Online cognitive behavioral therapy for prolonged grief after traumatic loss: a randomized waitlist-controlled trial.

Prolonged grief disorder, a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Prolonged grief symptoms can be effectively treated with face-to-face or internet-delivered cognitive behavioral therapy. Traumatic losses may elicit higher prevalence of severe grief reactions. While face-to-face cognitive behavioral therapy appears efficacious in treating prolonged grief symptoms in traumatically bereaved individuals, it is not yet clear if internet-based cognitive behavioral therapy is efficacious for this population. Therefore, we investigated the efficacy of a 12-week internet-delivered cognitive behavioral therapy for people bereaved through traffic accidents in a randomized waitlist-controlled trial (registration number: NL7497, Dutch Trial Register). Forty adults bereaved though a traffic accident were randomized to internet-based cognitive behavioral therapy (n = 19) or a waitlist control condition (n = 21). Prolonged grief, post-traumatic stress, and depression symptoms were assessed at baseline, post-treatment, and 8-week follow-up. Dropout in the treatment condition was relatively high (42%) compared to the control condition (19%). Nevertheless, multilevel analyses showed that internet-based cognitive behavioral therapy strongly reduced prolonged grief, post-traumatic stress, and depression symptoms relative to the control condition at post-treatment and follow-up. We conclude that internet-based cognitive behavioral therapy appears a promising treatment for traumatically bereaved adults.

Grief is a family affair: examining longitudinal associations between prolonged grief in parents and their adult children using four-wave cross-lagged panel models.

BACKGROUND: Losing a parent or spouse in adulthood may result in prolonged grief disorder (PGD) symptoms. PGD levels in parents may affect PGD levels in their adult offspring and the other way around. However, research on transmission of PGD in parent-child dyads is lacking. Consequently, we aimed to examine temporal associations between PGD levels in parent and adult children. METHODS: In doing so, we analyzed longitudinal self-report data on PGD levels (using the PG-13) assessed at 2, 11, 18, and 26 months after loss in 257 adult parent-child dyads from Denmark. Cross-lagged panel modeling was used for data-analyses. RESULTS: Changes in PGD levels in parents significantly predicted PGD levels in adult children, but not vice versa. Small through moderate cross-lagged effects (ß = 0.05 through 0.07) were found for PGD levels in parents predicting PGD levels in adult children at a subsequent time-point. These cross-lagged effects were found while taking into account the association between PGD levels in parents and adult children at the same time-point as well as the associations between the same construct over time and relevant covariates. CONCLUSIONS: Pending replication of these findings in clinical samples and younger families, our findings offer tentative support for expanding our focus in research and treatment of PGD from the individual to the family level.

Co-occurrence of approach and avoidance in prolonged grief: a latent class analysis.

Background: Prolonged grief disorder (PGD) has been included in the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders 5 Text Revision (DSM-5-TR). Loss-related avoidance behavior perpetuates grief and effective interventions for prolonged grief symptoms target such avoidance behavior. Yet, behaviors characterized by approach of loss-related cues (i.e. rumination, yearning, proximity seeking) are also implicated in prolonged grief reactions.Objective: To solve this paradox, we will test the Approach Avoidance Processing Hypothesis, which holds that loss-related approach and avoidance behaviors co-occur in PGD, using latent class analyses (LCA).Methods: Two-hundred eighty-eight bereaved adults (92% female) completed questionnaires assessing loss-related approach behaviors (rumination, yearning, proximity seeking), loss-related avoidance behaviors (anxious avoidance, experiential avoidance) and ICD-11 and DSM-5-TR prolonged grief symptoms.Results: LCA demonstrated the best fit for a three-class solution comprising a low approach/low avoidance class (n = 98, 34%), a high approach/low avoidance class (n = 79, 27%), and a high approach/high avoidance class (n = 111, 39%). The latter class showed significantly higher prolonged grief symptom levels and higher odds of probable PGD compared to the other classes.Conclusions: Co-occurrence of loss-related approach and avoidance appears characteristic to prolonged grief reactions. Distinguishing bereaved people with these behavioral patterns from those solely experiencing loss-related approach behaviors may improve the efficacy of PGD therapies.

A latent class analysis of bereaved adults showed high approach/high avoidance, high approach/low avoidance and low approach/low avoidance classes.The high approach/high avoidance class showed highest prolonged grief symptoms and higher odds of probable prolonged grief disorder.Co-occurrence of loss-related approach and avoidance appears to characterize prolonged grief.

Assessing DSM-5-TR and ICD-11 prolonged grief disorder in children and adolescents: development of the Traumatic Grief Inventory - Kids - Clinician-Administered.

BACKGROUND: Around 10% of bereaved youths experience symptoms of prolonged grief disorder (PGD). Recently, PGD was included in the two main classification systems for mental disorders: the ICD-11 and DSM-5-TR. Assessing PGD symptoms in youth is currently hindered by the lack of instruments for ICD-11 and DSM-5-TR criteria. To fill this gap, we developed an instrument to assess PGD symptoms in children and adolescents, the Traumatic Grief Inventory - Kids - Clinician-Administered (TGI-K-CA), based on input of grief experts and bereaved children. METHODS: Five experts rated the items on alignment with DSM-TR and ICD-11 PGD symptoms and comprehensibility. The adjusted items were then presented to seventeen bereaved youths (Mdnage = 13.0 years, range = 8-17 years). Using the Three-Step Test Interview (TSTI), children were asked to verbalize their thoughts while answering the items. RESULTS: Issues raised by experts were mostly related to alignment with the DSM-5-TR/ICD-11 symptom, ambiguous formulation of the items, or low comprehensibility for children and adolescents. Items raising fundamental issues according to experts were adjusted. The TSTI showed that children encountered relatively few problems with the items. Frequently reported problems with some of the items (e.g. regarding comprehensibility) led to final adjustments. CONCLUSION: With input from grief experts and bereaved youths, an instrument to assess PGD symptoms as defined in DSM-5-TR and ICD-11 in bereaved youths was finalized. Further quantitative research is currently undertaken to evaluate the instrument's psychometric qualities.

Children with symptoms of Prolonged Grief Disorder (PGD) experience a debilitating longing for and/or preoccupation with a deceased loved one.Assessment of PGD in youth is hindered by the lack of an instrument.With the involvement of grief experts and bereaved youth, the current study developed an instrument that can be used in bereaved children and adolescents.

Self-guided online treatment of disturbed grief, posttraumatic stress, and depression in adults bereaved during the COVID-19 pandemic: A randomized controlled trial.

OBJECTIVE: This randomized-waitlist controlled trial is the first study examining short-term effects of a self-guided online grief-specific cognitive behavioral therapy (CBT) in reducing early persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression symptoms in adults bereaved during the COVID-19 pandemic. METHOD: Sixty-five Dutch adults, bereaved at least three months earlier during the pandemic, with clinically-relevant PCBD, PTSD, and/or depression symptoms, were allocated to a treatment (n = 32) or waitlist condition (n = 33). Telephone interviews were conducted to assess PCBD, PTSD, and depression symptoms (using validated instruments) at baseline, post-treatment, and post-waiting period. Participants received an eight-week self-guided online grief-specific CBT including exposure, cognitive restructuring, and behavioral activation assignments. Analyses of covariance were performed. RESULTS: Intention-to-treat analyses indicated that people in the intervention condition showed significantly lower PCBD (d = 0.90), PTSD (d = 0.71), and depression (d = 0.57) symptom-levels post-treatment relative to waitlist controls post-waiting, while taking baseline symptom-levels and use of professional psychological co-intervention into account. CONCLUSIONS: The online CBT proved to be an effective intervention, reducing PCBD, PTSD, and depression symptoms. Pending replication of these findings, early online interventions may be widely implemented in practice to improve treatments for distressed bereaved people.

DSM-5-TR prolonged grief disorder levels after natural, COVID-19, and unnatural loss during the COVID-19 pandemic.

Background and objectives: A rise in prolonged grief disorder (PGD) levels was expected due to COVID-19 deaths. We tested this assumption, by comparing PGD-severity among people who experienced a death of a loved one during the pandemic caused by a natural (e.g., illness), COVID-19, or unnatural (e.g., accidents, suicides, homicides) loss on average 8 months earlier and in a subgroup of people bereaved ≥12 months earlier. Design and methods: Self-rated DSM-5-TR (acute) PGD levels (using the Traumatic Grief Inventory-Self Report plus) were compared among Dutch adults who experienced a natural (N = 1036), COVID-19 (N = 76), or unnatural loss (N = 271) during the pandemic. Analyses of covariance were used. Results: About two-thirds of the participants scored above the cut-off for (acute) probable PGD. Significantly higher acute PGD-severity was found in people after unnatural loss compared with COVID-19 (B = -2.44 (SE=0.87), p = .005) or natural loss (B = -1.78 (SE=0.45), p<.001). No significant differences in acute PGD-severity was found between people who experienced a natural or COVID-19 loss (B = 0.66 (SE=0.80), p = .413). PGD levels did not differ between the three groups for people who lost their loved one ≥12 months earlier (N = 380). Conclusions: We found that acute PGD-severity was significantly higher following unnatural deaths than after COVID-19 deaths or natural causes, but no differences were found for people who experienced a loss ≥12 months earlier.

Is it acceptable and feasible to measure prolonged grief disorder symptoms in daily life using experience sampling methodology?

INTRODUCTION: Current grief research is dominated by cross-sectional studies assessing prolonged grief disorder (PGD) symptoms retrospectively. Examining grief in daily life, using Experience Sampling Methodology (ESM), may advance the field. Because of the lack of ESM-research on PGD, we evaluated the acceptability and feasibility of assessing PGD symptoms in daily life of bereaved people. MATERIALS AND METHODS: ESM-items assessing PGD symptoms were developed using cognitive interviewing with five ESM/grief experts. Eighty bereaved adults completed these ESM-items five times a day for two weeks. Before and after this ESM-phase, interviews were administered assessing PGD retrospectively (using the Traumatic Grief Inventory-Clinical Administered). t-tests were performed comparing symptom severity of aggregated moment-to-moment recall (using ESM-items) with retrospective recall (based on interviews) of PGD symptoms. Acceptability of participating in ESM-research (assessed with the Reactions to Research Participation Questionnaire) was examined using descriptive statistics. Feasibility was evaluated by reporting compliance and retention rates. RESULTS: Minor changes were made to the ESM-items based on expert interviews. Average levels of aggregated moment-to-moment recall of the symptoms "yearning" (d = -1.04), "preoccupation with the deceased" (d = -0.91), "marked sense of disbelief" (d = -0.43), and "intense loneliness" (d = -0.28) were lower compared with retrospective recalling these symptoms. On average, bereaved people were neutral about personal benefits gained through participation in this EMS-study. They indicated that participation did not raise emotional reactions. Compliance and retention rates were 60% and 65%, respectively. DISCUSSION: Our findings indicate that whereas compliance and retention is challenging, using ESM to study PGD symptoms in daily life might be useful. Nevertheless, more research is needed.

The mediating role of state anger in the associations between intentions to participate in the criminal trial and psychopathology in traumatically bereaved people.

Victims of crimes have been granted increasing procedural rights to participate in the juridical process since the mid 1990s. However, knowledge about the (anti)-therapeutic effect of participation is limited. We examined the associations between symptom levels of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression and the intention to participate in a criminal trial. Furthermore, we investigated the mediating role of state anger in these associations. People who lost loved ones after a plane disaster with flight MH17 (N = 203) completed questionnaires within three weeks before the start of the criminal trial. Mediation analyses indicated that people, who did not intend to actively participate in the trial by delivering a written or oral victim statement, were less likely to experience anger, which is, in turn, associated with attenuated psychopathology levels. State anger explains 68% of the effect of the intention to exercise the right to speak on PCBD levels. An important limitation is the cross-sectional study design, which precludes conclusions about temporal associations. More research is needed to improve preparation and support of bereaved people when they intend to exercise their victim rights during a criminal trial.

Valid measurement of DSM-5 persistent complex bereavement disorder and DSM-5-TR and ICD-11 prolonged grief disorder: The Traumatic Grief Inventory-Self Report Plus (TGI-SR+).

INTRODUCTION: When grief reactions after bereavement are so intense that they impair daily functioning, a diagnosis of disturbed grief may apply. Slightly differing criteria-sets for disturbed grief are included in the ICD-11, the DSM-5, and its forthcoming text revision, DSM-5-TR. We examined psychometric properties of a new self-report measure, the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+), that assesses these criteria sets for Persistent Complex Bereavement Disorder (PCBD) as per DSM-5, and Prolonged Grief Disorder (PGD) as defined in ICD-11 and DSM-5-TR. MATERIAL AND METHODS: We examined the: i) factor structure, ii) internal consistency, iii) temporal stability, iv) convergent validity, v) known-groups validity, vi) probable caseness, and vii) optimal clinical cut-off scores in two Dutch bereaved samples. Sample 1 consisted of 278 adults, bereaved by various causes. Sample 2 included 270 adults who lost loved ones in a traffic accident. RESULTS: We found support for a 3-factor PCBD model, 1-factor DSM-5-TR model, and 1-factor ICD-11 PGD model. The DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD items demonstrated good internal consistency and temporal stability. Associations between disturbed grief symptoms and posttraumatic stress and depression levels supported convergent validity. Associations between demographic/loss-related variables and disturbed grief symptoms supported known-groups validity. Optimal clinical cut-offs for the TGI-SR+ total score were ≥ 75, ≥71, and ≥ 75 for probable caseness of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD, respectively. DISCUSSION: While replication of our findings in diverse bereaved samples is needed, we conclude that the TGI-SR+ is a reliable and valid measure to assess symptoms of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD.

Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: study protocol for a randomized controlled trial and a controlled trial.

Background: Losing a loved one during the COVID-19 pandemic is a potentially traumatic loss that may result in symptoms of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression. To date, grief-specific cognitive-behavioural therapy (CBT) has mostly been delivered through individual face-to-face formats, while studies have shown that online treatment also yields promising results. Offering treatment online is now more than ever relevant during the pan demic and may offer important benefits compared with face-to-face CBT, such as lower costs and higher accessibility. Our expectation is that grief-specific online CBT is effective in reducing PCBD, PTSD, and depression symptoms. Objective: Our aim is to evaluate the short-term and long-term effectiveness of grief-specific online CBT in reducing PCBD, PTSD, and depression symptom-levels for adults who lost a loved one during the COVID-19 pandemic. Method: This study consists of two parts. In part 1, a two-armed (unguided online CBT versus waitlist controls) randomized controlled trial will be conducted. In part 2, a two-armed (guided online CBT versus unguided online CBT) controlled trial will be conducted. Symptoms of PCBD, PTSD, and depression will be assessed via telephone interviews at pre-treatment/pre-waiting period, post-treatment/post-waiting period, and six months post-treatment. Potential participants are people who lost a loved one at least three months earlier during the COVID-19 pandemic with clinically relevant levels of PCBD, PTSD, and/or depression. Analysis of covariance and multilevel modelling will be performed. Discussion: This is one of the first studies examining the effectiveness of online grief-specific CBT. More research is needed before implementing online grief-specific CBT into clinical practice.

Antecedentes: Perder a un ser querido durante la pandemia de COVID-19 es una pérdida potencialmente traumática que puede resultar en síntomas de trastorno de duelo complejo persistente (PCBD en su sigla en inglés), trastorno de estrés postraumático (TEPT) y depresión. Hasta la fecha, la terapia cognitivo-conductual (TCC) específica para el duelo se ha proporcionado principalmente a través de formatos individuales cara a cara, mientras que los estudios han demostrado que el tratamiento en línea también produce resultados prometedores. Ofrecer tratamiento en línea es ahora más relevante que nunca durante la pandemia y puede ofrecer importantes beneficios en comparación con la TCC presencial, como menores costos y mayor accesibilidad. Nuestra expectativa es que la TCC en línea específica para el duelo sea eficaz para reducir el PCBD, el TEPT y los síntomas de depresión.Objetivo: Nuestro objetivo es evaluar la efectividad a corto y largo plazo de la TCC en línea específica para el duelo en la reducción de los niveles de PCBD, TEPT y síntomas de depresión en adultos que perdieron a un ser querido durante la pandemia de COVID-19.Método: Este estudio consta de dos partes. En la parte 1, se llevará a cabo un ensayo controlado aleatorio de dos brazos (TCC en línea no guiado versus controles con la lista de espera). En la parte 2, se llevará a cabo un ensayo controlado de dos brazos (TCC en línea guiada versus TCC en línea no guiada). Los síntomas de PCBD, TEPT y depresión se evaluarán mediante entrevistas telefónicas en el período de pretratamiento/pre-espera, post-tratamiento/post-período de espera y seis meses post-tratamiento. Los participantes potenciales son personas que perdieron a un ser querido al menos tres meses antes durante la pandemia de COVID-19 con niveles clínicamente relevantes de PCBD, TEPT y/o depresión. Se realizarán análisis de covarianza y modelado multinivel.Discusión: Este es uno de los primeros estudios que examinan la efectividad de la TCC en línea específica para el duelo. Se necesita más investigación antes de implementar la TCC en línea específica para el duelo en la práctica clínica.

DSM-5-TR prolonged grief disorder and DSM-5 posttraumatic stress disorder are related, yet distinct: confirmatory factor analyses in traumatically bereaved people.

Background: Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results. Objective: In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes. Methods: Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted. Results: For PTSD, a seven factor, so-called 'Hybrid' model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD). Conclusions: This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.

Antecedentes: El trastorno de duelo prolongado (PGD en su sigla en inglés) se incluyó recientemente en la revisión del texto del DSM-5 (DSM-5-TR). Hasta ahora, se desconoce si el PGD del DSM-5-TR se puede distinguir del trastorno de estrés postraumático (TEPT) relacionado con el duelo. Investigaciones anteriores que examinaron el carácter distintivo del trastorno de estrés postraumático y el duelo patológico se centraron en muestras con pérdidas no traumáticas, utilizaron conceptualizaciones obsoletas de los trastornos del duelo y arrojaron resultados mixtos.Objetivo: En una muestra grande de personas en duelo traumático, primero evaluamos la estructura factorial de TEPT y PGD por separado y luego evaluamos la estructura factorial al combinar los síntomas de TEPT y PGD para examinar la distinción entre los dos síndromes.Métodos: Se utilizaron datos autoreportados de 468 personas en duelo debido al desastre del avión MH17 (N = 200) o un accidente de tráfico (N = 268). Los 10 síntomas de PGD del DSM-5-TR se evaluaron con el Inventario de Autoreporte de Duelo Traumático Plus (TGI-SR +). Se utilizó la lista de chequeo de 20 ítems para el trastorno de estrés postraumático para el DSM-5 (PCL-5) para examinar los síntomas del TEPT. Se realizaron análisis factoriales confirmatorios.Resultados: Para el TEPT, un modelo de siete factores, llamado modelo 'híbrido', produjo el mejor ajuste. Para el PGD, un modelo de factor univariado se ajusta bien a los datos. Un modelo combinado con elementos de PGD que cargan en un factor y elementos de TEPT en siete factores (asociaciones entre las subescalas de PGD y TEPT r ≥ 50 y ≤ .71), más un factor de orden superior (es decir, factores de TEPT en un factor de TEPT de orden superior)) (asociación entre el factor TEPT de orden superior y el factor PGD r = .82) mostró un mejor ajuste que un modelo con toda la carga de síntomas de PGD y TEPT en un solo factor o dos factores (es decir, uno para PGD y otro para TEPT).Conclusiones: Este es el primer estudio que examina la estructura factorial del PGD según DSM-5-TR y el TEPT según DSM-5 en personas que enfrentan una pérdida traumática. Los hallazgos respaldan que el PGD constituye un síndrome que se distingue del TEPT, pero que está relacionado con él.

[Mourning together: on social support for bereaved people during the COVID-19 pandemic]. / Samen rouwen: over sociale steun aan nabestaanden gedurende de COVID-19-pandemie.

Background In the Netherlands over 9,400 people have died from the consequences of the COVID-19 virus. Aim To describe possible consequences of the COVID-19 pandemia and the measures to control the spread of the virus, for the experiences of loss and mourning and to describe what is needed to prevent grief problems. Method Discussion of selected literature and consideration. Results The COVID-19 measures have an impact on the experiences of loss and mourning of bereaved people. The possibilities to appeal to social relationships have been limited due to the isolation measurements. Therefore, bereaved people might have a heightened risk to develop grief problems. Even though social support is of crucial interest in the processing of a loss, grief can also interfere with the possibilities to use social relationships. Research demonstrated a negative relationship between grief and social problem-solving skills. Thereby bereaved people face an additional challenge, to develop new goals, roles and attachment relationships under the current COVID-19 measurements of social isolation. Conclusion In times of COVID-19 society should pay more attention to experiences of loss and grief in order to activate social support for people bereaved during the COVID-19 pandemic. Tijdschrift voor Psychiatrie 63(2021)1, 13-15.

PTSD treatment in times of COVID-19: A systematic review of the effects of online EMDR.

COVID-19 affects many societies by measures as "social distancing", forcing mental health care professionals to deliver treatments online or via telephone. In this context, online Eye Movement Desensitization and Reprocessing (EMDR) is an emerging treatment for patients with Posttraumatic Stress Disorder (PTSD). We performed a systematic review of studies investigating online EMDR for PTSD. Only one trial was identified. That uncontrolled open trial showed promising results. There is an urgent need to further examine the effects of online EMDR for PTSD, before its wider dissemination is warranted. Remotely delivered cognitive behavioural therapy seems the preferred PTSD-treatment in times of COVID-19.

Reliability and Validity of the Dutch Translation of the Filial Maturity Measure in Informal Caregivers.

This study explored the reliability and validity of a Dutch translation of the 10-item Filial Maturity Measure (FMM) in a sample of Dutch informal caregivers. The FMM was translated with a forward-backward method and completed by 93 informal caregivers (62 % response rate) with a need dependent parent. Dimensionality of the Dutch FMM was examined by principal component and internal consistency analyses. Criterion validity was examined by assessing correlations with filial love, filial autonomy and level of closeness between parent and child. Construct validity was tested by examining associations with the traits openness and agreeableness. In addition, the relationship with state and trait affectivity was explored. After removal of the item "I worry about turning out like my parent", the original dimensional structure, internal consistency, criterion and construct validity were confirmed. Additional exploration of the relation between the FMM subscales and trait and state affectivity scales demonstrated that filial maturity is at most weakly associated with trait affectivity. Both FMM scales showed a positive partial correlation with negative state affectivity. The Dutch FMM appears to be a reliable and valid instrument for measuring filial maturity of informal caregivers who provide care to their need dependent parent. The (non-)functioning of one item pointed to the necessity to validate the FMM, but also questionnaires in general in different populations.