Comlicated Grief, Depression, and Anxiety as Distinct Postloss Syndromes: A Confirmatory Factor Analysis Study

Department of Clinical Psychology, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, the Netherlands.
American Journal of Psychiatry (Impact Factor: 12.3). 12/2005; 162(11):2175-7. DOI: 10.1176/appi.ajp.162.11.2175
Source: PubMed


The authors used confirmatory factor analysis to replicate earlier findings that complicated grief, depression, and anxiety are distinct syndromes.
Data were derived from 1,321 bereaved individuals. Complicated grief was measured with the Inventory of Traumatic Grief. Depression and anxiety were measured with the SCL-90.
A model in which symptoms of complicated grief, depression, and anxiety loaded on separate factors was superior to a one-factor model, revealed good model fit, and was invariant across subgroups.
Previous findings of a distinction among complicated grief, depression, and anxiety were confirmed.

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Available from: P.A. Boelen, Nov 27, 2015
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    • "A number of studies published in the last years showed that prolonged grief can be differentiated from depression and PTSD (Boelen & Van den Bout, 2005; Boelen, Van den Hout, & Van den Bout, 2008). Differences between CGD and PTSD can be summarized as follows: (1) While yearning symptoms are the hallmark symptom group for CGD, intrusive symptoms are the core symptom group for PTSD. "
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    ABSTRACT: Following the death of a loved one, a small group of grievers develop an abnormal grieving style, termed complicated or prolonged grief. In the effort to establish complicated grief as a disorder in DSM and ICD, several attempts have been made over the past two decades to establish symptom criteria for this form of grieving. Complicated grief is different from depression and PTSD yet often comorbid with other psychological disorders. Meta-analyses of grief interventions show small to medium effect sizes, with only few studies yielding large effect sizes. In this article, an integrative cognitive behavioral treatment manual for complicated grief disorder (CG-CBT) of 25 individual sessions is described. Three treatment phases, each entailing several treatment strategies, allow patients to stabilize, explore, and confront the most painful aspects of the loss, and finally to integrate and transform their grief. Core aspects are cognitive restructuring and confrontation. Special attention is given to practical exercises. This article includes the case report of a woman whose daughter committed suicide.
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    • "Most studies examined differences in grief reactions within a relatively short period after the loss and found that time since the loss did not significantly impact the severity of prolonged grief symptoms or PGD diagnosis [9,12,16,17]. The focus on a sample of bereaved widows and orphans who considerably ranged in length of time since the death enabled the evaluation of the predictive power across a considerable period of time. "
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    ABSTRACT: The concept of Prolonged Grief Disorder (PGD) has been defined in recent years by Prigerson and co-workers, who have developed and empirically tested consensus and diagnostic criteria for PGD. Using these most recent criteria defining PGD, the aim of this study was to determine rates of and risks for PGD in survivors of the 1994 Rwandan genocide who had lost a parent and/or the husband before, during or after the 1994 events. The PG-13 was administered to 206 orphans or half orphans and to 194 widows. A regression analysis was carried out to examine risk factors of PGD. 8.0% (n = 32) of the sample met criteria for PGD with an average of 12 years post-loss. All but one person had faced multiple losses and the majority indicated that their grief-related loss was due to violent death (70%). Grief was predicted mainly by time since the loss, by the violent nature of the loss, the severity of symptoms of posttraumatic stress disorder (PTSD) and the importance given to religious/spiritual beliefs. By contrast, gender, age at the time of bereavement, bereavement status (widow versus orphan), the number of different types of losses reported and participation in the funeral ceremony did not impact the severity of prolonged grief reactions. A significant portion of the interviewed sample continues to experience grief over interpersonal losses and unresolved grief may endure over time if not addressed by clinical intervention. Severity of grief reactions may be associated with a set of distinct risk factors. Subjects who lose someone through violent death seem to be at special risk as they have to deal with the loss experience as such and the traumatic aspects of the loss. Symptoms of PTSD may hinder the completion of the mourning process. Religious beliefs may facilitate the mourning process and help to find meaning in the loss. These aspects need to be considered in the treatment of PGD.
    Full-text · Article · Jul 2010 · BMC Psychiatry
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    • "for depression and anxiety. This led the authors to assume related but distinguishable symptom clusters (Boelen, 2005). Principal axis factoring showed grief symptoms of 150 widowed individuals loading high on the grief factor and poorly on the anxiety and depression factors (Prigerson, 1996a). "
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    ABSTRACT: Organized violence has lasting and devastating effects at the individual and community level. Previous studies in crisis regions, including Rwanda, have revealed grave consequences of violence on psychological functioning, as presented in Chapter 1. With the epidemiological study described in Chapter 2, we assessed mental health problems and needs in the post-war Rwandan society. We conducted a cross-sectional survey to examine widows and orphans, two vulnerable groups that are prominently affected during wars. In 2007, 13 years after the 1994 genocide, we trained Rwandan psychology students to conduct psycho-diagnostic interviews. Under expert supervision, they interviewed 406 genocide survivors in five districts of Butare (southern Rwanda) for socio-demographic and clinical variables. The instruments included an event-list adapted to the context of the Rwandan genocide, the validated version of the Posttraumatic Stress Diagnostic Scale (PDS) and the Hopkins Symptom Checklist (HSCL-25), as well as the Prolonged Grief Disorder questionnaire (PG-13) and the Mini International Neuropsychiatric Interview (M.I.N.I.) suicide section C in Kinyarwanda. We recruited orphans from age 18 to 31 and widows without age restrictions. We found that the genocide victims had experienced on average 11.3 different types of potentially traumatic events during their lifetime. Most of them related to the genocide, such as expectation to die (89.9%), forced movement (89.7%), and forced to hide to be saved (88.9%). The most common worst life events were the genocide in general, sexual violence, and witnessing murder or massacre. Mental health problems were very frequent in the sample with 34.7% suffering from Posttraumatic Stress Disorder (PTSD), 7.9% Prolonged Grief Disorder (PGD), 40.9% Major Depression (MD), 50% Anxiety Disorder (AD), and 38.2% suicide ideation. The vulnerability of widows was higher on average. The sum of experienced traumatic event types was the best indicator for an increased risk to suffer from clinically relevant symptoms. At the time of interview, only 5.4% of all participants received professional psychological help. Mental health problems, in particular PTSD, are a major issue in post-conflict countries. I discuss general intervention approaches and specific psychotherapy of trauma-spectrum disorders adequate for application in post-war countries in Chapter 4. The great number of victims resulting from organized violence demands dissemination of effective short-term therapy to local human resources. I further present literature about the feasibility and effectiveness of trauma therapy dissemination for victims of organized violence. Accordingly, we performed a randomized controlled trial in Rwanda representing the second empirical study which, is described in Chapter 5. With the previously conducted cross-sectional epidemiological survey we had identified orphans and widows who had survived the 1994 genocide suffering from chronic PTSD. After a pre-test, we randomly assigned 76 genocide survivors to treatment or to a six-month waiting list (WL). In the first round of dissemination, clinical experts trained Rwandan Psychology graduates (B.A.) in Narrative Exposure Therapy (NET) and Interpersonal Therapy (IPT). The Rwandan Psychologists administered NET/IPT to the patients in the treatment group under constant expert supervision (first dissemination generation). In a second round of dissemination, we conducted a randomized trial to evaluate the train the trainer model. Skilled therapists, who had participated in the first round, trained and supervised a second generation of Rwandan psychologists to offer treatment to the WL group (second dissemination generation). We conducted evaluations before therapy and at three-, six-, and twelve-month follow-up interviews using the main outcome measures for PTSD, PGD, and MD. Participants of the first dissemination generation of NET/IPT therapists reported a significant reduction in PTSD symptoms (Effect Size (ES) = 1.48). Equally, NET/IPT in second dissemination generation was effective (ES = 1.15). PGD, MD, and suicidal tendency reduced substantially over time both in the NET/IPT and the WL group. Participants maintained and increased treatment gains at follow-up interviews. The results indicate that short-term trauma therapy can be disseminated in first and second generation to Rwandan graduates. It proved to be an effective intervention, which implies general feasibility in post-conflict societies. For a broader understanding of the project context, I present an overview of Rwanda’s history and culture in the Annex. Organisierte Gewalt hat lang anhaltende und verheerende Effekte auf das Individuum und die Gesellschaft. Frühere Studien aus Krisenregionen, einschließlich Ruanda, verdeutlichten die Folgen von Gewalt auf das psychische Funktionsniveau. In einer epidemiologischen Querschnittstudie erfassten wir psychische Probleme und Bedürfnisse ruandischer Genozid-Überlebender. Die Zielgruppen waren Witwen und Waisen – zwei häufig vorkommende und vulnerable Gruppen in Konfliktgebieten und Nach-Kriegs-Gesellschaften. Dreizehn Jahre nach dem ruandischen Genozid 1994, trainierten wir lokale Psychologiestudenten in der Anwendung psychodiagnostischer Interviews. Unter Expertensupervision befragten die Studenten 406 Genozidüberlebende in fünf verschiedenen Bezirken von Butare (südliches Ruanda). Die Instrumente enthielten eine an Ruanda adaptierte Ereignisliste zur Erfassung traumatischer Erlebnisse, eine validierte Version der Posttraumatischen Stress Diagnoseskala und der Hopkins Symptom Checkliste sowie der Suizid-Sektion C des Mini Internationalen Neuropsychiatrischen Interview auf Kinyarwanda. Wir rekrutierten Waisen zwischen 18 und 31 Jahren und Witwen ohne Altersbeschränkungen. Die Ergebnisse zeigten, dass die Genozidopfer im Durchschnitt 11,3 unterschiedliche Arten potentiell traumatischer Ereignisse durchlebt hatten. Die meisten Erlebnisse standen in direkter Verbindung zu dem Genozid, so wie Glaube, selber zu sterben (89,9%), Flucht vom Wohnort (89,7%), und Verstecken um zu überleben (88,9%). Die häufigste Antwort auf die Frage nach dem schlimmsten Erlebnis waren Genozid, sexuelle Gewalt, und Bezeugen eines Mordes oder Massakers. Psychische Probleme waren sehr häufig in der Stichprobe, 34,7% litten an einer Posttraumatischen Belastungsstörung (PTBS), 7,9% hatten eine Diagnose Anhaltender Trauer, 40,9% zeigten klinisch relevante Symptome einer Depression, 50% berichteten eine klinisch relevante Angstsymptomatik, und 38,2% hatten ein erhöhtes Suizidrisiko. Insgesamt waren Witwen vulnerabler für psychische Probleme. Die Summe der erlebten traumatischen Erlebnistypen war der beste Prädiktor für klinische Symptomatik. Zum Zeitpunkt des Interviews, erhielten nur 5,4% der Stichprobe psychologische Hilfe. Psychische Störungen, insbesondere die PTBS, sind gravierende Probleme in Post-Konflikt Ländern. Die große Anzahl von Opfern organisierter Gewalt, erfordert die Dissemination effektiver therapeutischer Module an lokale Ressourcen. Entsprechend untersuchten wir nachfolgend mit der vorliegenden Studie Machbarkeit und Effektivität der Dissemination von Psychotherapie. In der zuvor durchgeführten epidemiologischen Untersuchung hatten wir Genozidüberlebende identifiziert, die unter chronischer PTBS litten. Wir evaluierten die Wirksamkeit der Therapie anhand der Symptomatik der Teilnehmer mit der Klinischen Posttraumatischen Belastungs-Skala für DSM-IV (CAPS), dem Fragebogen zu Verzögerter Trauer (PG-13), und dem Mini Internationalen Neuropsychiatrischen Interview (M.I.N.I.) zu Depression und Suizid. Die Interviews wurden vor der Therapie sowie drei-, sechs-, und 12 Monate danach durchgeführt. Nach der initialen Diagnostik wurden die Teilnehmer randomisiert der Therapiegruppe oder der Sechs-Monat Warteliste zugeteilt. In einer ersten Disseminationsgruppe trainierten klinische Experten ruandische Psychologen (B.A.) in Narrativer Expositions Therapie (NET) und Interpersoneller Therapie (IPT). Unter Expertensupervision wendeten die lokalen Psychologen eine Kombination der Therapie-Module (NET/IPT) in der Therapiegruppe an. Sechs Monate später führten wir in einer zweiten Disseminationsgruppe die Evaluation eines Multiplikatoren-Modells durch. Drei Therapeuten der ersten Disseminationsgruppe trainierten und supervidierten eine weitere Gruppe ruandischer Psychologen bei der Durchführung der NET/IPT mit den Wartelisten-Teilnehmern. Nach sechs Monaten, berichteten die Therapie-Teilnehmer der ersten NET/IPT Disseminationsgruppe eine signifikante Reduktion der PTBS Symptomatik im Vergleich zu den Teilnehmern der Warteliste (korrigierte Effektstärke ,43). Unspezifische komorbide psychische Probleme wie Anhaltende Trauer und Depression reduzierten sich signifikant in beiden Bedingungen über die Zeit. Auch nach der NET/IPT der zweiten Disseminationsgruppe berichteten die Teilnehmer einen signifikanten Rückgang psychischer Probleme vergleichbar zur ersten Gruppe. Die Symptomreduktion wurde über die Zeit beibehalten bzw. erhöhte sich bis zur 12-Monat Nachuntersuchung mit einer Effektstärke von 1,48 in der ersten und 1,15 in der zweiten Disseminationsgruppe. Die Ergebnisse zeigen, dass Traumatherapie an ruandische Psychologen disseminiert werden kann. Es erwies sich als eine effektive Intervention, was eine generelle Machbarkeit der Dissemination von Psychotherapie in Post-Konfliktländern impliziert.
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