisciplinary day patient treatment programme. The day patient treatment comprised a weekly five-hour programme consisting of three phases with a duration of four months each. Objective: To evaluate the feasibility and potential effectiveness of the treatment programme. Method: Data were analyzed from 16 participants treated between October 2013 and March 2014. PTSD severity and PTSD/PCBD diagnoses were measured during the initial and final phases of treatment using the Clinician-Administered PTSD Scale for DSM-IV (CAPS) and the Traumatic Grief Inventory Self Report (TGI-SR). One clinical case is presented in more detail. Treatment attendance was also registered and therapist satisfaction was evaluated in a focus group. Results: Thirteen patients (81%) completed the treatment. Each day of the treatment programme was attended by a mean of 76% of the participants. In the focus group, therapists noted symptom reduction in their patients and they therefore regarded Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) as an effective therapy for their patients. During treatment, significant decreases in PTSD severity as well as diagnosable PTSD and PCBD were observed. Conclusions: Results support the feasibility and potential effectiveness of the day patient treatment programme for traumatic grief. The programme appears to be particularly suitable for refugees with severe PTSD and PCBD psychopathology, who may not benefit enough from usual care.

Planteamiento: Las personas en duelo que han perdido a un ser querido en circunstancias traumáticas pueden desarrollar síntomas del trastorno por duelo complejo persistente (TDCP) y/o trastorno por estrés postraumático (TEPT). Esto es particularmente habitual en refugiados, ya que con frecuencia se han enfrentado a múltiples pérdidas traumáticas. Se desarrolló un programa de tratamiento para pacientes con TEPT grave y duelo traumático que incluía terapia individual centrada en el duelo traumático dentro de un programa grupal multidisciplinario de tratamiento de día. El tratamiento de día consistía en un programa semanal de cinco horas que constaba de tres fases, con una duración de cuatro meses cada una. Objetivo: Evaluar la viabilidad y la eficacia potencial del programa de tratamiento. Métodos: Se analizaron los datos de dieciséis participantes tratados entre octubre de 2013 y marzo de 2014. Se midió la gravedad del TEPT y los diagnósticos de TEPT / TDCP durante las fases inicial y final del tratamiento utilizando la Escala de TEPT administrada por el clínico para el DSM-IV (CAPS, siglas en inglés de Clinician-Administered PTSD Scale for DSM-IV) y el Autoinforme del inventario de duelo traumático (TGI-SR, siglas en inglés de Traumatic Grief Inventory Self Report). Se presenta con más detalle un caso clínico. También se registró la asistencia al tratamiento y se evaluó la satisfacción del terapeuta en un grupo focal. Resultados: Trece pacientes (81%) completaron el tratamiento. A cada día del programa de tratamiento asistió una media del 76% de los participantes. En el grupo focal, los terapeutas observaron reducción de síntomas en sus pacientes y, por lo tanto, consideraron la psicoterapia ecléctica breve para el duelo traumático (BEP-TG, siglas en inglés de Brief Eclectic Psychotherapy for Traumatic Grief) como una terapia eficaz para sus pacientes. Durante el tratamiento, se observaron reducciones significativas de la gravedad del TEPT, así como de los diagnósticos de TEPT y TDCP. Conclusión: Los resultados apoyan la viabilidad y la eficacia potencial del programa de tratamiento de día para duelo traumático. El programa parece ser particularmente adecuado para refugiados con una psicopatología grave de TEPT y TDCP, que pueden que no se beneficien lo suficiente de asistencia médica frecuente.

Prolonged grief, depression, and posttraumatic stress in disaster-bereaved individuals: latent class analysis.

Background: Hundreds of individuals lost one or more significant others in the MH17 plane crash in 2014 in Ukraine. The current study is the first to explore subgroups of disaster-bereaved individuals based on presence of psychopathology clusters. This may inform the development of diagnostic instruments and tailored interventions. Objective: Aims of the current study were to examine (1) subgroups based on presence of prolonged grief disorder (PGD), major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) symptom clusters and (2) associations between class membership, disaster-related variables (i.e. experiencing multiple losses, conducting multiple burials for the same deceased, and time to confirmation of death), and a sense of unrealness. Method: Self-rated PGD (10 items of the Traumatic Grief Inventory represented in two symptom clusters), MDD (16-item Quick Inventory Of Depressive Symptomatology represented in one symptom cluster), and PTSD (20-item PTSD Checklist for DSM-5 represented in four symptom clusters) from 167 participants were subjected to latent class analysis to identify subgroups (i.e. classes). Correlates of class membership were assessed using the three-step approach. Results: A three-class solution yielded the best model fit. Class 1 (Resilient class; 20.0%) was predominantly characterized by low probability of PGD, MDD, and PTSD symptom clusters, class 2 (PGD class; 41.8%) by moderate to high probability of presence of PGD, and class 3 (Combined class; 38.2%) by moderate to high probability of presence of PGD, MDD, and PTSD symptom clusters. Compared with the Resilient class, a sense of unrealness was more likely to be experienced by individuals in the PGD class and the Combined class. Conclusions: Our results indicate that subgroups of disaster-bereaved individuals can be distinguished based on the presence of PGD, MDD, and PTSD symptom clusters. A sense of unrealness was the strongest distinguishing feature of the subgroups.

Symptoms of prolonged grief, post-traumatic stress, and depression after loss in a Dutch community sample: A latent class analysis.

Mental health problems following loss can manifest as heterogeneous symptomatology that may include symptoms of Prolonged Grief Disorder (PGD), Post-Traumatic Stress Disorder (PTSD), and Major Depressive Disorder (MDD). However, the co-occurrence of symptoms of these three disorders is still only partially explored. The aims of this study were to identify subgroups (i.e., classes) in a Dutch sample of bereaved individuals, based on severity and/or co-occurrence of symptoms and to identify predictors for these subgroups, taking into account all three disorders. Using data from 496 participants who filled in questionnaires assessing PGD, PTSD and MDD, we conducted latent class analyses to identify different symptom classes. Predictors of these classes were identified using one-way ANOVA, Chi Square tests and multinomial regression analysis. We found three different classes: a resilient class, a PGD class and a combined PGD/PTSD class. Violent cause of death, loss of a child, and loss of a partner were associated with membership of the combined PGD/PTSD class. This study increases our understanding of the predictability of symptomology outcome following bereavement. This is a first step towards designing assessment and intervention methods, specifically directed towards subgroups of individuals sharing characteristic symptomatology.

Early indicators of problematic grief trajectories following bereavement.

Background: Little is known about the development of Prolonged Grief Disorder (PGD) symptoms over time in adults. For clinical purposes, it would be useful to have knowledge about early indicators of a problematic grief trajectory. Objective: This study aimed to identify classes of bereaved individuals with similar trajectories of PGD symptoms and to design a provisional screening tool including symptoms predicting membership of classes with problematic grief trajectories. Method: In a Dutch sample of 166 bereaved individuals, we conducted a latent class analysis to identify classes of bereaved individuals with similar trajectories of PGD symptoms between two time points (mean of 6 and 18 months post-loss, respectively). Next, we used Receiver Operating Characteristic (ROC) analyses to examine which symptoms at baseline best predicted membership of classes with problematic grief trajectories. Results: We found four different classes: a class including individuals with persistent high PGD symptoms (class 1, 6%), a class of individuals with persistent moderate PGD symptoms (class 2, 35%), a class of individuals with slightly decreasing moderate PGD symptoms (class 3, 33%) and a class of individuals with persistent low PGD symptoms (class 4, 26%). The endorsement of symptoms 'yearning', 'stunned', 'life is empty' and 'bitterness' as present 'often' during the preceding month at baseline best-predicted membership of class 1 or 2. Conclusions: Two classes of individuals with problematic grief trajectories were identified. Four symptoms were found which could act as early indicators of these two classes in a provisional screening tool.

Contexto: Se sabe poco sobre el desarrollo en adultos de síntomas a lo largo del tiempo del llamado Trastorno de Duelo Prolongado (TDP). Por propósitos clínicos, es de utilidad tener conocimiento de indicadores precoces de una trayectoria de duelo problemática. Objetivo: Este estudio pretende identificar clases de individuos en duelo con trayectorias similares y diseñar un instrumento de discriminación provisional que incluya síntomas que predigan quiénes formaran parte de grupos con trayectorias de duelo problemáticas. Método: En una muestra holandesa de 166 personas en duelo, condujimos un análisis de clases latente cara a identificar grupos de individuos en duelo con similares trayectorias y síntomas de TDP entre dos momentos diferentes (una media de 6 y 18 meses post pérdida, respectivamente). A continuación, aplicamos análisis de características operativas de receptor (ROC) para examinar qué síntomas basales predicen mejor formar parte de un grupo con trayectorias de duelo problemáticas. Resultados: Encontramos 4 grupos diferentes: uno que incluye individuos con niveles altos y persistentes de síntomas de TDP (clase, 1.6%). Otro con síntomas persistentes moderados de TDP (clase, 2.35%), otro grupo con síntomas de TDP disminuyendo poco a poco (clase, 3.33%) y, finalmente, otro grupo con síntomas leves persistentes de TDP (clase, 4.26%). La presencia de síntomas como 'añoranza', 'anonadamiento', 'la vida se ha vaciado de sentido' y 'amargura' con presencia 'frecuente' durante el mes previo al momento basal, resultó ser el mejor predictor de pertenencia a las dos primeras clases más graves. Conclusiones: Se identificaron dos grupos de personas con trayectorias de duelo complicadas. Se encontraron, con un instrumento de discriminación provisional, cuatro síntomas que pueden ser considerados como indicadores precoces de estos dos grupos.