Prolonged grief disorder in ICD-11 and DSM-5-TR:Challenges and controversies

Prolonged grief disorder has recently been added to the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders 5, Text Revision. This historical development is often presented as a linear process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. The present contribution provides an overview of work contradicting this dominant narrative. First, I show that the developmental history of prolonged grief disorder has been nonlinear and that this yields questions on generalizability and problems with measurement of the newest criteria sets. Second, I highlight an important gap in the validity evidence: the distinction of prolonged grief disorder from normal grief. Third, I discuss concerns relating to the societal effects of the inclusion of prolonged grief disorder in diagnostic handbooks, including the medicalization of grief, development and adverse effects of pharmacotherapy and stigmatization. A more realistic, balanced view on the history, validity and societal impact of prolonged grief disorder appears appropriate. I recommend stringent validation of assessment instruments for prolonged grief disorder, convergence of criteria-sets, closing gaps in validity evidence and developing strategies to mitigate the negative effects of grief diagnoses.</p

COVID-19, natural, and unnatural bereavement:Comprehensive comparisons of loss circumstances and grief severity

BACKGROUND: Acute grief appears more severe after COVID-19 deaths than natural deaths. Prolonged grief disorder (PGD) also appears prevalent following COVID-19 deaths. Researchers hypothesize that specific loss characteristics and pandemic-related circumstances may precipitate more severe grief following COVID-19 deaths compared to (other) natural deaths. Systematic research on these hypotheses may help identify those most at risk for severe grief reactions, yet it is scant. OBJECTIVE: To compare loss characteristics, loss circumstances, and grief levels among people bereaved due to COVID-19, natural, and unnatural causes. METHODS: Adults bereaved through COVID-19 (n = 99), natural causes (n = 1006), and unnatural causes (n = 161) completed an online survey. We administered self-report measures of demographic variables (i.e., age, gender), loss characteristics (i.e., time since loss, relationship with the deceased, intensive care admission, expectedness of death), loss circumstances (i.e., saying goodbye appropriately, COVID-19 infection, quarantine, financial setbacks, social support satisfaction, altered funeral arrangements, funeral satisfaction), and prolonged grief symptoms. RESULTS: COVID-19 deaths (vs. other deaths) more often were parental deaths and less often child deaths. COVID-19 deaths (vs. natural deaths) were more often unexpected and characterized by an inability to say goodbye appropriately. People bereaved due to COVID-19 (vs. other deaths) were more often infected and quarantined. COVID-19 deaths (vs. other deaths) more often involved intensive care admission and altered funeral arrangements. COVID-19 deaths yielded higher grief levels than natural deaths (but not unnatural deaths). Expectedness of the death and the inability to say goodbye appropriately explained this effect. CONCLUSIONS: Bereavement due to COVID-19 is characterized by a unique set of loss characteristics and circumstances and elevated grief levels. Improving opportunities to say goodbye before and after death (e.g., by means of rituals) may provide an important means to prevent and reduce severe grief following COVID-19 deaths. HIGHLIGHTS: COVID-19 deaths have unique loss characteristics and circumstances and elicit more severe grief than natural deaths. Death expectedness and the ability to say goodbye appropriately appear important in understanding, preventing and treating grief following COVID-19 deaths

Grief Before and During the COVID-19 Pandemic:Multiple Group Comparisons

CONTEXT: Grief researchers are concerned that the coronavirus disease 2019 (COVID-19) pandemic will precipitate increases in severe, persistent, and disabling grief, termed prolonged grief disorder or persistent complex bereavement disorder. We recently demonstrated that higher grief levels are experienced after COVID-19-related bereavement than natural bereavement. Death circumstances during the pandemic (e.g., reduced social support, limited opportunities for death rituals) may also hamper the grief process for non-COVID-19-related bereavement, yet no quantitative research has specifically addressed this issue. OBJECTIVES: To test if grief severity is higher during than before the lockdown after non-COVID-19-related bereavement. METHODS: A cross-sectional survey including questions on sociodemographic and loss-related variables and a grief measure was conducted among a sample of 1600 bereaved adults (78% females), participating before (n = 731) or during (n = 869) the pandemic, including people who had experienced a loss before the pandemic (n = 456) or during the pandemic (n = 200) recently (five months ago or less). RESULTS: No significant differences emerged between grief levels in people participating before or during the pandemic. However, being recently bereaved during the pandemic elicited more severe grief than before it (d = 0.17; d = 0.18). Effects remained significant after controlling analyses for relevant loss-related variables. CONCLUSION: Among all bereaved persons, grief severity was no different during the pandemic compared with before the pandemic. However, experiencing a recent loss during the pandemic elicited more severe acute grief reactions than before the pandemic, suggesting that dealing with loss may be more difficult during this ongoing health crisis

How we continue bonds with deceased persons:The proximity-seeking behavior scale

Continuing bonds is a multifaceted process, encompassing perceptions, beliefs, illusions and hallucinations, and overt behaviors. We developed the Proximity-Seeking Behavior Scale (PSBS) to assess overt behavior to continue bonds with the deceased person. We had 694 bereaved adults complete an online survey. Exploratory and confirmatory factor analyses yielded a one-factor model for PSBS items. PSBS reliability was good. PSBS scores correlated positively with rumination and yearning, feeling connected to the deceased person, and prolonged grief and depression symptoms. The PSBS appears a reliable and valid instrument to assess proximity-seeking behaviors

When Thinking Impairs Sleep : Trait, Daytime and Nighttime Repetitive Thinking in Insomnia

We like to thank Dorien van Baar, Lisette van Breen, Rachel Renet, Marlene Stone, Britt van Hest, and Noraly Dekkers for their help with the data acquisition.Peer reviewedPublisher PD

Emotion Regulatory Strategies in Complicated Grief:A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsychInfo, Web of Science and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice

Barriers and facilitators of disclosing domestic violence to the healthcare service:A systematic review of qualitative research

Domestic violence victims are in frequent contact with the healthcare service yet rarely disclose. Therefore, it is critical to understand victims' experiences and perceptions regarding disclosure in healthcare settings. The goal of this review is to provide an updated synthesis of qualitative research identifying barriers and facilitators, advice, and positive and negative outcomes of adult victims' disclosure of domestic violence to healthcare professionals (HCPs). A systematic search of PsychINFO, CINAHL and Web of Science was conducted in January 2018. Thirty-four eligible studies were identified, including 783 domestic violence victims (781 females). Formal quality assessment indicated variable study quality. Barriers of disclosure included negative HCPs attitudes, victims' perceptions of safety and concerns about the consequences of disclosing. Facilitators of disclosing included a positive relationship with the HCP, HCPs directly asking victims about abuse, and HCPs ensuring that the environment is safe and disclosure is confidential. Victims advised increased awareness of HCPs reactions to disclosure and avoiding mirroring their perpetrators minimization. HCPs were encouraged to engage in direct questioning and maintain a supportive and secure environment. Positive and negative outcomes of abuse were identified, such as being able to leave the abuser or, on the other hand, the victims' situation not changing. Our results indicate that barriers for disclosure of domestic violence in healthcare settings persist despite the widespread implementation of policies and guidelines to counter them. Based on these findings, we provide recommendations for clinical practice and future research to help improve disclosure in healthcare settings

Public stigma of prolonged grief disorder:An experimental study

Prolonged grief disorder (PGD), characterized by severe, persistent and disabling grief, is being considered for inclusion in the International Classification of Diseases’ 11 (ICD-11) and a related disorder, Persistent Complex Bereavement Disorder (PCBD), is included for further investigation in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). Establishing diagnoses for pathological grief may lead to stigmatization. Additionally, it has been argued that people experiencing severe grief responses after loss of non-family members (i.e., disenfranchised grief) may experience more stigmatizing reactions. Yet, no research to date has investigated this. To fill this gap in knowledge, 379 adults from the general population were randomly allocated to read one of 4 different vignettes of a person with and without a grief disorder diagnosis who had lost a friend or a spouse. After reading the vignettes, we assessed: 1) characteristics ascribed to the person, 2) emotional reactions to the person, and 3) desire for social distance. Notably, people with a diagnosis were attributed relatively more negative characteristics, and elicited more anger, anxiety and pro-social emotions and a stronger desire for social distance. Stigmatization and its negative consequences appear a valid concern to the establishment of pathological grief disorders in diagnostic manuals

Sleep disturbances in bereavement:A systematic review

Severe, persistent and disabling grief occurs among a sizable minority experiencing bereavement, with diagnostic manuals newly including complicated grief (CG) disorders. Sleep disturbances/disorders have been established as worsening affective and stress-related conditions. However, the role of sleep difficulties in bereavement and CG has not received similar scientific attention. We therefore conducted a systematic review with narrative syntheses on this topic to clarify the role of sleep in bereavement (PROSPERO: CRD42018093145). We searched PubMed, Web of Science and PsychInfo for peer-reviewed English-language articles including (at least one) bereaved sample and sleep disturbance measure. We identified 85 articles on 12.294 participants. We answered seven pre-defined research questions demonstrating: high prevalence of sleep disturbances in bereavement; positive associations of grief intensity with sleep difficulties; preliminary indications of risk factors of post-loss sleep disturbance; higher prevalence of sleep disturbances in CG, enhanced by psychiatric comorbidity (i.e., depression); and initial evidence of causal relationships between (complicated) grief and sleep. Grief therapy partly improves sleep difficulties, yet no intervention studies have specifically targeted sleep problems in bereaved persons. Causal relationships between sleep and grief require further examination in intensive longitudinal investigations, including randomized trials, thereby clarifying whether treating sleep problems enhances CG treatment effects