Assessing DSM-5-TR and ICD-11 prolonged grief disorder in children and adolescents: development of the Traumatic Grief Inventory – Kids – Clinician-Administered

BackgroundBereaved ICU family surrogates are at risk of comorbid prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Knowledge about temporal relationships between PGD, PTSD, and depression is limited by a lack of relevant studies and diverse or inappropriate assessment time frames given the duration criterion for PGD. We aimed to determine the temporal reciprocal relationships between PGD, PTSD, and depressive symptoms among ICU decedents’ family surrogates during their first 2 bereavement years with an assessment time frame reflecting the PGD duration criterion.MethodsThis prospective, longitudinal, observational study examined PGD, PTSD, and depressive symptoms among 303 family surrogates of ICU decedents from two academic hospitals using 11 items of the Prolonged Grief Disorder-13, the Impact of Event Scale—Revised, and the depression subscale of the Hospital Anxiety and Depression Scale, respectively, at 6, 13, 18, and 24 months post-loss. Cross-lagged panel modeling was conducted: autoregressive coefficients indicate variable stability, and cross-lagged coefficients indicate the strength of reciprocal relationships among variables between time points.ResultsSymptoms (autoregressive coefficients) of PGD (0.570–0.673), PTSD (0.375–0.687), and depression (0.591–0.655) were stable over time. Cross-lagged standardized coefficients showed that depressive symptoms measured at 6 months post-loss predicted subsequent symptoms of PGD (0.146) and PTSD (0.208) at 13 months post-loss. PGD symptoms did not predict depressive symptoms. PTSD symptoms predicted subsequent depressive symptoms in the second bereavement year (0.175–0.278). PGD symptoms consistently predicted subsequent PTSD symptoms in the first 2 bereavement years (0.180–0.263), whereas PTSD symptoms predicted subsequent PGD symptoms in the second bereavement year only (0.190–0.214). PGD and PTSD symptoms are bidirectionally related in the second bereavement year.ConclusionsPGD, PTSD, and depressive symptoms can persist for 2 bereavement years. Higher PGD symptoms at 6 months post-loss contributed to the exacerbation of PTSD symptoms over time, whereas long-lasting PTSD symptoms were associated with prolonged depression and PGD symptoms beyond the first bereavement year. Identification and alleviation of depression and PGD symptoms as early as 6 months post-loss enables bereaved surrogates to grieve effectively and avoid the evolution of those symptoms into long-lasting PGD, PTSD, and depression.

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

Prolonged Grief Disorder in the Next of Kin of Adult Patients Who Die During or After Admission to Intensive Care

List of American patents which issued in January, 1836

Background: Grief is a multi-faceted experience including emotional, social, and physical reactions. Research in ICD-11 prolonged grief disorder (PGD) in different cultural contexts has revealed different or potentially missing grief symptoms that may be relevant. Objective: This study thus aimed to explore the prevalence of somatic symptom distress and its associations with grief and negative affect in a culturally diverse sample of bereaved individuals with symptoms of PGD. Methods: Based on cross-sectional survey data from the Measurement and Assessment of Grief (MAGIC) project, this study included 1337 participants (mean age 23.79 yrs, 76.1% female) from three regions (USA: 62.3%, Turkey/Iran: 24.2%, Cyprus/Greece: 13.5%), who experienced a loss of a significant other. Associations between somatic symptom distress (Somatic Symptom Scale, SSS-8), symptoms of PGD (International Prolonged Grief Disorder Scale, IPGDS-33), anxiety (Generalized Anxiety Disorder Questionnaire, GAD-7), depression (Patient Health Questionnaire, PHQ-9) as well as demographic and loss related characteristics were investigated. Three hundred and thirteen participants (23.4%) scored above the proposed cut-off for clinically severe PGD. Results: ‘High’ or ‘very high’ levels of somatic symptom distress were more frequent in a possible PGD group (58.2%), than in a non-PGD group (22.4%), p < .001, as divided per cut-off in the IPGDS. In a multiple regression analysis, PGD symptoms were significantly but weakly associated with somatic symptom distress (β = 0.08, p < .001) beyond demographics, loss-related variables, and negative affect. Negative affect (anxiety and depression) mediated the relationship of PGD symptoms with somatic symptom distress and the indirect effect explained 58% of the variance. Conclusions: High levels of somatic symptom distress can be observed in a substantial proportion of bereaved across cultures. Our findings suggest that PGD is related to somatic symptom distress partly and indirectly through facets of negative affect.

BackgroundAlthough 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.MethodIn 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.ResultsMost 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.ConclusionsPGD 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.

Posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD) are well-documented in parentally bereaved adolescents. Whether or not the parent's death is perceived as traumatic may be influenced by several end-of-life-related factors. This study aimed to examine the associations between end-of-life-related factors, symptoms of posttraumatic stress disorder (PTSD), symptoms of prolonged grief disorder and PGD, and the association between PTSD and PGD. Mann-Whitney U tests and Spearman correlation were used to analyze the relationships between end-of-life-related factors, PTSD, and PGD. Regretting one's decision to be present or not present at the time of death resulted in a significant difference in self-reported scores for PTSD, but not PGD.

Co-occurrence of prolonged grief disorder (PGD) with psychologic distress like posttraumatic stress disorder (PTSD) and depression is widely studied. However, only two non-ICU studies from Western countries have cross-sectionally examined co-occurring PGD, PTSD, depression, and anxiety symptoms among individuals who experienced traumatic bereavement, yielding inconsistent findings. Despite this, PGD symptoms frequently co-occur with anxiety symptoms, which strongly predicts PTSD-depression trajectories and PGD-PTSD-depression symptom states. To identify and examine transitions through distinct states of co-occurring PGD, PTSD, depression, and anxiety symptoms over the first two bereavement years among Taiwanese ICU bereaved who lost a family member to diseases. Prospective cohort study. MICUs of two Taiwanese medical centers. Three hundred three family members. None. Participants were surveyed at 6, 13, 18, and 24 months of post-bereavement with 11 items from the PG-13, the Impact of Event Scale-Revised, and depression and anxiety subscales of the Hospital Anxiety and Depression Scale. Latent transition analysis was used to examine the PGD-PTSD-depression-anxiety symptom states and their prevalence over time. At 6 months of post-bereavement, we identified four distinct PGD-PTSD-depression-anxiety symptom states (prevalence): resilient (62.7%), subthreshold PGD-depression (21.2%), PGD-dominant (11.2%), and co-occurring PGD-PTSD-depression-anxiety (4.9%). Symptom states were mostly stable over time; however, when participants transitioned between states, they typically moved toward lower distress states. At 24 months of post-bereavement, the prevalence rankings remained unchanged: resilient (81.1%), subthreshold PGD-depression (10.9%), PGD-dominant (5.5%), and co-occurring PGD-PTSD-depression-anxiety (2.5%). We consistently observed four distinct PGD-PTSD-depression-anxiety-symptom states during the first two bereavement years of ICU family members. Persistently elevated PGD symptoms, alone or with PTSD, depression, and anxiety, can already be detected within 6 months of bereavement, underscoring the need for early screening to provide timely psychologic support or treatments for those at risk of chronic PGD or co-occurring symptom states.

The recent introduction of prolonged grief disorder (PGD) as a diagnostic category may cause negative social reactions (i.e. public stigma). Vignette experiments demonstrate that persons with both PGD symptoms and a PGD diagnosis elicit more public stigma than persons who experience integrated grief. However, the strength of the influence of the diagnosis itself remains unclear: We aimed to clarify if the diagnostic label PGD produces additional public stigma beyond PGD symptoms. We further compared whether public stigma varies between the label PGD and the label major depressive episode (MDE) (when PGD symptoms are present) and if gender of the bereaved person influences public stigma or moderates the aforementioned effects. Eight-hundred fifty-two participants (77% female; Mage = 32.6 years, SD = 13.3) were randomly assigned to read online one of eight vignettes describing either a bereaved male or female, with PGD symptoms and PGD diagnosis; PGD symptoms and MDE diagnosis; PGD symptoms and no diagnosis, or no PGD symptoms and no diagnosis (i.e., integrated grief). Following the vignettes, participants indicated which negative characteristics they ascribed to the person, their emotional reactions, and preferred social distance from the person. People with PGD symptoms and PGD (or MDE) diagnosis were attributed more negative characteristics, and elicited more negative emotions and a stronger desire for social distance than people with integrated grief. However, public stigma did not differ for people with both PGD symptoms and diagnosis compared to people only experiencing PGD symptoms. Gender of the bereaved only had an influence on desired social distance, which was larger towards men. Helping severely distressed bereaved people (regardless of diagnostic status) cope with negative social reactions may help them adapt to bereavement. Results demonstrate that the experience of severe grief reactions, yet not a diagnostic label per se, causes public stigma.

IntroductionCurrent grief research is dominated by cross-sectional studies assessing prolonged grief disorder (PGD) symptoms retrospectively. Examining grief in daily life, using Experience Sampling Methodology (ESM), may advance the field. Because of the lack of ESM-research on PGD, we evaluated the acceptability and feasibility of assessing PGD symptoms in daily life of bereaved people. Materials and methodsESM-items assessing PGD symptoms were developed using cognitive interviewing with five ESM/grief experts. Eighty bereaved adults completed these ESM-items five times a day for two weeks. Before and after this ESM-phase, interviews were administered assessing PGD retrospectively (using the Traumatic Grief Inventory-Clinical Administered). t-tests were performed comparing symptom severity of aggregated moment-to-moment recall (using ESM-items) with retrospective recall (based on interviews) of PGD symptoms. Acceptability of participating in ESM-research (assessed with the Reactions to Research Participation Questionnaire) was examined using descriptive statistics. Feasibility was evaluated by reporting compliance and retention rates. ResultsMinor changes were made to the ESM-items based on expert interviews. Average levels of aggregated moment-to-moment recall of the symptoms “yearning” (d = −1.04), “preoccupation with the deceased” (d = −0.91), “marked sense of disbelief” (d = −0.43), and “intense loneliness” (d = −0.28) were lower compared with retrospective recalling these symptoms. On average, bereaved people were neutral about personal benefits gained through participation in this EMS-study. They indicated that participation did not raise emotional reactions. Compliance and retention rates were 60% and 65%, respectively. DiscussionOur findings indicate that whereas compliance and retention is challenging, using ESM to study PGD symptoms in daily life might be useful. Nevertheless, more research is needed.

Background: Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results. Objective: In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes. Methods: Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted. Results: For PTSD, a seven factor, so-called ‘Hybrid’ model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD). Conclusions: This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.

BackgroundRecognition that the loss of a loved one may result in prolonged grief disorder (PGD) has gained broad attention recently. PGD may disturb daily functioning to such a degree that mental health treatment is required. Because PGD symptoms often resemble symptoms of common mental disorders (CMD) such as anxiety, depressive, and post-traumatic stress disorder, clinicians may not consider a PGD diagnosis. Moreover, cultural varieties in expression of PGD may complicate recognition. This study explores the prevalence of PGD among both natives and refugees with anxiety, depressive, or trauma- and/or stressor-related disorders as well as clinicians' awareness and knowledge of PGD symptoms. In addition, a psychoeducation module on PGD symptoms is developed through patient expert collaboration.MethodsPrevalence of PGD symptoms is investigated among 50 participants who are referred to outpatient clinics for anxiety, depression, or post-traumatic stress, using the Traumatic Grief Inventory—Self Report Plus (TGI-SR+) and the Bereavement and Grief—Cultural Formulation Interview (BG-CFI). Clinicians will be interviewed on knowledge (gaps) with respect to PGD symptoms. Finally, focus groups with patient experts are held to develop a psychoeducation module tailored to the patients' needs, norms and values.ResultsThis study will show prevalence of PGD among patients who are referred for anxiety, depression, and post-traumatic stress, awareness and knowledge of clinicians on PGD symptoms, and will offer patient expert informed psychoeducation.DiscussionResearch on prevalence and recognition of PGD is vital. Study results of the prevalence of PGD will be compared to previous studies. Recognition of PGD as distinct disorder from CMDs requires clinicians' awareness of symptoms related to the loss of a loved one. Thereby, clinicians need to take cultural aspects related to death, bereavement and mourning into consideration.Ethics and disseminationThe study protocol will be carried out in accordance with relevant guidelines and regulations. Exploratory research to assess the prevalence of PGD in patients suffering from CMDs will facilitate adequate diagnosis by increasing clinician's awareness of PGD symptoms. Tailored PGD psychoeducation, co-created by culturally diverse patient experts and clinicians will be made publicly available.

BackgroundExposure to trauma and bereavement is common in conflict-affected regions. Previous research suggests considerable heterogeneity in responses to trauma and loss with varying symptom representations. The purpose of the current study was to (1) identify classes of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptom profiles among individuals who were exposed to both trauma and loss due to the Colombian armed conflict and (2) to examine whether sociodemographic, loss and trauma-related characteristics could predict class membership.MethodsThree hundred eight victims of internal displacement who had experienced trauma and loss were assessed through measures of PGD (PG-13), PTSD (PCL-C), and social support (DUKE-UNC). Latent class analysis (LCA) was performed to analyze differential profiles by symptoms of PGD and PTSD and multinomial logistic regression was used to analyze predictors of class membership.ResultsLCA revealed a four-class solution: a resilient class (23.6%), a PTSD-class (23.3%), a predominately PGD class (25.3%) and a high distress-class with overall high values of PGD and PTSD (27.8%). Relative to the resilient class, membership to the PGD class was predicted by the loss of a close family member and the exposure to a higher number of assaultive traumatic events, whereas membership to the PTSD class was predicted by the perception of less social support. Compared to the resilient class, participants in the high distress-class were more likely to be female, to have lost a close relative, experienced more accidental and assaultive traumatic events, and perceived less social support.DiscussionSpecific symptom profiles emerged following exposure to trauma and loss within the context of the Colombian armed conflict. Profiles were associated with distinct types of traumatic experiences, the degree of closeness to the person lost, the amount of social support perceived, and gender. The results have implications for identifying distressed subgroups and informing interventions in accordance with the patient’s symptom profile.

ABSTRACTBackground: 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.

Prolonged grief disorder (PGD, previously called complicated grief) is a debilitating condition that can develop following the loss of a loved one. The present study investigated the relationship between different features of personal goals of bereaved individuals and PGD symptom severity. To this end, 160 bereaved people were asked to write down seven important personal goals and to complete self-report measures of PGD and depression symptom severity. With respect to the form of goals, the findings showed that more severe PGD symptomatology was associated with lower specificity of goals, a reduced sense of control over achieving goals and a lower perceived likelihood of achieving goals. With respect to the content of the goals, it was found that mourners with more severe levels of PGD symptoms reported more goals that were associated with loss (compared with goals unrelated to the loss), more goals related to feeling states and less goals related to work/education and close relationships. Implications of these findings are discussed. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: • The severity of prolonged grief disorder (PGD) symptoms after bereavement is associated with different features of personal goals, including reduced specificity of goals, lower perceived probability and controllability of achieving goals and an enhanced focus on loss-related goals and goals related to feeling states. • In the treatment of PGD, it could be useful to change the negative beliefs that patients have about the probability and controllability of achieving goals and to help them in finding ways to achieve valued goals. • As recovery from loss hinges (in part) on the person's ability to continue (or restore) activities that are satisfying and meaningful, it could furthermore be fruitful to help patients to reduce their focus on 'inward-directed' goals (associated with their own feelings) and to increase their focus on 'outward-directed' goals (related to social, recreational and occupational activities).