Boelen, Paul A

de Keijser, Adrianus

van den Bout, Jan

English

Dissertations of the University of Groningen

   University of GroningenTraumatic grief as a  disorder distinct from bereavement-related depression and anxietyBoelen, Paul A; van den Bout, Jan; de Keijser, AdrianusPublished in:American Journal of PsychiatryIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2003Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Boelen, P. A., van den Bout, J., & de Keijser, A. (2003). Traumatic grief as a disorder distinct frombereavement-related depression and anxiety: A replication study with bereaved mental health carepatients. American Journal of Psychiatry, 160(7), 1339-1341.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 12-10-2022Am J Psychiatry 160:7, July 2003 1339BRIEF REPORTShttp://ajp.psychiatryonline.orgUniversitaire de Psychiatrie et Psychologie Médicale, Hôpital Casse-lardit-La Grave, Centre Hospitalier Universitaire de Toulouse, 170,Avenue de Casselardit, TSA 40031, 31059 Toulouse, Cedex 9, France;birmes.p@chu-toulouse.fr (e-mail).References1. Fullerton CS, Ursano RJ, Epstein RS, Crowley B, Vance KL, KaoTC, Baum A: Peritraumatic dissociation following motor vehi-cle accidents: relationship to prior trauma and prior major de-pression. J Nerv Ment Dis 2000; 188:267–2722. Marmar CR, Weiss DS, Metzler T: Peritraumatic dissociation andposttraumatic stress disorder, in Trauma, Memory, and Dissoci-ation. Edited by Bremner JD, Marmar CR. Washington, DC,American Psychiatric Press, 1998, pp 229–2523. Koopman C, Classen C, Spiegel D: Predictors of posttraumaticstress symptoms among survivors of the Oakland/Berkeley, Ca-lif, firestorm. Am J Psychiatry 1994; 151:888–8944. Shalev AY, Peri T, Canetti L, Schreiber S: Predictors of PTSD in in-jured trauma survivors: a prospective study. Am J Psychiatry1996; 153:219–2255. Brewin CR, Andrews B, Rose S, Kirk M: Acute stress disorderand posttraumatic stress disorder in victims of violent crime.Am J Psychiatry 1999; 156:360–3666. Harvey AG, Bryant RA: Two-year prospective evaluation of therelationship between acute stress disorder and posttraumaticstress disorder following mild traumatic brain injury. Am J Psy-chiatry 2000; 157:626–6287. Cardena E, Koopman C, Classen C, Waelde LC, Spiegel D: Psy-chometric properties of the Stanford Acute Stress ReactionQuestionnaire (SASRQ): a valid and reliable measure of acutestress. J Trauma Stress 2000; 13:719–7348. Horowitz MJ, Wilner N, Alvarez W: Impact of Event Scale: ameasure of subjective stress. Psychosom Med 1979; 41:209–2189. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD,Charney DS, Keane TM: The development of a Clinician-Admin-istered PTSD Scale. J Trauma Stress 1995; 8:75–9010. Tabachnick BG, Fidell LS: Multiple regression, in Using Multi-variate Statistics, 2nd ed. Edited by Tabachnick BG, Fidell LS.New York, HarperCollins, 1989, pp 123–191Brief ReportTraumatic Grief as a Disorder Distinct From Bereavement-Related Depression and Anxiety: A Replication StudyWith Bereaved Mental Health Care PatientsPaul A. Boelen, M.A.Jan van den Bout, Ph.D.Jos de Keijser, Ph.D.Objective: Earlier studies have shown that symptoms of trau-matic grief are distinct from those of bereavement-related de-pression and anxiety. This study was an attempt to replicatethat finding.Method: Data were derived from 103 patients. Traumatic griefwas measured with the Inventory of Traumatic Grief. Depres-sion and anxiety were measured with the Symptom Checklist.The distinctiveness of the three symptom clusters was deter-mined with principal axis factoring.Results: Symptoms of traumatic grief, depression, and anxietyclustered together in three distinct factors.Conclusions: These results confirm the previous finding of adistinction between symptoms of traumatic grief and symp-toms of bereavement-related depression and anxiety.(Am J Psychiatry 2003; 160:1339–1341)Several studies have shown that symptoms of trau-matic grief constitute a distinct form of bereavement-re-lated emotional distress apart from bereavement-relateddepression and anxiety (1). Using data on recently wid-owed elders, Prigerson et al. (2) found that symptoms oftraumatic grief (e.g., searching, preoccupation) were dis-PTSD Symptoms PTSD Diagnosisr 95% CI r 95% CI0.53** 0.24 to 0.73 0.48** 0.18 to 0.700.55** 0.26 to 0.75 0.44* 0.13 to 0.680.38* 0.05 to 0.63 0.26 – 0.08 to 0.540.53** 0.24 to 0.74 0.38* 0.05 to 0.630.56** 0.28 to 0.75 0.49* 0.19 to 0.710.40* 0.09 to 0.65 0.36* 0.03 to 0.620.81** 0.65 to 0.901340 Am J Psychiatry 160:7, July 2003BRIEF REPORTShttp://ajp.psychiatryonline.orgtinct from those of bereavement-related depression (e.g.,apathy, depressed mood). Prigerson et al. (3) found thattraumatic grief could be distinguished from both bereave-ment-related depression and anxiety in a community-based sample of recently bereaved elderly widows andwidowers.To our knowledge, the distinctiveness of the three symp-tom clusters has never been investigated with individualsother than recently bereaved elders whose partners diedfrom illness. Replication of this distinctiveness with othergroups is important in order to be able to determine thegeneralizability of previous results. The importance ofreplication is strengthened by the fact that high levels oftraumatic grief symptoms have been found to predict sub-sequent physical and mental health impairments (1).The aim of this study was to confirm that symptoms oftraumatic grief are distinct from those of bereavement-re-lated depression and anxiety in a group of outpatients whohad sought help for problems with grief after the death of afirst-degree relative (partner, parent, child, or sibling).MethodData were available for 103 outpatients from different outpa-tient clinics in the Netherlands. Forty-seven of them were origi-nally recruited for an ongoing grief intervention study; they hadsought treatment at their own initiative or had responded to ad-vertisements announcing the study. The other patients were orig-inally solicited for a study on the psychometric properties of theDutch version of the Inventory of Traumatic Grief (4). They hadsought help at their own initiative or were referred to one of theclinics by a physician. All patients underwent an intake interview,in which eligibility for the studies was checked. Subsequently,they completed different questionnaires. Included in the presentstudy were patients who had suffered the loss of a first-degree rel-ative, had experienced the loss at least 2 months earlier, were over18 years of age, and reported having emotional problems withgrief. The patients from the two studies who met these criteria didnot differ from each other with respect to age, gender, time sincethe loss, variation in kinship to the deceased and cause of loss,and symptom severity. Written informed consent was obtainedfrom all patients.According to the psychotherapists who conducted the intakeinterviews, 26 (25.2%) of the patients met the DSM-IV criteria fora depressive disorder, three (2.9%) met the criteria for an anxietydisorder, and 10 (9.7%) met the criteria for both a depressive andan anxiety disorder. None of the participants was receiving treat-ment at the time of the assessment, and 24 (23.3%) were using an-tidepressant medication. The participants’ mean age was 44.0years (SD=13.1). Most participants (74.8%) were female (N=77).The relative who had died was a spouse for 33.0% of the subjects(N=34), a child for 29.1% (N=30), a parent for 28.2% (N=29), and asibling for 9.7% (N=10); 42.7% of the participants (N=44) had losta loved one through illness. On average, 41.7 months (SD=61.4)had passed since the loss.Items for the traumatic grief factor were taken from the Inven-tory of Traumatic Grief, a 30-item questionnaire for assessing theseverity of traumatic grief symptoms (1). The Dutch version of theInventory of Traumatic Grief has been found to possess adequatereliability and validity (4). Items for the depression and anxietyfactors were taken from the Dutch version (5) of the 17-item de-pression subscale and 10-item anxiety subscale of the SCL-90 (6).Items in both subscales closely relate to depressive and anxiousstates as described in DSM-IV.To gain insight into the degree of distress among our subjects,the symptom scores were compared with those for referencegroups. Principal axis factoring with varimax rotation was per-formed to determine how the selected pool of items clustered to-TABLE 1. Factor Loadings for Symptoms of Traumatic Grief, Anxiety, and Depression Among 103 Bereaved PatientsSymptomLoading on Factor 1 (Traumatic Grief)aLoading on Factor 2 (Anxiety)bLoading on Factor 3 (Depression)cInventory of Traumatic GriefI feel that life is empty or meaningless without [deceased person] 0.84 –0.01 0.30I feel myself longing and yearning for [deceased person] 0.84 0.05 –0.09I feel like the future holds no meaning or purpose without [deceased person] 0.79 0.18 0.29I feel unable to imagine life being fulfilling without [deceased person] 0.78 –0.09 0.20I feel like I have become numb since the death of [deceased person] 0.75 0.12 0.20I feel lonely ever since [deceased person] died 0.71 0.12 0.31I feel stunned, dazed, or shocked over [deceased person]’s death 0.70 0.25 –0.01I think about [deceased person] so much that it can be hard for me to do the things I normally do 0.67 0.33 0.07The death of [deceased person] feels overwhelming or devastating 0.65 0.27 –0.06I feel that I have trouble accepting the death 0.62 0.29 0.13SCL-90 anxiety subscaleSuddenly scared for no reason 0.18 0.78 0.27Nervousness or shakiness inside 0.29 0.78 –0.09Trembling 0.15 0.78 0.22Spells of terror or panic 0.12 0.76 0.30Feeling fearful 0.23 0.74 0.38SCL-90 depression subscaleFeeling blue 0.24 0.25 0.80Worrying too much about things 0.12 0.26 0.74Feelings of worthlessness –0.04 0.39 0.68Feeling no interest in things 0.30 0.22 0.63A sense of emptinessd 0.55 0.11 0.62a Eigenvalue after rotation=6.12; variance explained=30.5%.b Eigenvalue after rotation=3.69; variance explained=18.4%.c Eigenvalue after rotation=3.17; variance explained=15.8%.d This is the most accurate back-translation of the Dutch version of SCL-90 item 51, “Your mind going blank.”Am J Psychiatry 160:7, July 2003 1341BRIEF REPORTShttp://ajp.psychiatryonline.orggether. Constraints of the study group size limited the number ofitems that could be included in this analysis. Consequently, weselected 10 items from the Inventory of Traumatic Grief, fiveitems from the SCL-90 depression subscale, and five items fromthe SCL-90 anxiety subscale. We selected the items that wereamong the most highly correlated with each scale’s total score. Aneigenvalue greater than 1.00 was the criterion used to determinethe number of factors underlying the items.ResultsThe mean score of these patients on the Inventory ofTraumatic Grief (mean=91.62, SD=19.08) was significantlyhigher than the mean score found in a Dutch subclinicalsample of 250 individuals who had lost a first-degree rela-tive (mean=82.52, SD=20.14) (t=4.84, df=102, p<0.001) (4).The patients were also compared with men and women inDutch psychiatric outpatient reference groups (5). TheSCL-90 depression score of the men in this study (mean=45.27, SD=18.72) was above average, while their SCL-90anxiety score (mean=24.69, SD=11.32) was average. Thedepression score of the women (mean=48.47, SD=11.13)was average, while their anxiety score (mean=24.53, SD=9.35) was below average. The symptom scores were not in-fluenced by time since the loss, kinship to the deceased, orcause of death.With respect to the principal axis factoring, examinationof the eigenvalues extracted before rotation showed theemergence of three factors with eigenvalues of 8.94, 2.68,and 1.34, accounting for 64.7% of the variance. The itemssorted themselves in three distinct factors (Table 1). Thefirst factor accounted for 30.5% of the variance. Symptomsof traumatic grief loaded highly on this factor, with factorloadings ranging from 0.62 to 0.84 and no loadings above0.33 on the other two factors. The second factor accountedfor 18.4% of the variance. Symptoms of anxiety had thehighest factor loadings on this factor (ranging from 0.74 to0.78) with no loadings above 0.38 on the other factors. Thethird factor accounted for 15.8% of the variance. Symp-toms of depression clustered together in this factor, withfactor loadings ranging from 0.62 to 0.80 and no loadingsabove 0.55 on the other two factors.DiscussionWith a group of midlife Dutch psychiatric outpatientswho had suffered the loss of a first-degree relative on aver-age nearly 3.5 years previously, we were able to replicatethe distinctiveness of three symptom clusters: traumaticgrief, bereavement-related depression, and bereavement-related anxiety. The findings suggest the cross-culturalgeneralizability of earlier findings with a U.S. community-based sample of late-life individuals whose spouses hadrecently died (2, 3).The results indicate that the complications of bereave-ment may include symptoms of traumatic grief that con-stitute a clinical entity distinct from bereavement-relateddepression and anxiety. This contrasts with DSM-IV, inwhich traumatic grief is not a separate clinical entity. Theresults suggest that different treatment methods may berequired for the various syndromes that develop in peoplewho fail to recover from bereavement (e.g., medication fordepression symptoms, anxiety management for symp-toms of anxiety, and exposure for traumatic grief). The de-velopment and evaluation of such specific treatmentmethods is an important challenge for future research.Received Oct. 23, 2001; revisions received July 11 and Nov. 14,2002; accepted Dec. 16, 2002. From the Department of Clinical Psy-chology, Utrecht University; and the Leeuwarden Division, MentalHealth Care Centre Friesland, Leeuwarden, the Netherlands. Addressreprint requests to Mr. Boelen, Department of Clinical Psychology,Utrecht University, P.O. Box 80140, 3508 TC Utrecht, the Netherlands;P.Boelen@fss.uu.nl (e-mail).References1. Prigerson HG, Jacobs SC: Traumatic grief as a distinct disorder:a rationale, consensus criteria, and a preliminary empiricaltest, in Handbook of Bereavement Research: Consequences,Coping, and Care. Edited by Stroebe MS, Hansson RO, StroebeW, Schut HAW. Washington, DC, American Psychological Associ-ation, 2001, pp 613–6472. Prigerson HG, Frank E, Kasl SV, Reynolds CF III, Anderson B,Zubenko GS, Houck PR, George CJ, Kupfer DJ: Complicated griefand bereavement-related depression as distinct disorders: pre-liminary empirical validation in elderly bereaved spouses. AmJ Psychiatry 1995; 152:22–303. Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF III, Shear MK,Newsom JT, Jacobs S: Complicated grief as a disorder distinctfrom bereavement-related depression and anxiety: a replica-tion study. Am J Psychiatry 1996; 153:1484–14864. Boelen PA, van den Bout J, de Keijser J, Hoijtink H: Reliabilityand validity of the Dutch version of the Inventory of TraumaticGrief (ITG). Death Stud 2003; 27:227–2475. Arrindell WA, Ettema J: SCL-90: een multidimensionele psycho-pathologie-indicator (SCL 90: Manual for a MultidimensionalIndicator of Psychopathology). Lisse, the Netherlands, Swets &Zeitlinger, 19866. Derogatis LR: SCL-90-R: Administration, Scoring, and Proce-dures Manual, II. Towson, Md, Clinical Psychometric Research,1983

Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: A replication study with bereaved mental health care patients

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Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: A replication study with bereaved mental health care patients

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