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Abstract

Recent studies have suggested that the vulnerability to complicated grief (CG) may be rooted in insecure attachment styles developed in childhood. The aim of this study was to examine the etiologic relevance of childhood separation anxiety (CSA) to the onset of CG relative to major depressive disorder, posttraumatic stress disorder, and generalized anxiety disorder in bereaved individuals. The Structured Clinical Interview for the DSM-IV, Inventory of Complicated Grief-Revised, and CSA items from the Panic Agoraphobic Spectrum Questionnaire were administered to 283 recently bereaved community-dwelling residents at an average of 10.6 months postloss. CSA was significantly associated with CG (OR = 3.2; 95% CI, 1.2-8.9), adjusting for sex, level of education, kinship relationship to the deceased, prior history of psychiatric disorder, and history of childhood abuse. CSA was not significantly associated with major depressive disorder, posttraumatic stress disorder, or generalized anxiety disorder.
... The demand for companion animals in South Korea is increasing because of ongoing social and demographic changes, including a low birth rate and an increasing prevalence of nuclear families and one-person households. Based on a survey conducted in 2017, 1 29.4% or 5.74 million out of 19.52 million households in the country were raising pets. Results from a survey indicated that 59.9% of respondents expressed an intention to utilize pet funeral facilities when their companion animals pass away. 2 This indicates the emergence of a culture where the death of a companion animal is regarded as a significant loss. 2 The loss of a companion animal is often regarded as a major life event and a challenging time for individuals, akin to the death of a loved one and the associated grieving process, which is considered a significant life crisis. ...
... 17 Adults who have experienced such trauma were found to have increased sensitivity to recent stressful life events, 18 and they are at risk of developing CG following the death of a close person, such as a spouse or friend. 19 Recent studies have shown that adults with a history of childhood trauma exhibit higher levels of grief reactions following the loss of a spouse. 20 However, the relationship between a history of childhood trauma and the presence of psychiatric symptoms in the context of pet loss remains unexplored in the current literature. ...
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Background: Loss of companion animals can result in various psychological reactions, including complicated grief, depression, anxiety, and insomnia. However, research on the prevalence of patients requiring clinical intervention is limited. Moreover, research examining the relationship between childhood trauma and psychological symptoms after pet loss is lacking. Therefore, this study aimed to investigate the rates of clinically significant psychological distress after pet loss and the impact of childhood trauma on adults who have experienced pet loss. Methods: An online survey was conducted with non-clinical adult participants who had experienced the loss of a companion animal. Psychiatric characteristics were evaluated using standardized assessments, including the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), and the Insomnia Severity Index (ISI). Childhood trauma was evaluated using the Childhood Trauma Questionnaire (CTQ). Results: In a sample of 137 individuals who had experienced pet loss, the percentages of those who exceeded the cutoff points were 55% for the ICG, 52% for the PHQ-9, 40% for the GAD-7, and 32% for the ISI. The group that reported childhood trauma exhibited significantly higher scores on the ICG (t = 2.16, P = 0.032), PHQ-9 (t = 3.05, P = 0.003), GAD-7 (t = 2.61, P = 0.010), and ISI (t = 2.11, P = 0.037) than in the group without childhood trauma. For participants who experienced pet loss for less than one year, there was no significant difference in the ICG between the trauma and non-trauma groups, as both had extremely high scores. However, the trauma group had a significantly higher PHQ-9 (t = 2.58, P = 0.012) than the non-trauma group. In contrast, for participants who experienced pet loss for more than one year, the trauma group had a significantly higher ICG (t = 2.22, P = 0.03) than the non-trauma group, while there was no significant difference in the PHQ-9. Additionally, the emotional abuse scores on the CTQ were most significantly correlated with the ICG scores even after controlling for depressive symptoms. Conclusion: People who experienced pet loss had significant psychological symptoms, ranging from 32% to 55%. Childhood trauma experiences affect complicated grief, depressive symptoms, anxiety symptoms, insomnia and prolonged grief disorder after pet loss. After pet loss, people with childhood trauma may require more psychological help than those without trauma.
... Moreover, separating with siblings/twins in adolescence or young adulthood may imply leaving from the parental home. Anxiety driven by early separation from parents has been connected to a series of negative mental health conditions such as complicated grief, more severe symptoms of depression, or later panic disorder [19][20][21]. Parental support acts like a "safety net" to enhance the resilience in coping with challenges and to sustain the successful transition of the child to adulthood [22,23]. Family closeness, support, attentiveness, and other positive factors are associated with a later timing of leaving, while teenagers living with step-parents or incomplete families tend to leave early due to a lack of resources [24][25][26]. ...
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Background Separating with close siblings and leaving the parental home at an early age represents a major life event for an adolescent (reflected by age at separation in a twin pair) and may predispose them to poor mental health. This study aims to examine the association of age at separation and residential mobility on depressive symptoms in late adolescence and young adulthood and to explore possible underlying genetic effects. Methods Residential mobility consisted of the number and total distance of moves before age 17. Based on 3071 twins from the FinnTwin12 cohort, we used linear regression to assess the association of age at separation and residential mobility with General Behavior Inventory (GBI) scores at age 17 and in young adulthood. A higher GBI score indicated more depressive symptoms occurred. Then, the mixed model for repeated measures (MMRM) was used to visualize the scores’ trajectory and test the associations, controlling for "baseline" state. Twin analyses with a bivariate cross-lagged path model were performed between the difference in GBI scores, between cotwins, and separation status for the potential genetic influence. Results Compared to twins separated before age 17, twins who separated later had significantly lower GBI scores at age 17 and in young adulthood. In MMRM, separation at a later age and a higher number of moves were associated with a higher GBI score in young adulthood. A small genetic effect was detected wherein GBI within-pair differences at age 17 were associated with separation status before age 22 (coefficient: 0.01). Conclusion The study provides valid evidence about the influence of siblings and family on depressive symptoms in later adolescence and young adulthood while finding some evidence for a reverse direction effect. This suggests more caution in the interpretation of results. A strong association between residential mobility and depressive symptoms was affirmed, although further detailed research is needed.
... With regard to the nature of the death, bereavement by sudden losses such as suicide, homicide or accidents is thought to predispose to PGD [25]. Exposure to childhood adversity has also been identified as a risk factor for PGD [26]. The limited studies carried out in children and adolescents suggest that, similar to adult populations, the female gender is a risk factor for the development of PGD in children [27,28]. ...
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Major changes to the concept of disorders specifically associated with stress have been made since the introduction of the latest revision of the International Classification of Diseases (ICD-11). With the ICD-11, a separate entity titled complex post-traumatic stress disorder (PTSD) was introduced to the classification systems for the first time, to include those who have suffered repeated, sustained and multiple forms of trauma, which is commonly associated with childhood abuse. The ICD-11 also includes an entity called prolonged grief disorder, to differentiate the boundaries between normal and atypical grief. Since the release of the ICD-11, there has been much discussion about the validity, utility, reliability and cross-cultural comparison of these disorders, as well as the comparability of these diagnoses with the DSM-V categories. This chapter aims to summarize the latest evidence on the disorders associated with stress, with special relevance to children and adolescents.
... Regarding hypothesis 2, it has been confirmed that the Fand M-REC, and empathetic communication at the time of loss predict a secure attachment. Although scientific literature had shown that insecure attachment plays a pivotal role in the development of CG (Lobb et al., 2010;Stroebe et al., 2005;Vanderwerker et al., 2006), our findings show that the experience of parents' support in the time of grief may become a milestone for the development of a secure attachment with them. Childhood experiences of maternal sensitive care are internalised in the Internal Working Models (MOI) of the attachment figures, constituting a crucial bridge between a child's experience and later relationships (Bowlby, 1980). ...
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The perception of the caregiver as a haven of safety in painful times is crucial for the development of a secure attachment style. The goal of this study is to retrospectively investigate the association of recalled emotional closeness to parents at the time of loss (REC) and how the news of loss was broken (HOW) with adult Complicated Grief and attachment style in 273 adults who lost a beloved person in childhood, using inventories of Complicated Grief and Parent and Peer Attachment, REC scale and an open-ended questionnaire on the circumstances of death. Data evidenced that REC and HOW scores in the experience of loss in childhood predicted less complicated grief and more secure attachment in the present.
... Interestingly, a previous study, which investigated the associations between attachment style and reactions to loss in a sample of caregivers before the patient's actual death, found that higher levels of anxious attachment were associated with a higher risk of developing prolonged grief (Lai et al., 2015). These findings are consistent with the theoretical basis of the attachment theory, which states that separation anxiety and adversity experienced during childhood may have a crucial impact on the response to later bereavement in adult life (Silverman et al., 2001;Vanderwerker et al., 2006). ...
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Several psychological dimensions influence the psychological adjustment of terminally ill cancer patients' caregivers, during the end-of-life phase. The present study explored the associations between attachment styles, mentalization, preparedness for death, and the severity of pre-loss grief symptoms in 102 caregivers of terminal cancer patients. The results of the network analysis showed that insecure attachment dimensions were positively associated with several central pre-loss grief symptoms. Mentalization and preparedness for death showed negative associations with several pre-loss grief symptoms. Interestingly, bitterness showed a negative association with need for approval and a positive association with mentalization. The results provided insight into the grieving process for palliative care providers to implement effective caregiver support interventions.
... Studies found several demographic factors that increase the risk for development of PGD, such as lower socioeconomic status, being female, and being older (Gilbar and Ben-Zur, 2002;Ferrario et al., 2004;Simon et al., 2005;Vanderwerker et al., 2006;Kersting et al., 2011;Newson et al., 2011;Sung et al., 2011;Hu et al., 2015;Fernández-Alcántara and Zech, 2017;Heeke et al., 2017;Lundorff et al., 2017;Specht et al., 2022). As these factors vary across cultural contexts and are related to cultural diversity, such as race, common mental health problems, socioeconomic constructs, and cultural norms and beliefs, they might affect the experience of losing a loved one and consequently the likelihood of developing PGD. ...
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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 term 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 of 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.
... Prigerson told us that the problem with the name "traumatic" grief was that after the destruction of the World Trade Center towers in 2001, people were confusing traumatic grief with PTSD. By this time, they had learned that disordered grief overlaps with but is distinct from depression, generalized anxiety, and PTSD (Boelen et al., 2007;Prigerson et al., 1995aPrigerson et al., , 1996Vanderwerker et al., 2006). Thus, they returned to calling it complicated grief. ...
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In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.
... The participants appear to have difficulty in the process of individuation and separation, evidenced by the descriptions of loss as physical pain within their own body and three of them compared the loss to an amputation. Research linking insecure attachment styles and separation anxiety developed in childhood with complicated grief reactions (Van Doorn et al, 1998;Vanderwerker et al, 2006) may help to explain the difficulties experienced by the participants. Therapeutic interventions to address the 'zero sum game' of feeling eclipsed, yet continuing to idealise, could focus on two main areas: the first to help the client develop a stronger sense of self and the second area to promote a more balanced and less polarised perspective of the deceased and others. ...
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2022 has witnessed a crescendo of controversial debate in grief and bereavement research, surrounding the inclusion of Prolonged Grief Disorder (PGD) in the revised Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V-TR). Criticisms of the inclusion of PGD focus on the potential for diagnosis narrowing the range of healthy functioning and any treatment gains associated with a PGD diagnosis being outweighed by the risk of pathologising individual differences and diversity in human behaviour (Ben-Zeev, Young & Corrigan, 2010). This qualitative research approaches ‘stuckness’ in grief from a non-pathologising, inductive and curious position that embodies the core, humanistic values of Counselling Psychology (Cooper, 2009). Four participants who reported feeling stuck in grief were interviewed and the resultant transcripts were analysed using Interpretative Phenomenological Analysis (IPA). The four superordinate themes: (‘Eclipsed by the deceased’; ‘The power in powerlessness’; ‘The double-edged sword of coping behaviours’ and ‘Living in Purgatory’) reveal novel insights into the significance and consequences of living with unresolved dilemmas of grieving. Findings support a meaning reconstruction approach to grief therapy and highlight the negative implications of holding a pathologising, time-limited, stage-based conceptualisation of grief. Implications for practice include combining person-centred therapy with targeted cognitive-behavioral grief interventions.
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This chapter begins with an evaluation of recent research that has accumulated about traumatic grief (TG) symptomatology. More specifically, the available evidence is reviewed to determine whether it satisfies requirements for the establishment of TG as a distinct clinical entity. Following this review, the authors discuss some advantages and disadvantages of developing standardized criteria for TG. Given their belief that the advantages outweigh the disadvantages, they then describe the logic behind the consensus criteria for TG proposed by a panel of experts. Results of a preliminary test of the proposed criteria set for TG are reported, directions for their further refinement are discussed, and assessment tools for TG are presented. The authors conclude by proposing ways to distinguish between normal and TG reactions and by suggesting directions for future research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Separation anxiety continues to be implicated as an early risk factor to adult emotional disorder but recent research findings are somewhat contradictory. Inconsistencies in approaches to measuring memories of early separation anxiety may have contributed to this lack of clarity. We report the development of a brief self-report instrument, the Separation Anxiety Symptom Inventory (SASI), which was designed to overcome some of these deficiencies in measurement. The SASI was shown to have a coherent factorial structure, high internal consistency (Cronbach's Alpha > .80) and test-retest reliability over an average of 24 months (Intraclass Correlation Coefficient = .89), with serial scores not being affected by changes in contemporaneous anxiety levels. Some index of the validity of the measure was achieved by (a) comparing SASI scores of index twins with descriptors of their "insecure" behaviours in early life provided by corresponding co-twins; (b) comparing SASI scores with retrospective DSM III-R diagnoses of early anxiety disorders obtained by structured interviews; and (c) examining SASI scores in subjects with histories of school refusal. The SASI provides a useful standardised measure which will aid in the further testing of the separation anxiety hypothesis of adult emotional disorder.
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Three potential sources of error in retrospective reports of childhood experiences are documented: low reliability and validity of autobiographical memory in general, the presence of general memory impairment associated with psychopathology, and the presence of specific mood-congruent memory biases associated with psychopathology. The evidence reviewed suggests that claims concerning the general unreliability of retrospective reports are exaggerated and that there is little reason to link psychiatric status with less reliable or less valid recall of early experiences. Nevertheless, it is clear that steps must be taken to overcome the limitations of retrospective reports and enhance their reliability.
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The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.
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Background. This study compared the relative influence of childhood and adulthood adversities on current diagnoses of Major Depressive Episode (MDE), Post-Traumatic Stress Disorder (PTSD) and Traumatic Grief (TG) among recently widowed older adults. Method. Eighty-five widowed persons were interviewed at a median of 4 months after their loss. The logistic regression procedure was used to estimate the effects of three childhood adversities (parental death, abuse, death of a sibling) and three prior adulthood adversities (death of a child, non-bereavement traumatic event, death of a sibling) on current diagnoses of MDE, PTSD and TG. Results. Adversities occurring in childhood (abuse and death of a parent) were significantly associated with TG and, secondarily, MDE, while adversities occurring in adulthood (non-bereavement traumatic event and death of a child) were only significantly associated with PTSD. The tendency of childhood adversities to predict TG and adult adversities to predict PTSD remained significant even after the clustering of adversities and comorbidity among psychiatric disorders were taken into account. Conclusions. The results suggest that there is a vulnerability to TG rooted in childhood experiences explicitly, with more recent traumas having a stronger influence on PTSD secondary to widowhood. The distinctive etiological risks for bereavement-related PTSD, MDE, and TG suggest that therapeutic approaches should be tailored to the particular syndrome(s) present.
Article
Few studies have examined the relationship between marital quality and adjustment to the impending loss of a terminally ill spouse. Most studies of marital quality and grief have been based on retrospective reports of the marriage rather than pre-loss assessments. Here, we tested the pre-loss cross-sectional effects of having a security-enhancing marriage on traumatic grief and depressive symptoms among 59 caregivers aged 50 and over of terminally ill spouses. We also examined whether insecure attachment styles were associated with traumatic grief and depressive symptoms. Findings suggest that security-increasing marriages and insecure attachment styles put spouses at risk for elevated traumatic grief symptoms. Results also indicate that marital quality and attachment style did not interact and that neither was significantly associated with depressive symptoms. The differences in the relationship of marital quality and attachment styles to the two outcomes suggest that the etiology of traumatic grief and depressive symptoms may be distinct.
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The study investigates whether a putative diagnosis of separation anxiety disorder can be identified in adulthood and whether there are continuities between juvenile and adult forms of the disorder. Seventy patients with conventional adult diagnoses of panic disorder and generalized anxiety disorder attending an anxiety clinic were administered an interview and checklist to assess separation anxiety (SA) symptoms in adulthood. Memories of early SA were assessed using the Separation Anxiety Symptom Inventory (SASI). A subsample was used to calibrate the checklist against assignment to a category of adult separation anxiety disorder (ASAD) based on the structured interview. In an expanded sample , patients assigned to the ASAD category returned statistically higher scores on the SASI, with the severity of juvenile SA symptoms accounting for 33% of the variance of adult SA scores (p < .001). Assignment of subjects to the putative ASAD category was not associated with any conventional adult anxiety diagnosis and symptoms of SA appeared to predate the onset of the other anxiety disorders. One possible explanation for the data is that, in some individuals, early onset separation anxiety disorder may persist into adulthood, but the symptoms may either be overlooked or, alternatively, obscured by secondary features such as panic.
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Psychiatric classification is still a topic of considerable discussion and debate in spite of major advances in the past two decades. The debate involves categorical versus dimensional approaches, cutoff numbers of symptoms to define a case, degree of impairment, objective diagnostic criteria versus more theoretically based criteria, episodic versus trait-like symptoms, and the role of atypical and subclinical symptoms. All of these issues have been raised for the anxiety disorders and depression. This article presents the conceptualization of a relatively novel and testable approach to the diagnosis and classification of panic and agoraphobia, the panic-agoraphobic spectrum, and pilot data on a new questionnaire to assess it. Pilot testing of the Panic-Agoraphobic Spectrum Questionnaire was undertaken with 100 inpatients who had lifetime diagnoses of panic disorder, unipolar depression, comorbid panic and unipolar depressive disorders, or an eating disorder. The instrument emphasizes impairment related to 144 behaviors and experiences in seven panic-agoraphobic symptom domains. Patients with panic disorder scored highest on the questionnaire, and those with comorbid depression showed even greater severity of illness. The scores of the patients with eating disorders and of the depressed patients differed from those of the other groups but also differed from 0. The spectrum model of panic and agoraphobia is a flexible and comprehensive means of describing this clinical complex. The proposed model, complementary to the categorical approach, presumably expresses a unitary pathophysiology. Its usefulness is discussed in terms of its value for patient-therapist communication, outcome measures, identification of subtle personality traits, and subtyping of patients for research and treatment.