Perception of grief responses: Are maladaptive grief responses and the stages of grief considered normal?

Literature indicates laypeople hold strong opinions about how persons should grieve. This study examined how individuals perceive normal grief. Participants across two distinct samples (Study 1: N = 510 via MTurk; Study 2: N = 210 via Qualtrics panels) completed the Perception of Grief Scale and Grief Expectations Questionnaire. Findings indicated participants endorsed maladaptive grief responses as normal relative to other responses to loss. Endorsement of maladaptive grief responses as normal predicted endorsement of grief work beliefs. If social expectations deem maladaptive grief to be normal, as this study suggests, bereaved individuals might implicitly push themselves to grieve maladaptively.

Rates and prospective psychosocial correlates of pre-loss grief in cancer and dementia family members.

This study examined changes in Pre-Loss Grief (PLG) among individuals whose family member has a life limiting illness and how baseline psychosocial factors predicted PLG. This two-wave study recruited family members of advanced cancer (N = 100) and dementia (N = 38) patients. A subsample completed 1-month follow-up (Cancer = 33; Dementia = 28). Higher caregiver burden and female participants predicted greater PLG at follow-up, accounting for baseline PLG. Family members of dementia patients (10.5%) were significantly more likely than family members of cancer patients (2.1%) to be in the "severe PLG" group. Findings demonstrate psychosocial factors related to PLG, informing interventions aimed at reducing PLG.

An evaluation of common risk factors for prolonged grief disorder using the international classification of diseases-11 criteria.

OBJECTIVES: Inclusion of Prolonged Grief Disorder (PGD) in the ICD-11 warrants examination of risk factors using diagnostic criteria as there is a paucity of research that has examined risk factors of PGD using the diagnostic criteria. This study examines if the identified risk factors for prolonged grief predict PGD using the diagnostic criteria across three samples. METHODS: A cross-sectional survey design was used to assess risk factors and PG-13 in three distinct samples of bereaved adults. The PG-13 was either parsed dichotomously using the ICD-11 diagnostic criteria to indicate presence of PGD or summed to index general grief severity.Results: When using ICD-11 diagnostic criteria, only female gender and high levels of pre-loss contact were identified in separate samples as increasing risk of diagnosis. The most replicable results across samples were found when using the summed PG-13 symptom scores. When using the PG-13 total score, younger age and more pre-loss contact with the deceased were associated with higher symptom levels, which replicated in all three studies.Conclusions: This study provided evidence that the extant literature using summed scores to explore risk factors might not generalize to the ICD-11 diagnostic criteria.

Initial impact of the COVID-19 pandemic on college student mental health: A longitudinal examination of risk and protective factors.

The spread of the novel coronavirus has led to unprecedented changes in daily living. College students (N = 205) completed a battery of questionnaires in April of 2020, after having completed similar measures 8, 5, and 2 months prior as part of a larger study. A repeated measures ANOVA suggested significantly greater depression and anxiety symptom severity during the pandemic than any other time during the 2019-2020 academic year. Two-thirds reported a level of distress above clinical cutoffs on the PHQ-9 and GAD-7. Pre-existing depression and anxiety symptom severity was associated with greater psychological distress during the pandemic. One quarter of students reported using substances to cope with the pandemic. Static and modifiable factors associated with psychological distress and controlling for pre-existing psychological distress were examined. Cognitive and behavioral avoidance, online social engagement, and problematic Internet use were associated with greater risk. Women and Latinx participants were more likely to experience elevated distress during the pandemic, even when controlling for distress prior to the pandemic.

Longitudinal associations between emotion malleability beliefs and avoidance in college students.

Emotion malleability beliefs, or beliefs that emotions are changeable versus fixed, may be an important and modifiable determinant of emotion regulation strategy employment and psychological distress. The present study evaluated the prospective relationship between college students' emotion malleability beliefs, depression and anxiety symptom severity, cognitive and behavioural avoidance, social engagement, and cognitive reappraisal. Participants were college students (N = 177) who completed a battery of questionnaires at the beginning of the academic year and again at a 6-month follow-up. Linear regression analyses indicated that emotion malleability beliefs predicted anxiety and depression, although this effect was not found when controlling for baseline symptom severity. Increases in emotion malleability beliefs were associated with more cognitive reappraisal and less cognitive and behavioural avoidance at follow-up when controlling for baseline levels of each variable. To the extent that emotion malleability beliefs predicted less avoidance at follow-up, anxiety and depression symptom severity was lower. Results suggest that emotion malleability beliefs predict avoidance and related psychological outcomes across the academic year.

Preparedness for the death of an elderly family member: A possible protective factor for pre-loss grief in informal caregivers.

BACKGROUND: Pre-loss grief (PLG) has been identified as a robust risk factor for Prolonged Grief Disorder, which will be added to the DSM 5-TR. Therefore, identifying treatment targets to reduce PLG is warranted. "Preparedness" has been found to strongly predict PLG. The work is nascent and a consensus has not been reached about how best to assess for preparedness, and no reliable measure of this construct exists. Before examining the relationship between preparedness and PLG, an in depth understanding of how family members define preparedness is warranted. OBJECTIVES: The purpose of this study was to develop a preliminary theoretical framework of preparedness for the loss. METHODS: This was achieved through prospective semi-structured interviews with family members of Stage 4 Cancer (N = 16) and Advanced Dementia (N = 24) patients. RESULTS: The overarching theme related to preparedness for the loss was the need to reduce uncertainty, both before the person passes away (i.e., present certainty) and after the person passes away (i.e., future certainty). Factors associated with the need to establish certainty in the present included, religiosity and spirituality, good relationship quality with the person with the life limiting illness, having access to support, good communication with person with life limiting illness, and acceptance of the impending death. Certainty for the future included, knowing what to expect due to past experience of loss, having plans for life without the person, and social support. CONCLUSION: This study provides a preliminary framework of preparedness for family members of individuals with life limiting illness.

Attributions About Bereaved Spouses: Testing the Myths of Coping With Loss.

Social expectations influence how we cope with loss and how people in our social networks respond to us. Wortman and Silver outlined Western cultural assumptions, or myths, about mourning, thought to influence judgments of one's grief response. In particular, the two myths hypothesized to affect social judgments about grievers' adjustment were related to (a) the intensities of the grief response and (b) the duration of the grief response. We assessed if these myths affected the attributions of potential support providers in a convenience sample of 510 Amazon Mechanical Turk community participants. The results indicated preheld expectancies that expressing and processing loss is important to recover from grief was related to attributions about the adjustment of spousally bereaved grievers in vignettes. However, any level of grief symptoms displayed in vignettes was associated with participants, indicating they would discourage expression of grief and distance themselves from the person grieving.

Preloss grief in family members of COVID-19 patients: Recommendations for clinicians and researchers.

Researchers have long examined grief-related reactions to the diagnosis of a loved one with a terminal illness, including preloss grief (PLG), which is the experience of grief symptoms prior to the loss of a loved one. Families face novel challenges when loved ones with COVID-19 become critically ill-most notably mandated physical separation-and may experience a wide range of PLG responses. This commentary examines the existing literature related to PLG as a means for understanding the psychological impact of COVID-19 deaths, identifies factors professionals can assess for and address when working with a family member of COVID-19 patients, and identifies areas for future research related to COVID-19 and PLG. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Causal explanations of depression and treatment credibility in adults with untreated depression: Examining attribution theory.

OBJECTIVES: Understanding depression as biologically caused has been shown to impact both treatment preferences and prognostic pessimism. Attribution theory has been posited as an explanation for this relationship. Given that evidence-based psychotherapy is effective yet often not delivered to individuals with depression, the present study sought to determine factors that impact treatment credibility. DESIGN: Non-treatment-seeking, depressed individuals (n = 229) were randomly assigned to read a psychoeducation article about depression that consisted of a biological causal explanation, psychosocial causal explanation, or a non-causal control. METHODS: Attributional dimensions of locus, stability, and control were examined as mediating the relationship between causal explanation and treatment credibility and prognostic pessimism. RESULTS: Individuals in the biological condition were more likely to find antidepressant medication a credible treatment for depression. The manipulation had no direct effect on preference for psychotherapy or prognostic pessimism. Attributional dimensions of locus, stability, and control did not mediate the relationship between causal explanation and treatment credibility. To the extent that the psychosocial article increased perceived instability of the depression cause, however, prognostic pessimism was reduced. CONCLUSIONS: The present study has implications for framing education about depression in mental health literacy programs and public awareness campaigns. PRACTITIONER POINTS: This study found that conceptualizing depression as biologically caused increased the credibility of medication but not psychotherapy Participants reading a biological explanation of depression demonstrated an increase on some aspects of stigma and prognostic pessimism Emphasizing the person-environment interaction rather than biological causes decreased the perceived stability of depression which was associated with a decrease in prognostic pessimism.

Modifiable risk and protective factors for anxiety disorders among adults: A systematic review.

Anxiety disorders are highly prevalent in the general population and associated with high rates of impairment and disability. This burden highlights the need to identify risk factors that individuals can modify without professional intervention. A systematic review was conducted to identify studies that examined modifiable risk and protective factors for anxiety disorders among adults in the general population. Searches were conducted in PubMed, PsycINFO and MEDLINE using medical subject headings and text words related to risk factors, protective factors, and each anxiety disorder. Screening, data extraction, and quality assessment were performed by three study authors. Modifiable risk and protective factors from 19 studies across seven countries were identified. Risk factors identified included cigarette smoking, alcohol use, cannabis use, negative appraisals of life events, avoidance, and occupational factors. Protective factors included social support, coping, and physical activity. Cigarette smoking was the most studied risk factor. Support was found for cigarette smoking as a risk factor for agoraphobia and panic disorder. Mixed results were found for generalized anxiety disorder and specific phobia. Across disorders, smoking frequency was associated with greater risk. Results indicate an important gap in the literature in that few studies have examined modifiable risk factors for anxiety disorders.

Which Brief Is Best? Clarifying the Use of Three Brief Versions of the Difficulties in Emotion Regulation Scale.

Emotion regulation is a fundamental affective process implicated in a range of clinically relevant phenomena such as mood, anxiety, and personality disorders, as well as self-harm and suicidality. Many self-report scales have been developed to measure this important construct, and the Difficulties in Emotion Regulation Questionnaire (DERS) is one of the most widely used. The DERS has extensive empirical support for its use, however, its long length impacts its utility and a briefer version is needed. Recently three brief versions of the DERS (DERS-16, DERS-SF, and DERS-18) were developed independently. Initial analyses of each of these measures found them to retain the excellent psychometric properties of the original DERS measure. However, it remains unclear which version is most ideally suited to briefly measure emotion regulation in clinical and research contexts. To clarify this point, the current study examined the existing brief DERS measures on internal reliability and concurrent validity indices in a large sample of undergraduate students (n = 1181). The reliability and validity of all three brief forms were found to be comparable. Additionally, if replicated, our results suggest that it may be useful for future research and clinical work to use brief versions that retain subscale scores (DERS-SF and DERS-18). Based on the results and the existing literature, we recommend that the emotion regulation field come to a consensus about which brief version to use for consistency and the ability to compare findings across studies.

Bereavement Challenges and Their Relationship to Physical and Psychological Adjustment to Loss.

OBJECTIVE: The psychosocial challenges confronted by bereaved survivors may contribute to poor bereavement adjustment. Measures of the challenges of bereavement are limited. This study is a preliminary examination of the factor structure of a new measure of bereavement challenges and their relationships to quality of life and mental illness in bereaved cancer caregivers. This measure was designed to identify intervention targets to reduce the likelihood of prolonged grief. METHODS: Caregivers of advanced cancer patients were administered measures of bereavement challenges (Bereavement Challenges Scale, BCS), quality of life (Medical Outcomes Study Short Form-36), prolonged grief (PG-13), and mental disorders (Structured Clinical Interview for the DSM-IV). Principal component factor analyses identified the underlying factor structure of the BCS. We examined associations between the factors and caregiver quality of life, prolonged grief, and rates of mental disorders. RESULTS: A factor analysis identified five factors: "Challenges with Connecting with Others," "Challenges with Change," "Challenges Imagining a Hopeful Future," "Challenges with Accepting the Loss," and "Challenges with Guilt." Greater endorsement of bereavement challenges was associated with worse quality of life, more severe symptoms of prolonged grief, and greater likelihood of meeting criteria for a mental disorder. CONCLUSIONS: Assessing the challenges associated with bereavement is important to understanding barriers to bereaved individuals' adjustment. The five factors of the BCS point to potential targets for clinical intervention. Additional research on the BCS is needed, including validation in larger more diverse samples, and confirmation that reduction of these challenges is associated with less psychiatric morbidity and, specifically, symptoms of prolonged grief.

A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder.

This trial assessed the feasibility, acceptability, tolerability, and efficacy of an Internet-based therapist-assisted cognitive-behavioral indicated prevention intervention for prolonged grief disorder (PGD) called Healthy Experiences After Loss (HEAL). Eighty-four bereaved individuals at risk for PGD were randomized to either an immediate treatment group (n = 41) or a waitlist control group (n = 43). Assessments were conducted at four time-points: prior to the wait-interval (for the waitlist group), pre-intervention, post-intervention, 6 weeks later, and 3 months later (for the immediate group only). Intent-to-treat analyses indicated that HEAL was associated with large reductions in prolonged grief (d = 1.10), depression (d = .71), anxiety (d = .51), and posttraumatic stress (d = .91). Also, significantly fewer participants in the immediate group met PGD criteria post-intervention than in the waitlist group. Pooled data from both groups also yielded significant reductions and large effect sizes in PGD symptom severity at each follow-up assessment. The intervention required minimal professional oversight and ratings of satisfaction with treatment and usability of the Internet interface were high. HEAL has the potential to be an effective, well-tolerated tool to reduce the burden of significant pre-clinical PGD. Further research is needed to refine HEAL and to assess its efficacy and mechanisms of action in a large-scale trial.

Commonalities in grief responding across bereavement and non-bereavement losses.

BACKGROUND: Despite implications for theory and treatment, commonality in responding to non-bereavement and bereavement losses are not well explicated. METHOD: This study identified the factor structure of the three most common responses to bereavement, prolonged grief, posttraumatic stress, and major depression in a bereaved community sample (n=151, 59% female, 68% white) from the U.S. recruited from Amazon's MTurk using a cross-sectional survey design, then cross-validated the structure in samples where people had lost other potentially self-defining roles; one's employment (n=157, 47% female, 69% white) and one's marriage (n=116, 62% female, 80% white). RESULTS: Results indicated that symptoms of prolonged grief, posttraumatic stress, and major depression were distinct factors in the bereaved sample, the three-factor solution was a good fit for the job-loss and divorce samples, and levels of grief in each sample appeared to be best predicted by time since loss and centrality of the loss to one's identity. LIMITATIONS: Limitations include potential sample bias due to convenience sampling, and the cross-sectional design did not allow examination of the stability of factors over time. CONCLUSIONS: These results suggest that grief is not a unique response to loss of loved one but instead may be a common phenomenology across types of loss. This implies that facilitating meaningful engagement in self-defining activities that compensate for the disrupting loss might be efficacious in promoting grief resolution without the need for working through individuals' emotional attachment to a specific individual or processing one's emotional responses to the loss.

A randomized open trial assessing the feasibility of behavioral activation for pathological grief responding.

This study investigated the feasibility of using behavioral activation to treat enduring postbereavement mental health difficulties using a two-arm, multiple baseline design comparing an immediate start group to a delayed start group at baseline, 12-, 24-, and 36-weeks postrandomization. Participants received 12-14 sessions of behavioral activation within a 12-week intervention period starting immediately after the first assessment or after 12weeks for the delayed start group. Prolonged grief, posttraumatic stress, and depression symptoms were assessed as outcomes. Compared with no treatment, behavioral activation was associated with large reductions in prolonged, complicated, or traumatic grief; posttraumatic stress disorder; and depression symptoms in the intent-to-treat analyses. Seventy percent of the completer sample at posttreatment and 75 percent at follow-up responded to treatment with 45 percent at posttreatment and 40 percent at follow-up being classified as evidencing high-end state functioning at 12-week follow-up.

Behavioral activation for pathological grief.

The death of a significant other often entails far-reaching changes in individuals' life that can contribute to pathological grief responses. This article reviews 3 prominent theories of grief resolution, highlights common factors proposed to be associated with pathological grief responses, and suggests that behavioral activation (Martell, Addis, & Jacobson, 2001) may address the factors contributing to pathological grieving. Behavioral activation applied to pathological grief may address loss related disruption by engaging bereaved individuals in their social environment and increasing contact with positive reinforcers that maintain sense of self. Two case studies are provided to demonstrate how behavioral activation can be adapted to remediate environmental disengagement, avoidance, and rumination typical of pathological grief responses.

Smiling in the face of adversity: the interpersonal and intrapersonal functions of smiling.

This study examined hypothesized interpersonal and intrapersonal functions of smiling in positive and negative affective contexts. Smiles were measured during a lab-based monologue task following either happy or sad emotion-evoking films. Psychological adjustment and social integration were measured longitudinally using data obtained in years prior to and after the experimental task. Duchenne (genuine) smiles predicted better long-term adjustment and this effect was mediated independently by both social integration and undoing of negative emotion during the monologue. These effects were observed only in the negative affective context. Non-Duchenne smiles were not related to psychological adjustment. Neither Duchenne nor non-Duchenne smiles during the monologue task were related to personality variables assessed in this study.

Coping with the threat of terrorism: a review.

Terrorism creates a ripple of fear and uncertainty. Although most individuals are resilient and recover over time, a minority remains functionally and psychologically impaired. In this paper, we examine research on coping strategies employed in the aftermath of terrorist events, theories and empirical findings related to appraisal processes that influence individuals' primary attributions of risk, and normative processes that shape secondary appraisals, which predict specific coping behaviors. We also describe individual diatheses and factors promoting resilience that may influence coping and functioning in the face of terrorism. Finally, we offer suggestions for future research.

A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder.

OBJECTIVE: The authors report an 8-week randomized, controlled proof-of-concept trial of a new therapist-assisted, Internet-based, self-management cognitive behavior therapy versus Internet-based supportive counseling for posttraumatic stress disorder (PTSD). METHOD: Service members with PTSD from the attack on the Pentagon on September 11th or the Iraq War were randomly assigned to self-management cognitive behavior therapy (N=24) or supportive counseling (N=21). RESULTS: The dropout rate was similar to regular cognitive behavior therapy (30%) and unrelated to treatment arm. In the intent-to-treat group, self-management cognitive behavior therapy led to sharper declines in daily log-on ratings of PTSD symptoms and global depression. In the completer group, self-management cognitive behavior therapy led to greater reductions in PTSD, depression, and anxiety scores at 6 months. One-third of those who completed self-management cognitive behavior therapy achieved high-end state functioning at 6 months. CONCLUSIONS: Self-management cognitive behavior therapy may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care.