Prevalence, Correlates, and Psychiatric Burden of Prolonged Grief Disorder in U.S. Military Veterans: Results From a Nationally Representative Study.

OBJECTIVES: To examine the point prevalence and correlates of prolonged grief disorder (PGD) in a nationally-representative sample of United States (U.S.) veterans. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative study of 2,441 U.S. veterans. RESULTS: A total of 158 (weighted 7.3%) veterans screened positive for PGD. The strongest correlates of PGD were adverse childhood experiences, female sex, non-natural causes of death, knowing someone who died from coronavirus disease 2019, and number of close losses. After adjusting for sociodemographic, military, and trauma variables, veterans with PGD were 5-to-9 times more likely to screen positive for post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. After additional adjustment for current psychiatric and substance use disorders, they were 2-3 times more likely to endorse suicidal thoughts and behaviors. CONCLUSIONS: Results underscore the importance of targeting PGD as an independent risk factor for psychiatric disorders and suicide risk.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder.

Objective The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Mania Following Bereavement: State of the Art and Clinical Evidence.

Bereavement is the state of loss, determined in most of the cases by the death of a close person. It is probably the greatest sorrow that can occur in an individual life. Grief is a normal, healthy response to loss, evolving through stages in the process of mourning. In some cases, bereavement may lead to the outburst of manic episode: despite literature data being scarce, reports have explored this important clinical entity, variously called as "funeral mania" or "bereavement mania". We systematically reviewed the literature exploring the possible relationships between bereavement and the onset of a manic episode, both first or recurrent pre-existing episode, besides describing a case report on a manic episode in the aftermath of a loss event, with an accurate evaluation of prior mild mood spectrum instability, supporting the role of loss-events as potential risk factor for bipolar illness progression. This article tries summarizing existing evidence on the debate whether clinicians should consider mania as a possible bereavement reaction.

Accommodating Grief on Twitter: An Analysis of Expressions of Grief Among Gang Involved Youth on Twitter Using Qualitative Analysis and Natural Language Processing.

There is a dearth of research investigating youths' experience of grief and mourning after the death of close friends or family. Even less research has explored the question of how youth use social media sites to engage in the grieving process. This study employs qualitative analysis and natural language processing to examine tweets that follow 2 deaths. First, we conducted a close textual read on a sample of tweets by Gakirah Barnes, a gang-involved teenaged girl in Chicago, and members of her Twitter network, over a 19-day period in 2014 during which 2 significant deaths occurred: that of Raason "Lil B" Shaw and Gakirah's own death. We leverage the grief literature to understand the way Gakirah and her peers express thoughts, feelings, and behaviors at the time of these deaths. We also present and explain the rich and complex style of online communication among gang-involved youth, one that has been overlooked in prior research. Next, we overview the natural language processing output for expressions of loss and grief in our data set based on qualitative findings and present an error analysis on its output for grief. We conclude with a call for interdisciplinary research that analyzes online and offline behaviors to help understand physical and emotional violence and other problematic behaviors prevalent among marginalized communities.

Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates.

INTRODUCTION: Complicated grief (CG) has been the subject of increasing attention in the past decades but its relationship with separation anxiety disorder (SEPAD) is still controversial. The aim of the current study was to explore the prevalence and clinical significance of adult SEPAD in a sample of help-seeking individuals with CG. METHODS: 151 adults with CG, enrolled in a randomized controlled trial comparing the effectiveness of (CG) treatment to that of interpersonal therapy, were assessed by means of the Inventory of Complicated Grief (ICG), the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression (HAM-D), the Work and Social Adjustment Scale (WSAS), the Adult Separation Anxiety Questionnaire (ASA-27), the Grief Related Avoidance Questionnaire (GRAQ), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), and the Impact of Events Scale (IES). RESULTS: 104 (68.9%) individuals with CG were considered to have SEPAD (ASA-27 score ≥22). Individuals with SEPAD were more likely to have reported a CG related to the loss of another close relative or friend (than a parent, spouse/partner or a child) (p=.02), as well as greater scores on the ICG (p=<.001), PDEQ (p=.004), GRAQ (p<.001), intrusion (p<.001) and avoidance (p=<.001) IES subscales, HAM-D (p<.001) and WSAS (p=.006). ASA-27 total scores correlated with ICG (p<.0001), PDEQ (p<.001) GRAQ (p<.0001) scores and both the IES intrusion (p<.0001) and IES avoidance (p<.0001) subscale scores. People with SEPAD had higher rates of lifetime post-traumatic stress disorder (PTSD) (p=.04) and panic disorder (PD) (p=.01). CONCLUSIONS: SEPAD is highly prevalent among patients with CG and is associated with greater symptom severity and impairment and greater comorbidity with PTSD and PD. Further studies will help to confirm and generalize our results and to determine whether adult SEPAD responds to CG treatment and/or moderates CG treatment response.

The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder.

Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety disorder (ASAD) is a manifestation of anxious attachment, or a form of agoraphobia, or a specific condition with clinically significant consequences. We conducted a study to examine these questions. A sample of 141 adult outpatients with panic disorder participated in the study. Participants completed standardized measures of separation anxiety, attachment style, agoraphobia, panic disorder severity and quality of life. Patients with ASAD (49.5% of our sample) had greater panic symptom severity and more impairment in quality of life than those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment among panic patients with ASAD compared to those without ASAD. However, the relationship between ASAD and attachment style is not strong, and adult ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that ASAD is a distinct condition associated with impairment in quality of life and needs to be better recognized and treated in patients with panic disorder.

A note on a nonparametric regression test through penalized splines.

We examine a test of a nonparametric regression function based on penalized spline smoothing. We show that, similarly to a penalized spline estimator, the asymptotic power of the penalized spline test falls into a small- K or a large-K scenarios characterized by the number of knots K and the smoothing parameter. However, the optimal rate of K and the smoothing parameter maximizing power for testing is different from the optimal rate minimizing the mean squared error for estimation. Our investigation reveals that compared to estimation, some under-smoothing may be desirable for the testing problems. Furthermore, we compare the proposed test with the likelihood ratio test (LRT). We show that when the true function is more complicated, containing multiple modes, the test proposed here may have greater power than LRT. Finally, we investigate the properties of the test through simulations and apply it to two data examples.

Mechanisms of change in cognitive behavioral therapy for panic disorder: the unique effects of self-efficacy and anxiety sensitivity.

The present study examined temporal dependencies of change of panic symptoms and two promising mechanisms of change (self-efficacy and anxiety sensitivity) during an 11-session course of cognitive-behavior therapy (CBT) for Panic Disorder (PD). 361 individuals with a principal diagnosis of PD completed measures of self-efficacy, anxiety sensitivity, and PD symptoms at each session during treatment. Effect size analyses indicated that the greatest changes in anxiety sensitivity occurred early in treatment, whereas the greatest changes in self-efficacy occurred later in treatment. Results of parallel process latent growth curve models indicated that changes in self-efficacy and anxiety sensitivity across treatment uniquely predicted changes in PD symptoms. Bivariate and multivariate latent difference score models indicated, as expected, that changes in anxiety sensitivity and self-efficacy temporally preceded changes in panic symptoms, and that intraindividual changes in anxiety sensitivity and self-efficacy independently predicted subsequent intraindividual changes in panic symptoms. These results provide strong evidence that changes in self-efficacy and anxiety sensitivity during CBT influence subsequent changes in panic symptoms, and that self-efficacy and anxiety sensitivity may therefore be two distinct mechanisms of change of CBT for PD that have their greatest impact at different stages of treatment.

Dream content in complicated grief: a window into loss-related cognitive schemas.

Bereavement and its accompanying psychological response (grief) constitute potent experiences that necessitate the reorganization of cognitive-affective representations of lost significant attachment figures during both wakefulness and dreaming. The goals of this preliminary study were to explore whether the dream content of 77 adults with complicated grief (CG) differed from that of a normative sample and whether CG patients who dream of the deceased differ from CG patients who do not dream of the deceased on measures of daytime emotional distress. CG dreams were characterized by more family and familiar characters including the deceased (in women), and fewer social interactions and emotions compared to norms. Increased representations of familiar characters in CG dreams may reflect attempts to reorganize relational cognitive schemas to compensate for the loss.

Parents bereaved by offspring suicide: a population-based longitudinal case-control study.

CONTEXT Suicide bereavement remains understudied and poorly understood. OBJECTIVES To examine outcomes of parents bereaved by the suicide death of their offspring and to compare these with both nonbereaved parent controls and parents who had offspring die in a motor vehicle crash (MVC). DESIGN Population-based case-control study. Suicide-bereaved parents were compared with nonbereaved matched control parents in the general population (n = 1415) and with MVC-bereaved parents (n = 1132) on the rates of physician-diagnosed mental and physical disorders, social factors, and treatment use in the 2 years after death of the offspring. Adjusted relative rates (ARRs) were generated by generalized estimating equation models and adjusted for confounding factors. SETTING Manitoba, Canada. PARTICIPANTS All identifiable parents who had an offspring die by suicide between 1996 and 2007 (n = 1415). MAIN OUTCOME MEASURES Mental and physical disorders, social factors, and treatment use. RESULTS Suicide bereavement was associated with an increased rate of depression (ARR, 2.14; 95% CI, 1.88-2.43), anxiety disorders (ARR, 1.41; 95% CI, 1.24-1.60), and marital breakup (ARR, 1.18; 95% CI, 1.13-1.23) in the 2 years after the suicide of an offspring, as compared with the 2 years prior to the death. Suicide-bereaved and MVC-bereaved parents had very few differences on predeath to postdeath outcomes. Depression rate increases were greater for MVC-bereaved parents (19.9%) compared with suicide-bereaved parents (15.9%; P = .005), whereas suicide-bereaved parents had higher rate increases of hospitalization for mental illness (P = .049). Suicide-bereaved parents were more likely than their MVC-bereaved counterparts to have depression (ARR, 1.30; 95% CI, 1.06-1.61), physical disorders (ARR, 1.32; 95% CI, 1.19-1.45), and low income (ARR, 1.34; 95% CI, 1.18-1.51) before their offspring's death. CONCLUSIONS Suicide bereavement is associated with adverse mental health and social outcomes. These consequences appear similar to those associated with MVC bereavement. Parents who lose offspring to suicide appear to be a vulnerable group even prior to their offspring's death.

The relationship between adult separation anxiety disorder and complicated grief in a cohort of 454 outpatients with mood and anxiety disorders.

BACKGROUND: Recent epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. Data from literature suggest that Adult Separation Anxiety Disorder (ASAD) may develop after a bereavement or threat of loss. Research has demonstrated that bereaved persons may present a clinically significant grief reaction, defined as Complicated Grief (CG) that causes a severe impairment in the quality of life. The aim of this study was to evaluate the relationship between ASAD and CG in a large cohort of outpatients with mood and anxiety disorders. METHODS: Study participants comprised 454 adult psychiatric outpatients with DSM-IV mood or anxiety disorders diagnoses. Diagnostic assessments were performed using the SCID-I; ASAD was assessed using an adapted version of the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS-adult). Complicated grief symptoms were assessed by the Inventory of Complicated Grief (ICG). Social and work impairments were evaluated using the Sheehan Disability Scale (SDS). Adult attachment styles were assessed by the Relationship Questionnaire (RQ). RESULTS: The overall frequency of ASAD in our sample was 43% and that of CG was 23%. Individuals with CG had a greater frequency of ASAD (56%) with respect to those without CG (40%). Subjects with CG plus ASAD reported higher scores on ICG and greater impairment on quality of life, as measured with SDS, than CG patients without ASAD. CONCLUSIONS: Adult separation anxiety disorder occurs in a high proportion of adult psychiatric outpatients with complicated grief. The association between these two conditions should be further investigated in light of their clinical implications.

Follow-up study of complicated grief among parents eighteen months after a child's death in the pediatric intensive care unit.

OBJECTIVE: We previously demonstrated that parents whose children die in a pediatric intensive care unit (PICU) have a high level of complicated grief symptoms 6 months after the death. In this study, we investigate the change in the extent of complicated grief symptoms among these parents between 6 and 18 months postdeath and identify factors predicting improvement. METHODS: One hundred thirty-eight parents of 106 children completed surveys at 6 and 18 months. Surveys included the Inventory of Complicated Grief (ICG), measures of grief avoidance, attachment, caregiving and social support, and demographics. Multivariable analysis was performed using generalized estimating equations to identify characteristics independently associated with improvement in ICG score. RESULTS: ICG scores were 33.4 ± 13.6 at 6 months and 28.0 ± 13.5 at 18 months, representing an improvement in ICG score of 5.4 + 8.0 (95% confidence interval [CI] 4.1-6.8, p < 0.001). Variables independently associated with greater improvement in ICG score included traumatic death and greater grief avoidance. Variables independently associated with less improvement included being the biological parent and having more responsive caregiving. Parents with one or two surviving children had more improvement in ICG score than those with no surviving children whereas parents with three or more surviving children had less improvement. CONCLUSION: Complicated grief symptoms decrease among parents between 6 and 18 months after their child's death in the PICU; however, high symptom levels persists for some. Better understanding of the trajectory of complicated grief will allow parents at risk for persistent distress to receive professional support.

Complicated grief and associated risk factors among parents following a child's death in the pediatric intensive care unit.

OBJECTIVE: To investigate the extent of complicated grief symptoms and associated risk factors among parents whose child died in a pediatric intensive care unit. DESIGN: Cross-sectional survey conducted by mail and telephone. SETTING: Seven children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network from January 1, 2006, to June 30, 2008. PARTICIPANTS: Two hundred sixty-one parents from 872 families whose child died in a pediatric intensive care unit 6 months earlier. MAIN EXPOSURE: Assessment of potential risk factors, including demographic and clinical variables, and parent psychosocial characteristics, such as attachment style, caregiving style, grief avoidance, and social support. MAIN OUTCOME MEASURE: Parent report of complicated grief symptoms using the Inventory of Complicated Grief. Total scale range is from 0 to 76; scores of 30 or higher suggest complicated grief. RESULTS: Mean (SD) Inventory of Complicated Grief scores among parents were 33.7 (14.1). Fifty-nine percent of parents (95% confidence interval, 53%-65%) had scores of 30 or higher. Variables independently associated with higher symptom scores in multivariable analysis included being the biological mother or female guardian, trauma as the cause of death, greater attachment-related anxiety and attachment-related avoidance, and greater grief avoidance. CONCLUSIONS: Parents who responded to our survey experienced a high level of complicated grief symptoms 6 months after their child's death in the pediatric intensive care unit. However, our estimate of the extent of complicated grief symptoms may be biased because of a high number of nonresponders. Better understanding of complicated grief and its risk factors among parents will allow those most vulnerable to receive professional bereavement support.

NIH Roundtable on Opportunities to Advance Research on Neurologic and Psychiatric Emergencies.

STUDY OBJECTIVE: The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community. METHODS: Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement. RESULTS: Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives. CONCLUSION: Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes.

Epidemiology of anxiety disorders.

This chapter presents an overview of the descriptive epidemiology of anxiety disorders based on recently completed surveys of the general population. The overall prevalence of anxiety disorders is shown to be quite high, but with considerable variation from the most prevalent (specific phobias) to the least prevalent (agoraphobia without a history of panic disorder) disorders. Age-of-onset (AOO) of anxiety disorders is typically in childhood or adolescence and the course is often chronic-recurrent. Anxiety disorders are highly comorbid with each other and with other mental disorders. Because of their early AOO, they are often the temporally primary disorders in comorbid profiles, raising the question whether early interventions to treat anxiety disorders might have a positive effect on the onset, persistence, or severity of secondary disorders such as mood and substance use disorders. This possibility has not yet been extensively explored but warrants further study given the high societal costs of anxiety disorders.

Grief and bereavement: what psychiatrists need to know.

THIS REVIEW COVERS FOUR AREAS OF CLINICAL IMPORTANCE TO PRACTICING PSYCHIATRISTS: a) symptoms and course of uncomplicated (normal) grief; b) differential diagnosis, clinical characteristics and treatment of complicated grief; c) differential diagnosis, clinical characteristics and treatment of grief-related major depression; and d) psychiatrists' reactions to patient suicides. Psychiatrists often are ill prepared to identify complicated grief and grief-related major depression, and may not always be trained to identify or provide the most appropriate course of treatment. Both conditions overlap with symptoms found in ordinary, uncomplicated grief, and often are written off as "normal" with the faulty assumption that time, strength of character and the natural support system will heal. While uncomplicated grief may be extremely painful, disruptive and consuming, it is usually tolerable and self-limited and does not require formal treatment. However, both complicated grief and grief-related major depression can be persistent and gravely disabling, can dramatically interfere with function and quality of life, and may even be life threatening in the absence of treatment; and both usually respond to targeted psychiatric interventions. In addition, patient suicide has been reported as one of the most frequent and stressful crises experienced by health providers, and psychiatrists are not immune to complicated grief or grief-related depression when they, themselves, become survivors. Thus, it is essential for psychiatrists to recognize their own vulnerabilities to the personal assaults that often accompany such losses, not only for their own mental health and well-being, but also to provide the most sensitive and enlightened care to their patients.

Does attachment avoidance help people cope with loss? The moderating effects of relationship quality.

Previous research has been inconsistent about the role of attachment avoidance in coping with loss. The present study sought to resolve this issue by examining the potential moderating role of relationship quality with the deceased. The authors used longitudinal data on bereaved spouses (N=50) collected at 4 and 18 months postloss. Three-way effects emerged among attachment avoidance, attachment anxiety, and marital quality in the prediction of complicated grief (CG) symptoms at 18 months, controlling for 4-month symptoms. Findings indicated that, in the context of high but not low marital quality, persons with a dismissingly avoidant attachment style (high avoidance, low anxiety) experienced marked reductions in CG symptoms from 4 to 18 months. Findings clarify the role of attachment avoidance in coping with loss and underscore that relationship quality is a critical factor in the attachment-grief relationship.

Complicated grief and impaired sleep in patients with bipolar disorder.

OBJECTIVES: To examine the relationship of sleep disturbance with complicated grief (CG) in patients with bipolar disorder (BD). METHODS: Adults with DSM-IV BD were asked if they ever experienced significant loss and, if so, completed the Inventory of Complicated Grief. Subjective sleep disturbance was assessed with the Pittsburgh Sleep Quality Index (PSQI). The association of CG with sleep disturbance was assessed in univariate t-tests, and in multivariate analyses controlling for the presence of anxiety disorder comorbidity and current bipolar recovery status. RESULTS: Individuals with CG had significantly higher mean PSQI scores (10.9 versus 7.9, p = 0.003) than those without CG. Further, within the group of BD participants who had experienced a significant loss, those with CG had significantly poorer sleep (p = 0.01). CG remained significantly associated with greater sleep impairment after adjustment for comorbid anxiety disorder and bipolar mood state. This additive impairment in sleep with CG comorbidity was evident for four of the PSQI component scales: sleep quality, sleep duration, sleep efficiency and sleep disturbance. CONCLUSIONS: Our data indicate a significant association of CG with poor sleep in individuals with BD. Disturbed sleep may be a mechanism by which CG increases the burden of illness in BD.

The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief.

BACKGROUND: Complicated grief (CG), variously called pathological or traumatic grief, is a debilitating syndrome that is not currently included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) nomenclature. One issue that remains under debate is whether this condition can be clearly distinguished from other psychiatric disorders, such as major depression and posttraumatic stress disorder, with which CG frequently coexists. METHODS: Using a structured clinical interview for CG and the Structured Clinical Interview for DSM-IV, trained experienced raters conducted careful diagnostic assessments of individuals seeking treatment of bereavement-related distress. All study participants met criteria for a current CG syndrome. Liberal criteria were used to diagnose DSM-IV disorders, making no attempt to decide if symptoms could be explained by grief. RESULTS: Of 206 who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder. When present, psychiatric comorbidity was associated with significantly greater severity of grief; however, even after adjustment for the presence of comorbidity, severity of CG symptoms was associated with greater work and social impairment. LIMITATIONS: It is likely that our study underestimated the rate of CG without comorbidity because fewer DSM diagnoses would have been made if a judgment about grief had been taken into consideration. CONCLUSIONS: Our data provide further support for the need to identify CG as a psychiatric disorder.