The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss.

BACKGROUND: Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. METHODS: 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). RESULTS: Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. CONCLUSION: The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. TRIAL REGISTRATION: Not applicable.

Psychometric properties of the German version of the Pre-loss Grief Questionnaire (PG-12-R).

This study aimed to develop a German version of the revised Pre-loss Grief Questionnaire (PG-12-R) and examine its factor structure, reliability and validity. The PG-12-R was assessed in a representative German sample (N = 2,515). Of these, 362 (14.4%) reported to have a loved one suffering from an incurable disease and 352 provided full data sets. Principal component factor analysis, scree-plot and parallel analysis were conducted. Results supported a one-factor model of PG-12-R with high internal consistency. Convergent validity was confirmed by negative correlations with psychological well-being and time since diagnosis and positive correlations with a more difficult perception of circumstances surrounding the illness and unpreparedness. The German version of the PG-12-R represents a reliable and valid measurement tool of pre-loss grief. It may be used as a screening measure for high levels of pre-loss grief to identify individuals who may need additional support.

Recognizing and Looking at Masked Emotional Faces in Alexithymia.

Alexithymia is a clinically relevant personality construct characterized by difficulties identifying and communicating one's emotions and externally oriented thinking. Alexithymia has been found to be related to poor emotion decoding and diminished attention to the eyes. The present eye tracking study investigated whether high levels of alexithymia are related to impairments in recognizing emotions in masked faces and reduced attentional preference for the eyes. An emotion recognition task with happy, fearful, disgusted, and neutral faces with face masks was administered to high-alexithymic and non-alexithymic individuals. Hit rates, latencies of correct responses, and fixation duration on eyes and face mask were analyzed as a function of group and sex. Alexithymia had no effects on accuracy and speed of emotion recognition. However, alexithymic men showed less attentional preference for the eyes relative to the mask than non-alexithymic men, which was due to their increased attention to face masks. No fixation duration differences were observed between alexithymic and non-alexithymic women. Our data indicate that high levels of alexithymia might not have adverse effects on the efficiency of emotion recognition from faces wearing masks. Future research on gaze behavior during facial emotion recognition in high alexithymia should consider sex as a moderating variable.

Deployment of attention to facial expressions varies as a function of emotional quality-but not in alexithymic individuals.

Background: Alexithymia is a risk factor for emotional disorders and is characterized by differences in automatic and controlled emotion processing. The multi-stimulus free-viewing task has been used to detect increased negative and reduced positive attentional biases in depression and anxiety. In the present eye-tracking study, we examined whether lexical emotional priming directs attention toward emotion-congruent facial expressions and whether alexithymia is related to impairments in lexical priming and spontaneous attention deployment during multiple face perception. Materials and methods: A free-viewing task with happy, fearful, angry, and neutral faces shown simultaneously was administered to 32 alexithymic and 46 non-alexithymic individuals along with measures of negative affect and intelligence. Face presentation was preceded by masked emotion words. Indices of initial orienting and maintenance of attention were analyzed as a function of prime or target category and study group. Results: Time to first fixation was not affected by prime category or study group. Analysis of fixation duration yielded a three-way interaction. Alexithymic individuals exhibited no prime or target category effect, whereas non-alexithymic individuals showed a main effect of target condition, fixating happy faces longer than neutral and angry faces and fearful faces longer than angry faces. Discussion: Our results show evidence of attentional biases for positive and fearful social information in non-alexithymic individuals, but not in alexithymic individuals. The lack of spontaneous attentional preference for these social stimuli in alexithymia might contribute to a vulnerability for developing emotional disorders. Our data also suggest that briefly presented emotion words may not facilitate gaze orientation toward emotion-congruent stimuli.

Migratory grief: a systematic review.

Introduction: Migration is often accompanied by interpersonal, material and abstract losses and can be associated with migratory grief. The correlates of migratory grief have not yet been sufficiently addressed in research. This review aims to systematically investigate the relationship between migratory grief and psychopathology, to map the current state of research on this highly relevant topic and to derive relevant implications for the target group. Method: A systematic literature search of electronic databases (PubMed/Medline, PsycINFO, Web of Science) was conducted up until January 2023. Primary empirical quantitative and qualitative studies with migrants were included that assessed the association between migratory grief and psychopathology, using a specific instrument for migratory grief (quantitative) or named migratory grief as relevant topic (qualitative). Studies that only captured aspects of migratory grief, were not written in English, or were descriptive/non-peer-reviewed publications, were excluded. A quality assessment of all studies included was performed using the Mixed Methods Appraisal Tool. The results were synthesized using a narrative synthesis approach. Results: All studies (quan. = 4; qual. = 1) were cross-sectional and used convenience samples. The studies had a mean number of 83 participants with a total of N = 487 participants included in the current review. All included studies reported a significant relationship between migratory grief and psychological distress. Discussion: Despite the quality of the included studies being limited, our results show that there is a link between migratory grief and depression among refugees and migrants. However, there are only few studies in this currently and certainly also in the future relevant field of research, which is why further studies on factors influencing migratory grief as well as associations with other disorders would be desirable. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023403448.

Depressive symptoms and visual attention to others' eyes in healthy individuals.

BACKGROUND: Eye contact is a fundamental part of social interaction. In clinical studies, it has been observed that patients suffering from depression make less eye contact during interviews than healthy individuals, which could be a factor contributing to their social functioning impairments. Similarly, results from mood induction studies with healthy persons indicate that attention to the eyes diminishes as a function of sad mood. The present screen-based eye-tracking study examined whether depressive symptoms in healthy individuals are associated with reduced visual attention to other persons' direct gaze during free viewing. METHODS: Gaze behavior of 44 individuals with depressive symptoms and 49 individuals with no depressive symptoms was analyzed in a free viewing task. Grouping was based on the Beck Depression Inventory using the cut-off proposed by Hautzinger et al. (2006). Participants saw pairs of faces with direct gaze showing emotional or neutral expressions. One-half of the face pairs was shown without face masks, whereas the other half was presented with face masks. Participants' dwell times and first fixation durations were analyzed. RESULTS: In case of unmasked facial expressions, participants with depressive symptoms looked shorter at the eyes compared to individuals without symptoms across all expression conditions. No group difference in first fixation duration on the eyes of masked and unmasked faces was observed. Individuals with depressive symptoms dwelled longer on the mouth region of unmasked faces. For masked faces, no significant group differences in dwell time on the eyes were found. Moreover, when specifically examining dwell time on the eyes of faces with an emotional expression there were also no significant differences between groups. Overall, participants gazed significantly longer at the eyes in masked compared to unmasked faces. CONCLUSIONS: For faces without mask, our results suggest that depressiveness in healthy individuals goes along with less visual attention to other persons' eyes but not with less visual attention to others' faces. When factors come into play that generally amplify the attention directed to the eyes such as face masks or emotions then no relationship between depressiveness and visual attention to the eyes can be established.

Prolonged grief disorder in ICD-11 and DSM-5-TR: differences in prevalence and diagnostic criteria.

Background: Prolonged grief disorder (PGD) was recently included as a disorder in the ICD-11 and DSM-5-TR. Although both classification systems use the same name, the criteria content, and diagnostic approach vary. This study aimed to estimate the respective prevalence of PGDICD-11 and PGDDSM-5-TR and examine the diagnostic agreement while varying the diagnostic algorithm of PGDICD-11 (bereavement vs. symptom period; varying number of accessory symptoms). Methods: A representative sample of the German general population (N = 2,509) was investigated, of which n=1,071 reported the loss of a close person. PGD symptoms were assessed with the Traumatic Grief Inventory - Self Report Plus (TGI-SR+). Results: The point prevalence of PGD among the bereaved varied between 4.7%-6.8%, depending on the criteria and diagnostic algorithm. The prevalence of PGDDSM-5-TR was significantly lower than the prevalence of PGDICD-11. The diagnostic agreement between both criteria sets was substantial and increased after the number of accessory symptoms for PGDICD-11 was increased from one to three. The most common symptoms were intrusive thoughts/images related to the deceased person, longing for the deceased person, and difficulty accepting the loss. Conclusion: The results demonstrate that the prevalence of PGD significantly varies depending on the application of the diagnostic algorithm and criteria. PGD affects a substantial proportion of the general population and should be addressed by healthcare providers. However, applying the minimum ICD-11 criteria could lead overestimating the prevalence. Therefore, further harmonizing the ICD-11 and DSM-5-TR criteria and diagnostic algorithm for PGD seems appropriate.

Alexithymia and interpersonal problems in healthy young individuals.

BACKGROUND: Alexithymia refers to a multidimensional personality trait with the facets difficulties identifying feelings (DIF), difficulties describing feelings (DDF), and externally orientated thinking (EOT). Alexithymia is a risk factor for mental and somatic disorders. Previous research with patients suffering from various disorders showed positive relationships between alexithymia and interpersonal problems. Only one study analyzed the link between alexithymic features and interpersonal difficulties in healthy individuals but yielded inconclusive findings because participants' negative affects were not controlled. A widely accepted conceptualization of interpersonal problems relies on the interpersonal circumplex, which is defined by two orthogonal dimensions, agency and communion. In the present study, we analyzed which facets of alexithymia are associated with the two interpersonal problem dimensions and the global severity of interpersonal distress, after adjusting for negative affect. METHODS: Two-hundred healthy young individuals (100 women) participated in the study. Alexithymic features were assessed using the 20-Item Toronto Alexithymia Scale (TAS-20). Interpersonal problems were measured with the Inventory of Interpersonal Problems (IIP-D). Participants' state and trait anxiety, depressive symptoms, and verbal intelligence were also assessed. RESULTS: All alexithymia scales were positively correlated with general interpersonal distress. Regression results suggested that the TAS-20 subscale DIF was the primary predictor of general interpersonal distress after controlling for negative affectivity. The scale DDF correlated negatively with the IIP-D dimension agency. According to our regression analysis, DDF was a predictor of (low) agency controlling for negative affects. Moreover, DDF correlated negatively with the IIP-D dimension communion. Our regression results indicate that DDF was a predictor of (low) communion independent of negative affect. Correlations between alexithymia facets and IIP-D subscales did not differ between genders. CONCLUSIONS: Difficulties identifying feelings seem to be linked to a high level of general interpersonal distress. Difficulties in recognizing one's feelings may disrupt emotion regulation, which could heighten the general risk of interpersonal problems. Difficulties describing feelings could be a central factor contributing to interpersonal problems related to low communion as well as low agency, since emotion expression and communication are crucial in establishing experiences of social closeness and directing other people's behavior.

Psychological burden of achalasia: Patients' screening rates of depression and anxiety and sex differences.

OBJECTIVE: Achalasia is associated with reduced quality of life in affected patients but research regarding the psychological burden of achalasia in terms of depression and anxiety is scarce. The current study therefore aims to investigate rates of depression and anxiety in patients with achalasia in relation to prevalence rates in the general population and to examine the extent to which achalasia-related characteristics (time since diagnosis, symptom load, achalasia-related quality of life, treatment history) predict symptoms of depression and anxiety. METHODS: Using validated screening instruments, rates of depression and anxiety were assessed in a cross-sectional survey of a sample of 993 patients with achalasia and compared to population controls stratified by age and sex. Associations between depression and anxiety and achalasia-related factors were explored using linear regression. RESULTS: Compared to population controls, screening rates of female patients with achalasia were between 3.04 (p = .004) and 7.87 (p < .001) times higher for depression and 3.10 (p < .001) times higher for anxiety, respectively. No significant differences were found for male patients with achalasia. Both achalasia-related quality of life and symptom load were independently related to impaired mental health. CONCLUSION: Women appear to be specifically affected by the psychological burden of achalasia, pointing to sex-specific or gendered experiences of the disease. In addition to symptom reduction, psychological support may prove beneficial for improving the well-being of patients with achalasia.

Cognitive Avoidance Is Associated with Decreased Brain Responsiveness to Threat Distractors under High Perceptual Load.

Cognitive coping strategies to deal with anxiety-provoking events have an impact on mental and physical health. Dispositional vigilance is characterized by an increased analysis of the threatening environment, whereas cognitive avoidance comprises strategies to inhibit threat processing. To date, functional neuroimaging studies on the neural underpinnings of these coping styles are scarce and have revealed discrepant findings. In the present study, we examined automatic brain responsiveness as a function of coping styles using functional magnetic resonance imaging. We administered a perceptual load paradigm with contemptuous and fearful faces as distractor stimuli in a sample of N = 43 healthy participants. The Mainz Coping Inventory was used to assess cognitive avoidance and vigilance. An association of cognitive avoidance with reduced contempt and fear processing under high perceptual load was observed in a widespread network including the amygdala, thalamus, cingulate gyrus, insula, and frontal, parietal, temporal, and occipital areas. Our findings indicate that the dispositional tendency to divert one's attention away from distressing stimuli is a valuable predictor of diminished automatic neural responses to threat in several cortical and subcortical areas. A reduced processing in brain regions involved in emotion perception and attention might indicate a potential threat resilience associated with cognitive avoidance.

Stigmatization profiles and psychological distress in people at high risk of infection with COVID-19 -A study conducted in Germany from March to August 2021.

COVID-19-related stigmatization of affected people or people at risk of infection has been shown to enhance the reluctance of affected individuals to use health services and reduce their mental health. It is thus highly important to gain a thorough understanding of COVID-19-related stigmatization. The present study's first aim was to explore stigmatization profiles of experienced stigmatization (anticipated stigmatization, internalized stigmatization, enacted stigmatization, disclosure concerns) and stigmatization practices in 371 German people at high risk of infection using latent class analyses. The second aim was to investigate the relationship between stigmatization profiles and psychological distress via multiple regression analysis taking into account other possible negative and positive risk factors. Our results showed two stigmatization profiles: "high stigmatization group" and "low stigmatization group". Belonging to the "high stigmatization group" was significantly correlated with higher levels of psychological distress. Other risk factors significantly related to psychological distress were mental health disorders in the past, exposure to COVID-19, fear related to COVID-19, perceived risk of being infected, lower perceived self-efficacy, and lower subjective knowledge about COVID-19.

Interpersonal problems and recognition of facial emotions in healthy individuals.

Background: Recognition of emotions in faces is important for successful social interaction. Results from previous research based on clinical samples suggest that difficulties in identifying threat-related or negative emotions can go along with interpersonal problems. The present study examined whether associations between interpersonal difficulties and emotion decoding ability can be found in healthy individuals. Our analysis was focused on two main dimensions of interpersonal problems: agency (social dominance) and communion (social closeness). Materials and methods: We constructed an emotion recognition task with facial expressions depicting six basic emotions (happiness, surprise, anger, disgust, sadness, and fear) in frontal and profile view, which was administered to 190 healthy adults (95 women) with a mean age of 23.9 years (SD = 3.8) along with the Inventory of Interpersonal Problems, measures of negative affect and verbal intelligence. The majority of participants were university students (80%). Emotion recognition accuracy was assessed using unbiased hit rates. Results: Negative correlations were observed between interpersonal agency and recognition of facial anger and disgust that were independent of participants' gender and negative affect. Interpersonal communion was not related to recognition of facial emotions. Discussion: Poor identification of other people's facial signals of anger and disgust might be a factor contributing to interpersonal problems with social dominance and intrusiveness. Anger expressions signal goal obstruction and proneness to engage in conflict whereas facial disgust indicates a request to increase social distance. The interpersonal problem dimension of communion appears not to be linked to the ability to recognize emotions from facial expressions.

Trait anger and negative interpretation bias in neutral face perception.

Introduction: Anger is a basic emotion helping people to achieve goals by preparing the body for action and prompting others to change their behavior but is also associated with health issues and risks. Trait anger, the disposition to experience angry feelings, goes along with an attribution of hostile traits to others. Negative distortions in the interpretation of social information have also been observed in anxiety and depression. The present study examined the associations between components of anger and negative interpretation tendencies in the perception of ambiguous and neutral schematic faces controlling for anxiety, depressed mood, and other variables. Methods: A sample of 150 young adults performed a computer-based perception of facial expressions task and completed the State-Trait Anger Expression Inventory (STAXI-2) along with other self-report measures and tests. Results: Trait anger and anger expression correlated with the perception of negative affects in neutral but not in ambiguous faces. More specifically, trait anger was linked to the attribution of anger, sadness, and anxiety to neutral faces. Trait anger predicted perceived negative affects in neutral faces when adjusting for anxiety, depression, and state anger. Discussion: For neutral schematic faces, the present data support an association between trait anger and negatively biased interpretation of facial expression, which is independent of anxiety and depressed mood. The negative interpretation of neutral schematic faces in trait angry individuals seems not only to comprise the attribution of anger but also of negative emotions signaling weakness. Neutral schematic facial expressions might be useful stimuli in the future study of anger-related interpretation biases.

Linguistic predictors of symptom change in an internet-based cognitive behavioural intervention for prolonged grief symptoms.

This study investigates linguistic predictors of reduction in prolonged grief symptoms following a writing intervention in an internet-based cognitive behavioural therapy for people bereaved by cancer. Data stem from a randomized control clinical trial with 70 people. The Linguistic Inquiry and Word Count program was used to analyse patient language. Absolute change scores and reliable change index were used to calculate reduction in grief symptoms and clinical significant change. Best subset regression and Mann-Whitney U tests were conducted. A higher reduction of prolonged grief symptoms was correlated with more social words in the first module (ß = -.22, p = .042), less risk (ß = .33, p = .002) and body words (ß = .22, p = .048) in the second module and more time words in the third module (ß = -.26, p = .018). Patients with clinically significant change showed a higher median in function words in the first module (p = .019), a lower median in risk words in the second module (p = .019) and a higher median in assent words in the last module (p = .014) compared to patients without clinically significant change. Findings suggest that it may be beneficial for therapists to encourage a more detailed description of patients' relationship with their deceased relative during the first module, a change in perspective during the second module and a summary of past, present and future aspects at the end of therapy. Future studies should include mediation analyses to allow causal attribution of the studied effects.

Non-conscious processing of fear faces: a function of the implicit self-concept of anxiety.

BACKGROUND: Trait anxiety refers to a stable tendency to experience fears and worries across many situations. High trait anxiety is a vulnerability factor for the development of psychopathologies. Self-reported trait anxiety appears to be associated with an automatic processing advantage for threat-related information. Self-report measures assess aspects of the explicit self-concept of anxiety. Indirect measures can tap into the implicit self-concept of anxiety. METHODS: We examined automatic brain responsiveness to non-conscious threat as a function of trait anxiety using functional magnetic resonance imaging. Besides a self-report instrument, we administered the Implicit Association Test (IAT) to assess anxiety. We used a gender-decision paradigm presenting brief (17 ms) and backward-masked facial expressions depicting disgust and fear. RESULTS: Explicit trait anxiety was not associated with brain responsiveness to non-conscious threat. However, a relation of the implicit self-concept of anxiety with masked fear processing in the thalamus, precentral gyrus, and lateral prefrontal cortex was observed. CONCLUSIONS: We provide evidence that a measure of the implicit self-concept of anxiety is a valuable predictor of automatic neural responses to threat in cortical and subcortical areas. Hence, implicit anxiety measures could be a useful addition to explicit instruments. Our data support the notion that the thalamus may constitute an important neural substrate in biased non-conscious processing in anxiety.

Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement.

Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Emotions in Covid-19 Twitter discourse following the introduction of social contact restrictions in Central Europe.

Aim: Non-pharmaceutical interventions such as lockdowns have played a critical role in preventing the spread of the Covid-19 pandemic, but may increase psychological burden. This study sought to examine emotions reflected in social media discourse following the introduction of social contact restrictions in Central Europe. Subjects and methods: German-language Twitter posts containing '#corona' and '#covid-19' were collected between 2020/03/18 - 2020/04/24. A total of 79,760 tweets were included in the final analysis. Rates of expressions of positive emotion, anxiety, sadness and anger were compared over time. Bi-term topic models were applied to extract topics of discussion and examine association with emotions. Results: Rates of anxiety, sadness and positive emotion decreased in the period following the introduction of social contact restrictions. A total of 16 topics were associated with emotions, which related to four general themes: social contact restrictions, life during lockdown, infection-related issues, and impact of the pandemic on public and private life. Several unique patterns of association between topics and emotions emerged. Conclusion: Results suggest decreasing polarity of emotions among the public following the introduction of social contact restrictions. Monitoring of social media activity may prove beneficial for an adaptive understanding of changing public concerns during the Covid-19 pandemic.

Positive attentional bias mediates the relationship between trait emotional intelligence and trait affect.

Emotional intelligence and, in particular, the component emotion regulation may increase well-being and improve mood and coping with negative emotions. In the present eye-tracking study, we examined whether attention allocation to positive stimuli mediates the relationship between emotion regulation abilities and trait affect. Gaze behavior of 104 healthy adults was analyzed in a free-viewing task, in which happy, sad, angry, and neutral faces were shown simultaneously for ten seconds. Dwell time on facial expressions was used as indicator of attention allocation. Trait emotional intelligence was assessed using the Self-Rated Emotional Intelligence Scale. Self-report measures of state and trait positive and negative affect, trait anxiety, and depression were administered. In general, participants viewed longer at happy than at negative or neutral faces. The results of mediation analyses indicated that intrapersonal and interpersonal emotion regulation abilities were indirectly related to trait positive affect through attention to happy faces. Moreover, dwell time on happy faces had a mediating effect on the relationship between interpersonal emotion regulation ability and trait anxiety. Preference for positive social signals might form one attentional pathway through which emotion regulation abilities promote positive mood and buffer the development of anxiety reactions in everyday life.

Factors associated with pre-loss grief and preparedness in relatives of people with cancer during the COVID-19 pandemic: A cross-sectional study.

OBJECTIVES: Before the loss of a loved one to cancer, relatives have time to adapt to the impending death. However, due to the current COVID-19 pandemic, adjustment to an imminent death may be more difficult. This study investigates factors related to pre-loss grief and preparedness during the COVID-19 pandemic and their relationship with COVID-19 related fears. METHODS: Data of 299 participants from a cross-sectional study was used. Participants were included if they were relatives of people with cancer, spoke German and were at least 18 years. Multivariate linear regression analyses were conducted to measure the relationship between predictors (dysfunctional coping, emotion-focused coping, problem-focused coping, attachment anxiety, attachment avoidance, COVID-19 related fears, prognosis, perceived depth of the relationship, perceived conflict in the relationship, health status) and pre-loss grief, preparedness for caregiving and preparedness for death as the dependent variables. RESULTS: Perceived depth (ß = .365, p < .001), COVID-19 related fears (ß = .141, p = .002), prognosis for death (ß = .241, p < .001), dysfunctional coping strategies (ß = .281, p < .001) and emotion-focused coping strategies (ß = -.320, p < .001) significantly predicted pre-loss grief. Prognosis for death (ß = .347, p < .001), dysfunctional coping strategies (ß = -.229, p < .001), emotion-focused coping strategies (ß = .242, p < .001), COVID-19 related fears (ß = -.112, p = .037) and health status (ß = .123, p = .025) significantly predicted preparedness for death. Dysfunctional coping (ß = -.147, p = .009), problem-focused coping (ß = .162, p = .009), emotion-focused coping (ß = .148, p = .017), COVID-19 related fears (ß = -.151, p = .006), attachment anxiety (ß = -.169, p = .003), perceived conflict in the relationship with the patient with cancer (ß = -.164, p = .004), perceived depth in the relationship (ß = .116, p = .048) and health status (ß = .157, p = .003) significantly predicted preparedness for caregiving. CONCLUSIONS: This study shows COVID-19 pandemic impacts on the grieving process of relatives of patients with cancer. Consequently, screening for pre-loss grief, preparedness and their associated factors may help provide early support for relatives of people with cancer at need. However, further research is needed to help understand the stability of pre-loss grief and preparedness.

The Relationship Between Pre-Loss Grief, Preparedness and Psychological Health Outcomes in Relatives of People With Cancer.

The aim of this study was to examine the simultaneous effects of pre-loss grief, preparedness for death and preparedness for caregiving on different psychological health outcomes in relatives of people with cancer. Two hundred ninety-nine relatives of people with cancer participated in a cross-sectional online survey. Participants were included if they spoke German and were 18 years or older. Multivariate regression analysis was conducted. Pre-loss grief was significantly associated with depression (ß = .388, p < .001), anxiety (ß = .429, p < .001), somatization (ß = .221, p < .001) and satisfaction with life (ß = -.205, p < .001). Preparedness for death was significantly associated with somatization (ß = -.247, p < .001). Results suggest that people with high scores in pre-loss grief and low scores in preparedness for death are in need of early support. Interventions should address pre-loss grief and the various aspects of preparedness for death and take into account the psychological health in relatives of people with cancer. Future studies should investigate underlying mechanisms.