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Summary articles of the lectures Loss & Psychotrauma

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In this document i have summarized the articles we needed to study for the lectures. (this does not include the articles of the workshop or notes from the lectures). It is for the course Loss & psychotrauma - master Clinical Psychology - Utrecht University.

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  • 13 januari 2022
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  • 2021/2022
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Summary articles Loss & Psychotrauma CP-UU
Lecture 1:
Stroebe, M.S., Schut, H.A.W. & Stroebe, W. (2007). The health consequences of bereavement: A review. The Lancet, 370, 1960-1973.
10.1016/S0140- 6736(07)61816-9
We look at the relation between bereavement and physical and mental health. Although grief is not a disease and most people adjust without
professional psychological intervention, bereavement is associated with excess risk of mortality, particularly in the early weeks and months
after loss. It is related to decrements in physical health, indicated by presence of symptoms and illnesses, and use of medical services. We
summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death,
intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the effectiveness of
psychological intervention programmes. Intervention should be targeted at high-risk people and those with complicated grief or bereavement-
related depression and stress disorders.
Research on stressful life-events has progressed during the past three decades. Death of a spouse ranks as the life-event needing the most
intense readjustment on the SRRS. Bereavement is defined as the situation of having recently lost a significant person through death.
- Of children younger than 18 years, 3·4% have experienced the death of a parent,9 whereas in elderly populations, spousal
bereavement is most frequent, with about 45% of women and 15% of men older than 65 years becoming widowed.
It is associated with a period of intense suffering for most individuals, with an increased risk of developing mental and physical health
problems. Adjustment can take months or even years and is subject to substantial variation between individuals and across cultures. For a few
people, mental and physical ill-health is extreme and persistent. For this reason, bereavement is a concern not only for preventive care but
also for clinical practice. Grief is defined as the mainly emotional reaction to bereavement, incorporating diverse psychological and physical
reactions.
The article asks 3 questions:
1. What psychological and physical effects does loss of a loved person have on survivors?
2. Is the risk of succumbing to health disorders greater in bereaved than non-bereaved counterparts?
3. Can counsellors and therapists help to reduce the health problems of bereaved people?
Morality of bereavement:
Overall patterns 
For several decades, researchers have examined whether the death of a loved one increases the mortality risk of the bereaved person—
understood popularly as dying of a broken heart. There are several confounders such as socioeconomic and lifestyle factors the bereaved
spouse would have shared with their deceased partner, which could affect the bereaved spouse’s health as well. Other potential confounders
include cases of deaths from accidents involving both spouses and remarriage of the healthiest widowed individuals. Most of the findings
indicate an early excess risk of mortality, although some researchers have also noted risks persisting for longer than 6 months after
bereavement.
Subgroup differences 
Some researchers have examined subgroup differences such as sex and age patterns, education and ethnic origin, household size and number
of children. Most, though not all findings confirm that there are sex differences in the mortality of spousal bereavement; widowers (compared
with married same-sex counterparts) are at relatively more excessive risk of mortality than widows (compared with married same-sex
counterparts). That sex-difference patterns can vary across types of loss (spousal, child, parent) is noteworthy. Death of a child has been
reported to have an even greater effect on mothers than fathers. Furthermore, patterns of mortality by sex in bereaved people could be
altering with changing sex roles in recent decades. With respect to age, findings of studies have also indicated a greater mortality risk for
younger than for older bereaved people who have lost their spouse.
Cause of death 
Bereaved people die excessively from various causes. Excess mortality in widowed populations is highest in the early months, and decreases
with increasing duration of bereavement. Mortality was very high for accidental and violent causes and alcohol-related diseases, moderate for
chronic ischaemic heart disease and lung cancer, and small for other causes of death.
Physical ill health:
General patterns 
Some investigators have reported a greater occurrence of physical health complaints in bereaved people (compared with matched controls),
ranging from physical symptoms (headaches, dizziness, indigestion, and chest pain) to high rates of disability and illness, greater use of medical
services (in some studies), and drug use. Some results from research suggest that bereaved individuals who are most in need of health care
might not be obtaining help.
Specific debilitating aspects 
Other research groups have identified additional debilitating aspects of physical ill health in bereaved populations. Older widowed individuals
reported substantially increased activity-limiting pain and moderate-to-severe current pain. Bereavement has also been associated with
weight loss. Concluding, People who have been bereaved are more likely to have physical health problems, particularly those who have been
bereaved recently. Bereaved individuals also have higher rates of disability, medication use, and hospitalisation than non-bereaved
counterparts.
Psychological symptoms and ill health:
Bereavement is also associated with various psychological symptoms and illnesses. (grief reactions in the article!). Psychological reactions are,
generally speaking, most intense in early bereavement. Growing evidence suggests that depression and grief might represent distinct, though
related, clusters of reactions to bereavement. Bereavement is a harrowing experience for most people, one that causes considerable upset
and disruption of everyday life. For most people the experience, though difficult, is tolerable and abates with time. For some, however, the
suffering is intense and prolonged. Psychological reactions to bereavement are diverse, varying between individuals as well as between
cultures and ethnic groups. Reactions vary in nature and intensity according to the type of lost relationship. Scientific investigation has
recorded specific reaction patterns to various different types of bereavements.
Changes during bereavement 
Changes in symptoms of bereavement over time were originally described in terms of stages or phases of shock, yearning and protest, despair,
and recovery, and lately in terms of tasks. This so-called task model is used in guiding counselling and therapy. The four tasks of grieving are:

,accepting reality of loss; experiencing the pain of grief; adjusting to the environment without the deceased; and relocating the deceased
emotionally and moving on. Not all grieving individuals undertake these tasks, nor, if they do, do they undertake them in a fixed order. Both
individual and cultural differences may play a role.
Resilience versus vulnerability 
Researchers have reported that over the long-term, most bereaved people are resilient, recovering from their loss, emotionally and physically,
with time. Although identifying what makes people susceptible to psychological disorders has a long research tradition, the problem of
bereavement can also be approached by studying the factors that make people resilient. For example, researchers have focused on positive
growth or, more specifically, on creativity that might come about as a result of (early-life) bereavement. Thus some people gain from their
bereavement experience.
Psychiatric disorders 
In some cases, especially when the loss of life has been massive or the nature of the deaths horrific, the bereaved develop post-traumatic
stress disorder. Of course, bereaved individuals can have a combination of disorders, developing, for example, both post-traumatic stress
disorder and major depressive disorder, further complicating their grief reaction.
Complications in the grieving process 
In some cases, the grieving process can become complicated or disturbed, perhaps because of other mental-health difficulties. Complicated
grief has been defi ned as a deviation from the normal (in cultural and societal terms) grief experience in either time course, intensity, or both,
entailing a chronic and more intense emotional experience or an inhibited response, which either lacks the usual symptoms or in which onset
of symptoms is delayed.
Additional medical implications:
Bereavement can have an even broader range of consequences than those already discussed. Bereavement has been shown to be associated
with impaired memory performance, nutritional problems, work and relationship difficulties and difficulties concentrating; and decreases in
social participation. And health-care costs for bereaved individuals have been shown to be higher. These health effects are likely to be
associated with changes in different underlying physiological mechanisms.
Risk factors:
Risk factors are summarized in table 2. We have noted that situational, intrapersonal, interpersonal, and coping factors affect bereavement
outcome. They do so in complex ways and there could be interactions between factors (between personality and circumstances of death) that
operate to affect outcome.
Intervention efficacy:
Since bereavement increases the risk of negative health outcomes for some individuals, research needs to establish whether intervention is to
be recommended and whether intervention is actually effective. The focus here is on psychological and not medical or pharmacological
intervention. Grief interventions can be divided into primary, secondary, and tertiary preventive interventions.
- Primary preventive interventions are those in which professional help is available to all bereaved individuals irrespective of
whether intervention is indicated. Secondary preventive interventions are designed for bereaved individuals who, through
screening or assessment, can be regarded as more vulnerable to the risks of bereavement (high levels of distress, traumatic
circumstances of loss, etc). Tertiary preventive interventions denote those providing therapy for complicated grief, grief-related
depression, or post-traumatic disorders, usually evident longer after bereavement.

Lecture 2
Heide, F.J.J ter, Mooren, T.M., & Kleber, R.J. (2016). Complex PTSD and phased treatment in refugees: A debate piece. European Journal of
Psychotraumatology, 7, 1, 10.3402/ejpt.v7.28687.
Asylum seekers and refugees have been claimed to be at increased risk of developing complex posttraumatic stress disorder (complex PTSD).
Consequently, it has been recommended that refugees be treated with present-centred or phased treatment rather than stand-alone trauma-
focused treatment. This recommendation has contributed to a clinical practice of delaying or waiving trauma-focused treatment in refugees
with PTSD.
- The aim of this debate piece is to defend two theses: (1) that complex trauma leads to complex PTSD in a minority of refugees
only and (2) that trauma-focused treatment should be offered to all refugees who seek treatment for PTSD.
Research and treatment of complex PTSD centre around the hypothesis that complex traumatic experiences (complex trauma) lead to a
posttraumatic syndrome (complex PTSD) that is clearly distinguishable from regular post-traumatic stress disorder. The terms ‘‘complex
trauma’’ and ‘‘complex PTSD’’ are often used interchangeably. Complex trauma refers to complex traumatic experiences, and complex PTSD
to complex posttraumatic symptoms.
Complex trauma:
The experience of war has been a central element in the search for a distinction between relatively delineated traumatic events, such as a
robbery, disaster, or traffic accident, and more complicated traumatic events. This got broadened to include the experience of (domestic)
violence in children and women. It was suggested that a meaningful clinical distinction may be made between single traumatic events and
repeated, prolonged, interpersonal traumatic events occurring in a context of totalitarian control.
- Complex trauma is defined in the ISTSS guidelines as: ‘‘exposure to repeated or prolonged instances or multiple forms of inter-
personal trauma, often occurring under circumstances where escape is not possible due to physical, psychological,
maturational, family/environmental, or social constraints’’. In the ICD-10 it is defined as: catastrophic stress which ‘‘must be so
extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality’’.
Many refugees meet these definitions.
Complex PTSD:
Several diagnoses have been put forward to describe the psychological consequences of complex trauma, most notably complex PTSD,
Disorders of Extreme Stress Not Otherwise Specified (DESNOS), and Enduring Personality Change After Catastrophic Experience (EPCACE). Of
these, DESNOS has been most extensively studied, however it is currently described as additional symptoms of PTSD. Existence of a clearly
delineated complex posttraumatic syndrome has been more explicitly acknowledged in ICD than in DSM. ICD-10 contains the only formal
diagnosis of complex PTSD: Enduring Personality Change After Catastrophic Experience or EPCACE.
- EPCACE is characterised by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or
hopelessness, a chronic feeling of ‘‘being on edge’’ as if constantly threatened, and estrangement. Patients cannot be diagnosed
as experiencing both EPCACE and PTSD.

, Trauma focused and phased treatment:
The clinical relevance of recognising the existence of complex PTSD in a patient is because the diagnosis is believed to merit a treatment plan
that is different from that recommended by treatment guidelines for PTSD in adults.
- Treatment guidelines for PTSD in adults recommend trauma-focused treatment as a first line intervention for all patients with
chronic PTSD. Trauma-focused treatment can be defined as treatment that focuses on ‘‘the patients’ memories of their
traumatic events and the personal meanings of the trauma’’ .Examples are prolonged exposure or eye movement
desensitisation and reprocessing therapy (EMDR).
- The ISTSS guidelines for complex PTSD recommend the implementation of phased treatment. This consists of a first phase that
focuses on safety, symptom reduction, and skills training; a second phase that focuses on processing of traumatic memories;
and a third phase that focuses on social and psychological (re-)integration.
The theory of phased treatment for complex PTSD and its emphasis on safety and psychological decompensation has had a major impact on
treatment for traumatised asylum seekers and refugees. For a long time, the emphasis has been on protecting refugee patients from
emotional overburdening through trauma-focused therapy by delaying or avoiding trauma-focused treatment. Unsafe circumstances and
complex PTSD are frequently used as reasons for deviating from treatment guidelines for PTSD in refugees.
The review has 2 theses : 1) I. Complex trauma leads to complex PTSD in a minority of refugees only and 2) II. Trauma-focused treatment
should be offered to all refugees who seek treatment for PTSD.
Conclusion:
Conclusion All clinicians and researchers working with refugees, regardless of whether or not they endorse the concepts of complex PTSD and
phased treatment in refugees, strive to alleviate suffering in this highly burdened group of patients. What this paper aims at is not so much
polarising the debate as encouraging careful diagnostics of traumatised refugees while discouraging the practice of long-term stabilisation in
refugees who are perceived as too vulnerable for trauma-processing. Although there may be valid clinical reasons to postpone trauma-focused
treatment in refugees, such as untreated psychosis, we pose that there is currently no evidence that justifies the use of complex PTSD and lack
of refugee status as exclusion criteria for trauma-focused treatment in refugees in general.

Bryant, R.A (2019). Post-traumatic stress disorder: A state-of-the-art review of evidence and challenges. World Psychiatry, 18, 259-269.
10.1002/wps.20656.
Although traumatic stress has been known for over 100 years by a number of terms, including “shell shock”, “battle fatigue”, or “soldier’s
heart” , it was only in the 1980s that persistent stress reactions were recognized in psychiatric nosology. Since that time, our knowledge about
PTSD has grown significantly. However, in spite of this, the field of traumatic stress has often been dogged with controversy over the very
definition of PTSD, its etiology, and optimal means for treatment. In this context, this review outlines our current understanding of PTSD,
including diagnostic definitions, prevalence and risk factors, conceptual models, treatment approaches, and some of the major challenges
currently facing the field.
Diagnostic definitions:
There are currently two major diagnostic definitions of PTSD.
1. The DSM-5 requires that a person experience or witness a major traumatic event (exposure to actual or threatened death, serious
injury or sexual violence) (Criterion A). If one has experienced or witnessed such an event, there are four symptom clusters that
he/she should manifest. First, one needs to have at least one of the following re-experiencing symptoms: intrusive distressing
memories, recurrent distressing dreams, dissociative reactions (e.g., flashbacks), intense or prolonged psychological distress at
exposure to reminders of the trauma, marked physiological reactions to internal or external cues symbolizing or resembling an
aspect of the traumatic event (Criterion B). Second, one is required to have active avoidance of internal (e.g., thoughts, memories)
and/or external (e.g., situations, conversations) reminders of the trauma (Criterion C). Third, at least two “alterations in cognitions
and mood” symptoms are needed, including inability to remember an important aspect of the traumatic event, persistent and
exaggerated negative thoughts about oneself or the world, persistent distorted cognitions about the cause or consequences of the
event, pervasive negative emotions, markedly diminished interest, feeling detached or estranged from others, persistent inability to
experience positive emotions (Criterion D). Finally, one has to present at least two of the following arousal symptoms: irritable
behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with
concentration, sleep disturbance (Criterion E). People are required to manifest these symptoms for more than one month after
trauma exposure, in order to minimize pathologization of normal stress reactions.
- In addition to PTSD, the DSM-5 also includes the diagnosis of acute stress disorder, which describes stress reactions occurring
in the first month after trauma exposure.
2. The recently approved ICD-11 diagnostic guidelines for PTSD strategically adopt a narrow focus on fear circuitry symptoms,
comprising re-experiencing of the traumatic event, avoidance of reminders, and a perception of heightened current threat (reflected
by various forms of arousal). Central to this definition is the proposition that a core component of PTSD is re-experiencing the
memories of the traumatic event in the present.
Another diagnostic construct that is worth noting is complex PTSD, which has been introduced in the ICD-11. To receive this
diagnosis, one needs to present the core PTSD symptoms, and in addition experience disturbances in self-identity (e.g., negative self-
concept), emotional dysregulation (e.g., emotional reactivity, violent outbursts), and persistent difficulties in relationships. Although
most commonly seen in the wake of prior prolonged childhood abuse, this disorder can also occur in survivors of other severe
traumas, such as torture.
Prevalence:
Although many people are exposed to traumatic events at some point in their lives, most of them rebound to enjoy pretrauma levels of
psychological functioning. Epidemiological studies have reported lifetime PTSD prevalence rates of 13.0- 20.4% for women and 6.2-8.2% for
men. The World Mental Health Surveys have observed higher 12-month prevalence rates in high-income (Northern Ireland: 3.8%; US: 2.5%;
New Zealand: 2.1%) than in low- and middle-income countries (Colombia: 0.3%; Mexico: 0.3%).
There is evidence that some features of a traumatic event are more likely to trigger PTSD. Overall, interpersonal violence typically leads to
higher rates of PTSD. In fact, the World Mental Health Surveys found that organized, physical or sexual violence increased the risk for PTSD. In
studies that have focused on individual countries (which is methodologically sounder, because it allows greater consistency of potential

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