GRIEF, BEREAVEMENT AND PROLONGED GRIEF DISORDER
, LECTURE 1 – INTRODUCTION TO LOSS & PSYCHOTRAUMA
Loss & Psychotrauma can be distinguished as concepts.
Loss → Separation from someone or something that you are attached to. This can
be a personal loss, but also a material loss such as work.
Seperation distress (grief) → Pain, sadness; yearning for/preoccupation with what
is lost; difficulties accepting and believing the object of attachment is gone.
Psychotrauma → Experiencing or witnessing an event that is threatening to safety,
control, integrity, health of self or others. This can lead to traumatic distress.
Traumatic distress → Reexperiencing, anxiety, hypervigilance, sense of current
threat (difficulties accepting and believing threat is in the past).
Both loss and psychotrauma are negative and stressful, however, they can be
distinguished from one another by their description of the situation.
Loss and trauma are usually different concepts; however, they can co-occur, hence,
traumatic loss. Loss & Psychotrauma can overlap into traumatic loss and traumatic
grief.
GRIEF
Bereavement → Situation of having lost a loved one/relative
Grief → The emotional/psychological responses to this loss
Mourning → Behavioural and social expressions of grief, which are shaped by the
practices of a given society or cultural group (e.g. mourning rituals)
Unhealthy, disordered, complicated grief → General terms for stagnated grief –
possibly developing into a full-blown disorder
,Prolonged Grief Disorder → Term for formal classification of grieving disorder in
DSM-5-TR and ICD-11
Prevalence of loss
- In 2021, 169.000 people died in The Netherlands
- All deceased people leave behind +- 5 relatives
Worldwide, 69 people died in 2021; leaving behind 345 million people.
Misconceptions about grief
1. Normal grieving is a process occurring in stages or phases (denial, anger,
bargaining, depression, acceptance)
2. The same reactions are always part of the grieving process
3. Intense emotions in the initial period of mourning predict healthy adjustment,
absence of reactions indicate unhealthy, abnormal grief
4. Losing a child is always worse than losing a partner – which are both worse
than losing a parent.
5. A grieving process ends after 1 year (partners) or 2 years (children)
What is grief?
• Grief is the primary emotional reaction to the death of a significant other.
• Grief is a complex emotional syndrome accompanied by physical
symptoms.
• Grief involves a wide range of possible cognitive and behavioral reactions.
Primarily: separation distress
→ Separation distress is an automatic response occurring after being separated from
an attachment figure
→ Attachment figure = person providing a safe heaven for you (parent, partner)
→ Attachment figure = person you are responsible for as a caretaker
Feelings in separation distress = Yearning, longing
Behavior in separation distress = Proximity seeking (searching)
Thoughts in separation distress = Preoccupation with thoughts about deceased
and death event
Perceptions in separation distress = Sensation of seeing/hearing the person,
feeling that separation is unreal
Adjusting to loss is all about tasks, not about stages/phases. For the individual
exposed to grief or loss, these are:
- Facing the reality of the loss
- Allowing the emotions aroused by the loss to be felt
- Continuing usual, valued activities
,Normal, healthy grief is all about processes and tasks that need to be
completed.
Duo-process model of coping with bereavement:
A person grieving will accelerate between loss-oriented and restoration-oriented
behaviors.
In normal, healthy, adaptive grief, a person will oscillate between these two.
Grief is disturbed when this oscilation is disturbed: when there is either too much
focus on the loss-oriented or the restoration-oriented tasks.
What is disturbed, unhealthy grief? Literature says:
- Chronic grief → Too much grief
- Supressed/Delayed grief → Too little grief grief
- Ambivalent grief → Grief after a disturbed relationship
The problem with these terms is that they are simplistic and vague, and not
supported by evidence.
Different sets of criteria have been created after realizing that the concepts above
were not right.
Now, both DSM-5 and ICD-11 recognize the existence of Prolonged Grief Disorder.
,ICD-11 PGD DSM-5 PGD
A. Event History of bereavement of a A. Event and Death of a close person at least
Criterion. person close to them. Time Criteria. 12 months ago.
B. Separation Persistent & pervasive grief B. Separation Development of persistent grief
Distress. response characterised by either Distress. response characterised by
longing or persistent either yearning/longing or
preoccupation with the deceased. preoccupation with the
deceased, which have been
present most days for at least
the last month to a clinically
significant degree.
C. Intense Intense emotional pain. C. Cognitive, At least three of the following
Emotional Difficulty accepting the death. Emotional, and symptoms have been present
Pain. Feeling a loss of oneself. Behavioural most days:
Inability to experience a positive Symptoms. - Identity disruption.
mood. - Marked sense of disbelief.
Emotional numbness. - Avoidance of reminders.
Difficulty engaging with social - Intense emotional pain.
activities. - Difficulty reintegrating.
- Emotional numbness.
- Feel that life is meaningless.
- Intense loneliness.
D. Functional Significant impairment in important D. Functional Significant distress or
Impairment. areas of functioning. Impairment. impairment in important areas of
If functioning is maintained, it is functioning.
only through significant additional
effort.
E. Cultural Pervasive grief response has E. Cultural Duration & severity of the
and Time persisted for an abnormally long Orientation. bereavement reactor clearly
Criteria. period. exceed expected social, cultural,
Grief responses lasting for less or religious norms for the
than 6 months and for longer individual’s cultural context.
periods in some cultural contexts
should not be regarded as meeting
this requirement.
F. Relation to Symptoms are not better
Other Mental explained by another disorder or
Disorders. attributable to physiological
effects of a substance or other
condition.
,Criterion A
- ICD describes an event criterion, while DSM-5 describes an event and time
criterion
Criterion B
- Both ICD and DSM describe separation stress
Criterion C
- ICD describes intense emotional pain, while DSM-5 describes cognitive,
emotional and behavioral symptoms
Criterion D
- Both name a functional impairment criterion. However, ICD says that
functioning can be maintained, but through significant additional effort
Criterion E
- Both name cultural criterion, but ICD describes a time criteria here
Criterion F
- DSM-5 states that if symptoms are better explained, a diagnosis can not be
made
So, important differences between ICD-11 and DSM-5 for Prolonged Grief
Disorder:
- Typological vs. detailed description of criteria
o More detail in the DSM-5
- Number of symptoms and severity specification for diagnosis
o More symptoms and severity in DSM-5
- Timing after loss when diagnosis can be made
o More than 6 months for ICD-11, more than 12 for DSM-5
ASSESSING DISTURBED, UNHEALTHY GRIEF AND PROLONGED GRIEF
DISORDER
Diagnosing Prolonged Grief Disorder
Differences between PGD and healthy evaluation
- Degree of progress in the grieving process
o PGD: No progress, worsening of condition over time
- Duration of grief reactions
o PGD: Grief reactions persist 6 months or 12 months post-loss
- Degree of suffering
o PGD: Grief causes distress + impairs functioning
When these three indicate that PGD might be present, you can make a stepped
diagnostic assessment.
,Stepped diagnostic assessment:
1. Self-report questionnaire to get indication of disturbed grief
2. Clinical interview to make formal diagnosis PGD
One of the instruments that can be used for the diagnosis is the
Traumatic Grief Inventory Self Report Plus (TGI-SR+)
- Allows to set diagnosis of probably PGD as defined in DSM-5-TR and ICD-11
- Total score of ≥ 71 indicates clinically relevant PGD.
How prevalent is PGD related psychopathology following loss?
- 10% of people get PGD following natural losses
- 49% of people get PDG following unnatural/violent losses
Another study found 1.5% and 1.2% in their sample. Among bereaved participants,
the prevalence was 3.3% to 4.2%.
How prevalent is overall psychopathology following loss?
Following loss, PGD can develop, but depression and PTSD are also common.
Should we divide individuals following loss into groups that develop one or more
diagnosis, that’s about 10%.
About 40% of them will develop mild symptoms, but recovers after time.
50% is deemed resilient, and will show the process of healthy grief.
After an unexpected loss, there is a seven times higher chance that the individual will
experience an episode of depression, an eight times higher chance they will engage
in a period of alcohol abuse, and a thirty-seven times higher chance of experiencing
PTSD.
→ This data was collected on a cohort of 60-65-year-olds; however, other ages point
to equal findings.
,Experiencing sudden death of a loved one increases risk of different mental
disorders.
RISK FACTORS AND PROTECTIVE FACTORS FOR EMOTIONAL DISTRESS
FOLLOWING LOSS
Risk factors and protective factors
Socio-demographic variables
- Gender (women experience more emotional distress)
- Age (the younger, the better)
- High education is protective factor
Social reactions
- Perceived support is more important than actual support
- Stigmatisation (receiving negative responses from the environment) blocks
recovery
Personality factors
- Vulnerability to depression, anxiety (neuroticism)
- Attachment style (anxious attachment vs. secure attachment)
Family relationship
- Death of child or partner leads to more intense reactions.
o Goes against all that is natural
o Close attachment figures are more viral to one’s identity and life
Cause of death
- Unnatural, violent death leads to more problems
o Causes more acute traumatic stress blocking adjustment
o More severe stress in aftermath
o Greater violation of basic cognitions (safety, trust, control)
CONCLUSIONS OF PART 1 OF LECTURE
- Only a subset of those affected by loss will have longlasting and severe
negative emotional responses (psychiatric disorders)
- Many situational factors, socio-demographic and loss-related variables
influence responses to a loss in a complex interplay
- Many factors can not be changed with psychological interventions
- These interventions focus on psychological variables and mechanisms that
can be changed.
, Article: Disturbed grief: Prolonged Grief Disorder (PGD) and
Persistent Complex Bereavement Disorder (PCBD). (Boelen &
Smid, 2017)
Headsup:
PCBD and PGD are essentially the same and information in the article is relevant to
both disorders. The term PGD will be used.
Traditional models of grief suggest that bereaved individuals should follow the same
process towards recovery from loss. However, the concept of stages of grief
occurring in a specific order is inadequate.
The newer Grief Task model proposes that normal grief is the successful
achievement of grief tasks, with no recommended or specific order in which to
achieve the tasks. Complications in managing these tasks indicate disturbed grief.
Grief tasks of the Grief Task Model
• Accepting the reality of the loss
• Processing the associated pain
• Adjusting to a world without the deceased
• Finding an enduring connection with the deceased in the midst of embarking
on a new life
What defines Prolonged Grief Disorder and Persistent Complex Bereavement
Disorder?
PGD differs from normal and uncomplicated grief, in terms of the distress and
disability caused by the reactions and their persistence and pervasiveness. It is
only when these reactions are experienced on more days than not, causing severe
distress and impairment in important areas of functioning more than six months
after loss that a PGD diagnosis is applicable.
When to suspect PGD
• When, more than six months (ICD-11, 12 months for DSM-5) after the death
of someone close, patients present with persistent, distressing, and
disabling grief reactions that are out of proportion to or inconsistent with
cultural, religious, or age appropriate norms.
• When, more than six months after a loss, patients present with persistent,
distressing, and disabling separation distress, difficulties with
confronting the reality and irreversibility of their loss, and report a
pervasive sense of meaninglessness about life without the deceased loved
one.
, The distress in individuals with PGD might be maintained by:
• Negative cognitions and avoidance behaviours.
• Sensitivity to loss-related stimuli.
o For example after a road traffic incident death, images of a particular
car might trigger the accident and associated pain.
How common is PGD?
PGD occurs in 5%-10% of bereaved individuals.
PGD in children
• Criteria for children are similar to those for adults, except that the condition
can already be classified at six months after loss (12 months in adults).
• Symptoms can manifest differently in children than in adults → for example, in
an obsession with death during play.
• Interventions can reduce the severity of grief reactions in children without PGD
symptoms with small to moderate effects, and with relatively greater effects in
children with symptoms. Interventions that include confrontation with the most
distressing aspects of the loss are particularly helpful.
• Treatments:
o Group based Family Bereavement Program
o Trauma and Grief Component Therapy developed for adolescents.
o Cognitive behavioral interventions
PGD co-existing with other physical and mental health conditions
PGD is associated with an elevated risk of poor physical health, suicidality, reduced
quality of life, and functional impairment. It is distinguishable from major depressive
disorder, post-traumatic stress disorder, generalized anxiety disorder, and adult
separation anxiety disorder.
After traumatic bereavement, co-occurrence of PGD with PTSD and/or major
depression among individuals showing signs of severe emotional distress is
common.
Risk factors for PGD
• Elevated risk for women those with lower education.
• Personality traits linked to PGG: insecure attachment & neuroticism.
• Relationship nature matters: death of a partner or child increases PGD risk
• Loss of a close and important relationship.
Severity and associations of grief:
• More severe grief associated with unnatural and violent losses (homicide,
accidents, criminal attacks, suicide, unexpected death).
• Elevated risk of persistent distress after unnatural loss in immigrant ethnic
minorities, refugees, and conflict-affected groups.
