Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity.

“An important consideration, however, is that PTEs can also alter the availability of resources (Hobfoll 1989, 2002), and the loss of resources (e.g., decrease in income) has been associated with reduced prevalence of resilience (Bonanno et al. 2007a).”

“[16,18,116,117,123] On balance it appears that CG is different from PTSD.”

“A considerable body of research associates past encounters with trauma and current life stress with both increased risk for PTSD (Brewin et al., 2000) and a decreased likelihood of minimal-impact resilience following PTEs (Bonanno et al., 2007).”

“grief reactions, which may involve various emotions, cognitive impairment, health problems, and impaired role functioning (Bonanno et al., 2007).”

“These symptoms have been shown to be distinct from depressive and anxiety symptom clusters (Bonanno et al., 2007; Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 1995, 1996, 1999).”

“Accordingly, although myriad factors assumed to characterize family or community resilience have been described, these factors have not yet been tested against actual resilient outcomes.”

“Two recent studies, one after the 2004 tsunami and one after the 9/11 terror attacks, show that 30–50% of the bereaved with PGD did not meet criteria for other kinds of psychopathology (Bonanno et al., 2007; Kristensen et al., 2009).”

“Whilst complicated grief shares some overlapping symptoms with depression, anxiety and post-traumatic stress disorder, it largely exhibits distinct symptoms (Dillen et al., 2009; Boelen and van den Bout, 2005; Bonanno et al., 2007).”

“Major advances have been made in our understanding of the phenomenology and course of grief in adults.(4-28) We define grief as the subjective experience of loss, but bereavement refers to status with respect to loss, regardless of subjective experience.”

“, 2007; Latham & Prigerson, 2004). Many mental health outpatients exhibit symptoms of PGD (Piper et al., 2001) regardless of presenting complaint, and clinicians may wish to add a brief measure of PGD symptoms to any self-report instruments they typically administer to patients at intake. For these purposes, the ICG (…”

“However, a small percentage of individuals experiencing strong grief reactions do go on to develop complicated grief, a state characterized by significant and impairing grief symptoms that do not transition from an acute to integrated state (Bonanno et al., 2007).”

“the analyses of bereavement, which is reliably associated, in the short term, with depressive, grief, and PTSD symptoms (Bonanno et al., 2007).”

“Bereaved participants were also asked questions corresponding to symptoms associated with CG (Bonanno et al., 2007; Horowitz et al., 1997; Prigerson et al., 1999; Prigerson et al., 2009): strong yearning for the deceased; recurrent and intrusive recollections of the death event; intense distress over symbolic reminder…”

“…validity of its respective grief construct, above and beyond the predictive effects of depression and anxiety, in relation to indicators of long-term physical and mental health consequences (Boelen & van den Bout, 2005; Bonanno et al., 2007; Latham & Prigerson, 2004; Prigerson et al., 1999).”

“Bonanno et al. (2007) used the PCL-C with survivors of 9/11 victims, and Ramchand, Marshall, Schell, and Jaycox (2008) used it with individuals subjected to community violence, with both finding it to have strong psychometrics.”

“Although PGD shares some overlapping symptoms with depression, anxiety and PTSD, it largely exhibits distinct symptoms (Bonanno et al., 2007).”

“…service members is especially concerning given that maladaptive grief, while often comorbid with PTSD in bereaved adults, has shown evidence of incremental validity beyond the predictive effects of PTSD in relation to indicators of morbidity and functional impairment (e.g., Bonanno et al. 2007).”

“…utility as a unique predictor (controlling for symptoms of mood and anxiety disorders) of physical and psychological outcomes, such as suicidality (Latham and Prigerson 2004), high blood pressure and heart problems (Prigerson et al. 1997) as well as psychological adjustment (Bonanno et al. 2007).”

“A number of studies have investigated prolonged grief reactions in different bereaved populations and reported PGD rates ranging from 12% to 64% [8,9,14,28,30-32].”

“, 2017) and previous literature distinguishing pathological grief from depression (Boelen and van den Bout, 2005; Bonanno et al., 2007).”

“These reactions range from major depressive disorder (MDD) to posttraumatic stress disorder (PTSD) to a pathological grief response variously referred to as prolonged, complicated, or traumatic grief (referred to as PGD in this paper; Boelen& van den Bout, 2005; Bonanno et al., 2007; Prigerson et al., 2009).”

“Complicated grief symptoms uniquely differ from depression and posttraumatic stress disorder (Boelen, Lenferink, Nickerson, & Smid, 2018; Bonanno et al., 2007; Djelantik, Smid, Kleber, & Boelen, 2017; Lenferink, de Keijser, Smid, Djelantik, & Boelen, 2017; Malgaroli, Maccallum, & Bonanno, 2018;…”

“The PCL has shown good psychometric properties in other studies of PTSD following bereavement (Bonanno et al., 2007; Schnider et al., 2007) and in a study of individuals who experienced community violence (Ramchand, Marshall, Schell, & Jaycox, 2008).”

“CG have been shown to be distinct from bereavementrelated depression and anxiety [8, 9].”

“Furthermore, some authors (Spuij, Stikkelbroek, Goudena, & Boelen, 2008) suggested that the specific phenomenology of grief problems is less pronounced in CTG, as its focus is primarily on the PTSD symptoms that interfere with the ability to grieve.”

“In the general population, there is evidence that grief predicts negative health outcomes independently from PTSD and depression (Bonanno et al., 2007), and that direct exposure to trauma worsens grief (Neria et al.”

“, 1999; Latham & Prigerson, 2004) that has demonstrated the incremental validity of prolonged grief (Bonanno et al., 2007).”

“The syndrome results in significant impairment in quality of life ([8]; [9]; [10]) and can be distinguished from other stressrelated conditions such as major depression and posttraumatic stress disorder ([11]; [12]; [13]; [8]; [9]).”

“These data are consistent with the literature on PGD [17,20,41] and thus support the proposal to include PGD in the next versions of the DSM and ICD.”

“Our finding that PGD was independently associated with impaired functioning, which also agrees with other studies,([4,46]) has some important implications.”

“An overlap in symptoms of depression and grief has been shown.(30,36) Grief is related to the loss, whereas depressive symptoms indicate lowered mood irrespective of the circumstances.”

“A rapidly increasing body of strong clinical and empirical evidence suggests that complicated grief is distinct from normal grief, PTSD, and depression (eg, Bonanno, Neria, Mancini, Coifman, Litz, & Insel, 2007 ; Prigerson et al, 1995 ).”

“Bereavement is a risk factor for depression (Kersting et al., 2007), but complicated grief and depression are unique phenomena (Bonanno et al., 2007).”

“Research has demonstrated incremental validity of prolonged grief (Bonanno et al., 2007).”

“Furthermore, a good deal of research converges on the conclusion that CG is a distinctive construct that displays incremental validity in predicting deleterious medical and psychological outcomes beyond those predicted by depression and anxiety disorders (Bonanno et al., 2007; Lichtenthal et al., 2004; Prigerson et al…”

“…disorder; Boelen & van den Bout, 2005; Boelen, van den Bout, & de Keijser, 2003; Ogrodniczuk et al., 2003; Prigerson et al., 1996; Prigerson, Frank et al., 1995) and uniquely predictive of a number of negative mental and physical health outcomes (Bonanno et al., 2007; Prigerson et al., 1997).”

“Recent empirical work supports the notion that the inability to find any meaning in a loss is associated with distress and complicated grief (Bonanno et al., 2007; Davis et al., 1998; Keesee et al., 2008; Lichtenthal et al., 2010), whereas positive meaning reconstruction is negatively correlated with complicated grief…”

“[31] Consistent with the previous research,[32] participants in this group had significantly lower levels of functioning than married or asymptomatic bereaved (Table 1).”

“In a number of community samples, prolonged grief (PG) symptoms independently predict level of functional impairment and response to psychosocial and antidepressant interventions beyond both depression and anxiety symptoms (Bonanno et al., 2007; Golden & Dalgliesh, 2010).”

“…attention in recent years as it is linked with a range of negative health outcomes independent of bereavement-related depression or anxiety (Bonanno et al., 2007; Maciejewski et al., 2016; Prigerson et al., 2009; Shear et al., 2011) and shows better outcomes in response to grief-targeted…”

“[40, 41] Also, the finding that PGD was independently associated with functional impairment is consistent with other bereavement studies[22, 23, 42] and suggests the usefulness of PGD as a unique psychiatric disorder in future diagnostic manuals.”

“In addition, like other sudden, unexpected, and often violent deaths (such as homicides, motor vehicle crashes, and natural disasters), suicide also seems to produce higher levels of PTSD type symptoms (intrusive reliving, avoidance of triggering reminders of the death, and physiological hyperarousal; Kaltman and Bona…”

“…distinct negative consequences beyond the effects of depression and anxiety (Boelen & van den Bout, 2008; Boelen, van den Bout, & de Keijser, 2003; Bonanno et al., 2007a, 2007b; Lichtenthal, Cruess, & Prigerson, 2004; Prigerson, Frank, et al., 1995; Prigerson, Shear, et al., 1995), and responds…”

“” The PCL-C has shown high reliability in previous samples of bereaved individuals (Bonanno et al., 2007) and also in our study at T1 (a1⁄4 .”

“Thirdly, as CG is distinct from other mental disorders (Bonanno et al., 2007; O'Connor et al., 2010; Tsutsui et al., 2014), it is associated with different types of symptoms and adaptation difficulties, and most importantly, it needs unique and specific types of support or intervention (Shear et al.”

“Moreover, PGD symptoms have been found to predict health impairments over and above these neighbour syndromes attesting to the incremental validity of PGD (Bonanno et al., 2007).”

“Furthermore, CG has been effectively differentiated from depression and posttraumatic stress disorder (PTSD) (Bonanno et al., 2007; Prigerson, Bierhals, Kasl, Reynolds, Shear, et al., 1996; Prigerson, Frank, et al.,”

“PGD has been differentiated from Post-Traumatic Stress Disorder (PTSD) and post-loss depression (Boelen & Van Den Bout, 2005; Bonanno et al., 2007; Lichtenthal, Cruess, & Prigerson, 2004).”

“In addition, there is a growing consensus that strong evidence exists of a distinct diagnostic category of prolonged grief reaction, which needs to be differentiated from these disorders (Bonanno et al. 2007).”

“There is significant overlap between PTSD, complicated grief, and depression (Bonanno et al., 2007; Burke, Neimeyer, & McDevitt-Murphy, 2010; Craig, Sossou, Schnak, & Exxex, 2008; Pivar & Field, 2004), and recent trials report the success of cognitive–behavioral therapy in treating grief reactions in the general popul…”

“Since the proposition of CG, a sizeable set of independent studies have supported its validity, by showing that symptoms of CG constitute a unidimensional symptom cluster that is distinct from other bereavement-related distress forms and that predicts enduring functional and health impairments (among others, see Boele…”

“…analysis have shown that these syndromes are correlated but distinguishable (Boelen, van de Schoot, van den Hout, de Keijser, & van den Bout, 2010; Bonanno et al., 2007; Lenferink, de Keijser, Smid, Djelantik, & Boelen, 2017; Li & Prigerson, 2016; Nickerson et al., 2014; O’Connor et al., 2010).”

“[2,4, 5, 19–23] Studies have concluded that PTS is predictive of, or contributes to, the development of PGS.”

“Second, although CG has consistently been found to be an independent construct,[3,58–60] co-morbidity with PTSD and depression is common in CG[59] and was a feaure of this sample.”

“The past decade has seen increasing interest in identifying pathological grief experiences that include experiences of prolonged yearning for the deceased and distress over the death that persist over time and impair healthy functioning (Bonanno et al., 2007).”

“These grief symptoms commonly do not constitute a psychiatric disorder and may resolve without formal mental health treatment (Bonanno et al., 2007; Bonanno et al., 2002; Middleton, Burnett, Raphael, & Martinek, 1996; Zhang, El-Jawahri, & Prigerson, 2004).”

“This syndrome, variously described as ‘prolonged’ or ‘complicated’ grief, has substantial and long-term effects on well being and role functioning, over and above depression and posttraumatic stress disorders [5,6].”

“CG is more prolonged and severe than expected (Bonanno et al., 2007; Castro & Rocha, 2012; Newson, Boelen, Hek, Hofman, & Tiemeier, 2011; Stroebe et al., 2007), affects the individual’s functional capacity (Tomita & Kitamura, 2002; Wittouck, Van Autreve, De Jaegere, Portzky, & van Heeringen, 2011),…”

“An accumulating body of research has found that this syndrome of " complicated " grief (CG) is distinct from anxiety and depressive disorders and has unique effects on functioning (Bonanno, et al., 2007; Prigerson, et al., 1996).”

“Although many bereaved individuals experience a transient period of grief and mild to moderate depression (Bonanno et al., 2002, 2007; Shear et al., 2011), a subset of approximately 10% to 20% has a more chronic and intense response and may experience complicated grief (CG) reactions (Bonanno and…”

“The PCL-C has shown high reliability in previous samples of bereaved individuals [21], and, also in our study, at T1 (α = 0.”