J Psychopathol Behav Assess (2011) 33:254–263 DOI 10.1007/s10862-010-9214-5
Separation and Traumatic Distress in Prolonged Grief: The Role of Cause of Death and Relationship to the Deceased Jason M. Holland & Robert A. Neimeyer
Published online: 12 January 2011 # Springer Science+Business Media, LLC 2011
Abstract A distinction has been drawn between symptoms of separation distress (e.g., yearning/longing for the lost relationship) and traumatic distress (e.g., numbness, anger/ bitterness) in prolonged grief disorder (PGD), a chronic and severe form of grieving that has been shown to predict a range of negative mental and physical health outcomes. The present study relied upon information from 947 recently bereaved young adults and tested the hypothesis that levels of separation distress primarily would be influenced by aspects of the relationship with the deceased (i.e., primary attachment figures vs. more distant relationships), whereas levels of traumatic distress would be influenced more by situational factors surrounding the death itself (i.e., cause of death). Results generally supported this hypothesis with a few important qualifications. Implications for the assessment and treatment of bereaved individuals are discussed. Keywords Prolonged grief . Separation distress . Trauma . Violent death . Relationships The views expressed here are the authors’ own and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. J. M. Holland VA Palo Alto Health Care System, Stanford University School of Medicine, Stanford, CA, USA R. A. Neimeyer University of Memphis, Memphis, TN, USA J. M. Holland (*) Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, MC 5797, Stanford, CA 94305-5797, USA e-mail:
[email protected]
In the last 15 years, tremendous progress has been made in improving our understanding of complicated or prolonged grief reactions (Prigerson et al. 1995b, 2009), ultimately resulting in a refined set of diagnostic criteria for Prolonged Grief Disorder (PGD) proposed for the 5th edition of the Diagnostic and Statistical Manual (DSM; Prigerson et al. 2008). PGD is characterized by a range of chronic and severe grief symptoms, including intense separation distress, intrusive thoughts about the lost relationship, a sense of meaninglessness, and functional impairment in day-today life (Prigerson et al. 2008). Notably, PGD symptoms have been shown uniquely to predict a range of negative outcomes (controlling for other psychiatric symptoms), including heart problems, high blood pressure, changes in eating and smoking habits, suicidal ideation, and global psychological adjustment (Bonanno et al. 2007; Latham and Prigerson 2004; Prigerson et al. 1997), highlighting the importance of accurate identification and assessment of these symptoms and their risk factors in clinical practice. Despite the recent strides made in our understanding of PGD, bereavement researchers have pointed out that the distinction between traumatic aspects of loss (e.g., anger/bitterness, numbness/shock, shattered worldview) and separation-related aspects (e.g. yearning/pining, loneliness) as well as our understanding of the unique risk factors associated with these different manifestations of grief remain somewhat murky (Stroebe et al. 2001). Thus, the purpose of the present study is to examine cause of death (e.g., homicide, accident, natural causes) and relationship to the deceased (e.g., immediate family, friend) as factors that may differentially predict separation- and traumatic-related aspects of PGD. A number of factor analytic studies have concluded that PGD symptoms are distinct from the symptoms of other psychiatric disorders (i.e., depression, generalized anxiety,
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posttraumatic stress; Boelen and van den Bout 2005; Boelen et al. 2003a; Chen et al. 1999; Prigerson et al. 1995a, 1996). In particular, one of the cardinal features of PGD is that it is characterized by intense separation distress—a cluster of symptoms that are not presently represented by any other psychiatric disorder in DSM-IV (Prigerson et al. 2008). Nevertheless, the symptoms of PGD do share some overlap with the symptoms of other disorders. Most significantly, researchers and clinicians have noted that trauma-like symptoms often follow particularly highimpact losses (Rubin et al. 2003; Stroebe et al. 2001), and some have found it useful to draw a distinction between separation and traumatic distress as two related components of PGD (e.g., Prigerson and Jacobs 2001; Neimeyer et al. 2006). It has been suggested that different risk factors may vary in the degree to which they impact these two components of PGD, with relational and attachment-based aspects of the loss (e.g., kinship, closeness to the deceased) being more strongly related to separation distress and situational factors surrounding the death itself (e.g., violent vs. natural causes, whether or not it was an act of volition) being more strongly related to traumatic distress (Rynearson 1994; Stroebe et al. 2001). Support for such a hypothesis has been provided by Pynoos and Nader (1988) who studied the grief and posttraumatic stress reactions of school children following a sniper attack. Specifically, these researchers noticed a more pronounced posttraumatic stress reaction among children who had a greater degree of exposure to the violence, whereas greater separation anxiety and grief were observed for children who were closer to a victim of the shooting (Eth and Pynoos 1985). Considering the potentially strong presentation of traumatic distress among those who have experienced the violent death of a loved one, some have raised the possibility of treating “traumatic grief” as a distinct subtype of PGD (Stroebe et al. 2001). It should be noted, however, that others have failed to find a clear link between loss by violent means and increased traumatic distress (Jacobs 1993; Prigerson et al. 2002). For example, Prigerson and her colleagues (2002) examined levels of separation and traumatic distress among a sample of 151 clients in a psychiatric outpatient clinic in Pakistan who had lost a first degree relative by different means of death. Somewhat counterintuitively, the cause of death (i.e., violence, drowning, accident, or health) was not found to predict traumatic distress symptoms. However, those bereaved by homicide showed higher levels of separation distress compared to those bereaved by accidents. The present study seeks to clarify these divergent findings by replicating and expanding upon past research with a large community sample of bereaved young adults who lost a range of relationships by a variety of different
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causes of death. In particular, this study will examine the following hypotheses: 1. Symptoms of separation and traumatic distress can be distinguished from one another using factor analytic procedures. 2. Losses by violent means (i.e., homicide, suicide, accident) will result in prolonged grief reactions mostly characterized by traumatic distress. Furthermore, cause of death is predicted to be linked less strongly to levels of separation distress. 3. The loss of primary attachment figures (i.e., immediate family members) will result in prolonged grief reactions primarily characterized by separation distress (compared to those who lost a friend or extended family member). However, relationship to the deceased is not anticipated to strongly predict traumatic distress symptoms.
Method Participants and Procedure Participants in this study were drawn from a larger data set of bereaved college students who, following institutional review, were recruited in their introductory psychology courses across four waves of data collection at the University of Memphis, a large state university serving an ethnically and economically diverse student body (see Currier et al. 2008, for a complete description of this larger sample). Each participant was at least 18 years of age and also reported the death of a friend or loved one within the past 2 years. For each wave, eligible participants completed a single-session questionnaire that included measures of grief symptoms as well as questions concerning their demographic characteristics (e.g., age, ethnicity, gender) and the circumstances surrounding their loss (e.g., regarding the cause of death and their relationship to the deceased). If participants experienced multiple losses, they were asked respond to the questions with regard to the loss that “had the greatest impact” on them. Some waves of the data collection used different measures and omitted others. Therefore, these analyses were restricted to only that subset of participants (n=1022) who completed the Inventory of Complicated GriefRevised (ICG-R; Prigerson and Jacobs 2001), which was used to create scores for separation distress and traumatic distress. Given the emphasis on relationship to the deceased and cause of death in this study, the analyses were further restricted to only those who clearly specified their relationship to the deceased and the cause of death of their loved
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one. Specifically, ambiguous responses (e.g., undetermined cause of death) or responses of “other” with no further elaboration were omitted. Thus, 947 bereaved individuals made up the sample for the present study. The current sample ranged in age from 18 to 53 years with a mean of 21.0 years (Median = 19.0, SD=4.9). Women made up 75.3% of the sample (n=713), and 24.7% were men (n=234). In addition, 56.5% of the participants were Caucasian (n = 535), 38.1% African American (n=361), 1.6% Asian American (n=15), and 3.8% were of another ethnicity (n=36), reflecting the undergraduate distribution of ethnicities at the urban research institution. The most commonly reported types of loss were those due to natural, anticipated causes (e.g., cancer), which made up 47.8% of the losses in the sample (n=453). Other losses in the sample were due to natural sudden causes (e.g., heart attack; 22.7%, n=215), fatal accident (18.4%, n=174), suicide (4.5%, n=43), and homicide (6.5%, n=62). Most participants had lost an extended family member (e.g., grandparent, uncle, cousin; 64.3%, n=609). However, a sizable number of participants reported losing a friend (27.9%, n=264) or an immediate family member (e.g., parent, sibling, child, spouse/partner; 7.8%, n=78).
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(Hogan et al. 2004; Neimeyer et al. 2006; Prigerson et al. 2002). Consistent with Prigerson and Jacobs’ (2001) suggested grouping of items, in the present study we summed items 2, 3, 5, 6, and 22 to create a measure of separation distress. Example separation distress items included, I feel myself longing and yearning for [the deceased] and I feel drawn to places and things associated with [the deceased]. Our measure of traumatic distress was created by summing items 4, 7, 8, 9, 11, 14, 17, 19, 21, 23, and 26; dividing by 11 (the number of items in the traumatic distress measure); and then multiplying by five (the number of items in the separation distress measure), in order to ensure that the two measures were on the same scale. The traumatic distress measure included items such as, I have lost my sense of security or safety since the death...and I feel like I have become numb since the death.... It should be noted that our measure of traumatic distress excluded item 13, I go out of my way to avoid reminders that [the deceased] is gone, as this study used a version of the ICG-R that did not include this item. In this study, our measures of separation distress and traumatic distress were internally consistent (α=.83 and α=.89, respectively) and were significantly correlated with one another (r=.75).
Measures of Separation and Traumatic Distress Plan of Analysis Measures of separation and traumatic distress were created with items from the ICG-R. This measure is composed of 30 declarative statements to which responses are made on a five-point Likert-type scale describing the frequency of symptoms (e.g., from 1 = never to 5 = always). A Dutch version of the ICG-R has displayed high internal consistency (α=.94), concurrent validity (r=.71) with scores from the Texas Revised Inventory of Grief (Faschingbauer 1981), and good test-retest reliability (r=.92) over a period ranging from 9 to 28 days (Boelen et al. 2003b). The ICG-R has also been shown to predict a range of serious long-term health and mental health consequences of bereavement, justifying its interpretation as a measure of PGD symptomatology (Ott 2003; Prigerson et al. 1997; Prigerson and Jacobs 2001). In addition, a recent study suggests that PGD symptoms (as measured by the ICG-R) are distributed along a continuum, highlighting the potential utility of studying a range of PGD symptomatology (Holland et al. 2009b). Although past research suggests that the ICG-R has a unidimensional structure (Boelen et al. 2003b), Prigerson and Jacobs (2001) have a drawn a distinction between symptoms of separation and traumatic distress and identified items on the ICG-R that tap into these two symptom clusters. Notably, past researchers have successfully used these groupings of items as separate measures to test hypotheses related to separation and traumatic distress
Confirmatory Factor Analysis As a preliminary step, we performed a confirmatory factor analysis to evaluate how well a 2-factor model of prolonged grief fit our data. In this analysis we tested a 1-factor solution and a 2-factor solution with the five separation distress ICG-R items loading on one factor and the 11 traumatic distress ICG-R items loading on the other. In evaluating these models, we relied upon a variety of fit indices, including the chi-square goodness-of-fit test, the comparative fit index (CFI; Bentler 1990), the standardized root mean square residual (SRMR), and the RMSEA (Browne and Cudeck 1993). The chisquare goodness-of-fit test assesses the discrepancy between the observed covariance matrix and the covariance matrix of the fitted model. With large samples, however, the null hypothesis of equivalence will be rejected for virtually any parsimonious model, and with a small sample model misfit may be undetected. Therefore, we relied primarily on the other fit indices. CFI values >.90 and SRMR values
