Conflicted or close: Which relationships to the deceased are associated with loss-related psychopathology?
TL;DR: In this article, the authors proposed a theoretical model in which past closeness and conflict are related to prolonged grief and depression via concrete and symbolic continuing bonds (CB) and tested this model in a sample of bereaved family members.
Abstract: OBJECTIVES Prior studies have shown that pre-loss closeness and conflict with a deceased person are associated with the severity of symptoms of prolonged grief and/or depression. Nevertheless, mechanisms underlying these relationships are not well understood. We propose a theoretical model in which past closeness and conflict are related to prolonged grief and depression via concrete and symbolic continuing bonds (CB). The aim of our study was to test this model in a sample of bereaved family members. METHODS Individuals (N = 244) who had lost a family member from 0.5 to 8.0 years before the survey completed the Quality of Relationships Inventory-Bereavement Version, the Continuing Bonds Scale, the Prolonged Grief Disorder-13 scale, and the Patient Health Questionnaire-9. RESULTS The findings partially confirmed our model. Closeness was positively and moderately associated with symptoms of prolonged grief but not with symptoms of depression. Conflict was positively and weakly associated with symptoms of depression and prolonged grief. All of these relationships were only partially mediated by concrete/maladaptive and symbolic/adaptive CB. CONCLUSIONS The differences in the relationship of past closeness and conflict to prolonged grief and depression symptoms suggest that inter- and intrapersonal mechanisms of prolonged grief and depressive symptoms may be distinct. If future, especially longitudinal studies, confirm our model, CB would be a possible target for interventions for bereaved persons who had a close and/or conflicted relationship with a deceased family member and experience loss-related psychopathology. PRACTITIONER POINTS Continuing bonds (CB) are a potential target of interventions for bereaved persons who had a close and/or conflicted relationship with a deceased family member and experience symptoms of prolonged grief and/or depression. Internalization of the capacity to care for yourself and feel autonomous in a safe and stable therapeutic relationship may lead to increased self-confidence, promote working through past experiences in the relationship with the deceased, and gradual reduction of concrete forms of CB. Increasing awareness and acceptance of emotional experiences may contribute to the appreciation of past relationship with a deceased person and the growth of symbolic forms of CB. Future research should focus on verifying the effectiveness of the attachment-informed therapeutic approach to working with CB.
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TL;DR: This review will discuss behavioral and neuropsychological components of loneliness in humans, social isolation in rodent models, and the neurochemical regulators of these behavioral phenotypes with a neuroanatomical focus on the corticostriatal and limbic systems.
Abstract: In social species such as humans, non-human primates, and even many rodent species, social interaction and the maintenance of social bonds are necessary for mental and physical health and wellbeing. In humans, perceived isolation, or loneliness, is not only characterized by physical isolation from peers or loved ones, but also involves negative perceptions about social interactions and connectedness that reinforce the feelings of isolation and anxiety. As a complex behavioral state, it is no surprise that loneliness and isolation are associated with dysfunction within the ventral striatum and the limbic system – brain regions that regulate motivation and stress responsiveness, respectively. Accompanying these neural changes are physiological symptoms such as increased plasma and urinary cortisol levels and an increase in stress responsivity. Although studies using animal models are not perfectly analogous to the uniquely human state of loneliness, studies on the effects of social isolation in animals have observed similar physiological symptoms such as increased corticosterone, the rodent analog to human cortisol, and also display altered motivation, increased stress responsiveness, and dysregulation of the mesocortical dopamine and limbic systems. This review will discuss behavioral and neuropsychological components of loneliness in humans, social isolation in rodent models, and the neurochemical regulators of these behavioral phenotypes with a neuroanatomical focus on the corticostriatal and limbic systems. We will also discuss social loss as a unique form of social isolation, and the consequences of bond disruption on stress-related behavior and neurophysiology.
12 citations
TL;DR: Severity of PGD and depression symptoms are positively associated with suicidal ideation among bereaved individuals, highlighting the need to attend to both PGd and depressive symptoms in understanding risk for suicidal ideated individuals.
Abstract: OBJECTIVES
We examined associations between the severity of symptoms of prolonged grief disorder (PGD) and depression and recent suicidal ideation among bereaved family members.
METHODS
Individuals who survived the death of a family member 1-8 year earlier (N = 225) were surveyed using self-report measures in the cross-sectional study. Regression analyses were conducted to test the multivariable effects of PGD and depression symptom severity-including their interactive effect-on recent suicidal ideation among the full sample and subsample of suicidal ideators (n = 38).
RESULTS
The severity of PGD symptoms was positively associated with frequency of recent suicidal ideation in the full sample and subsample of suicidal ideators. Depressive symptoms were positively related to suicidal ideation in the full sample; however, they were significant only in the presence of PGD symptoms in the subsample of suicidal ideators.
CONCLUSIONS
Severity of PGD and depression symptoms are positively associated with suicidal ideation among bereaved individuals, highlighting the need to attend to both PGD and depressive symptoms in understanding risk for suicidal ideation among bereaved individuals.
2 citations
TL;DR: In this article , the authors identified risk factors for prolonged grief symptom severity in family members 1 year after patient death in relation to the family member and the patient during ongoing palliative care and during bereavement.
Abstract: OBJECTIVES
Up to 10% of bereaved individuals can develop prolonged grief disorder. Several risk factors for prolonged grief symptom severity in family members have been identified, but there is a lack of knowledge regarding the multivariable effects between family members coping with loss and patient-related factors for prolonged grief symptom severity during bereavement. The aim was to identify risk factors for prolonged grief symptom severity in family members 1 year after patient death in relation to (1) the family member and the patient during ongoing palliative care and (2) the family member during bereavement.
METHODS
The participants consisted of family members (n = 99) of patients admitted to palliative home care in Sweden. The participants completed a survey during ongoing palliative care and at a follow-up 1 year after the patient's death.
RESULTS
The model selection chose 4 demographic and 4 preloss variables: family member's nervousness and stress, the patient's sense of security during palliative care, family members' sense of security during palliative care, and a family member attachment security anxiety dimension. Two postloss variables were positively associated with prolonged grief symptom severity: family members' continuing bond - internalized and continuing bond - externalized.
SIGNIFICANCE OF RESULTS
How family members coped depended on (i) variables linked to the family members themselves, (ii) the relationship to the patient, and (iii) some patient-specific variables. There was also a link between preloss variables and postloss prolonged grief symptom severity. Hence, it should be possible to identify family members with a heightened risk for longer-term prolonged grief symptoms.
References
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TL;DR: In this article, the adequacy of the conventional cutoff criteria and several new alternatives for various fit indexes used to evaluate model fit in practice were examined, and the results suggest that, for the ML method, a cutoff value close to.95 for TLI, BL89, CFI, RNI, and G...
Abstract: This article examines the adequacy of the “rules of thumb” conventional cutoff criteria and several new alternatives for various fit indexes used to evaluate model fit in practice. Using a 2‐index presentation strategy, which includes using the maximum likelihood (ML)‐based standardized root mean squared residual (SRMR) and supplementing it with either Tucker‐Lewis Index (TLI), Bollen's (1989) Fit Index (BL89), Relative Noncentrality Index (RNI), Comparative Fit Index (CFI), Gamma Hat, McDonald's Centrality Index (Mc), or root mean squared error of approximation (RMSEA), various combinations of cutoff values from selected ranges of cutoff criteria for the ML‐based SRMR and a given supplemental fit index were used to calculate rejection rates for various types of true‐population and misspecified models; that is, models with misspecified factor covariance(s) and models with misspecified factor loading(s). The results suggest that, for the ML method, a cutoff value close to .95 for TLI, BL89, CFI, RNI, and G...
76,383 citations
TL;DR: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity, which makes it a useful clinical and research tool.
Abstract: OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
26,004 citations
TL;DR: An overview of simple and multiple mediation is provided and three approaches that can be used to investigate indirect processes, as well as methods for contrasting two or more mediators within a single model are explored.
Abstract: Hypotheses involving mediation are common in the behavioral sciences. Mediation exists when a predictor affects a dependent variable indirectly through at least one intervening variable, or mediator. Methods to assess mediation involving multiple simultaneous mediators have received little attention in the methodological literature despite a clear need. We provide an overview of simple and multiple mediation and explore three approaches that can be used to investigate indirect processes, as well as methods for contrasting two or more mediators within a single model. We present an illustrative example, assessing and contrasting potential mediators of the relationship between the helpfulness of socialization agents and job satisfaction. We also provide SAS and SPSS macros, as well as Mplus and LISREL syntax, to facilitate the use of these methods in applications.
25,799 citations
TL;DR: In this article, a framework for hypothesis testing and power analysis in the assessment of fit of covariance structure models is presented, where the value of confidence intervals for fit indices is emphasized.
Abstract: A framework for hypothesis testing and power analysis in the assessment of fit of covariance structure models is presented. We emphasize the value of confidence intervals for fit indices, and we stress the relationship of confidence intervals to a framework for hypothesis testing. The approach allows for testing null hypotheses of not-good fit, reversing the role of the null hypothesis in conventional tests of model fit, so that a significant result provides strong support for good fit. The approach also allows for direct estimation of power, where effect size is defined in terms of a null and alternative value of the root-mean-square error of approximation fit index proposed by J. H. Steiger and J. M. Lind (1980). It is also feasible to determine minimum sample size required to achieve a given level of power for any test of fit in this framework. Computer programs and examples are provided for power analyses and calculation of minimum sample sizes.
8,401 citations
Harvard University1, Brigham and Women's Hospital2, University of California, San Francisco3, Yale University4, St Christopher's Hospice5, University of California, Los Angeles6, Cedars-Sinai Medical Center7, University of Western Sydney8, University of Missouri–St. Louis9, Stony Brook University10, University of Memphis11, Columbia University12, Memorial Sloan Kettering Cancer Center13, Utrecht University14, University of Zurich15, Boston University16, Veterans Health Administration17
TL;DR: The psychometric validity of criteria for prolonged grief disorder (PGD) is tested to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.
Abstract: Background: Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction. Methods and Findings: A total of 291 bereaved respondents were interviewed three times, grouped as 0–6, 6–12, and 12– 24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment. Conclusions: The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11. Please see later in the article for the Editors’ Summary.
1,437 citations