Anthony D. Mancini

Complicated grief and related bereavement issues for DSM‐5

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over‐and under‐diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over‐diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders. Depression and Anxiety, 2011.

Resilience to loss and potential trauma.

Initial research on loss and potentially traumatic events (PTEs) has been dominated by either a psychopathological approach emphasizing individual dysfunction or an event approach emphasizing average differences between exposed and nonexposed groups. We consider the limitations of these approaches and review more recent research that has focused on the heterogeneity of outcomes following aversive events. Using both traditional analytic tools and sophisticated latent trajectory modeling, this research has identified a set of prototypical outcome patterns. Typically, the most common outcome following PTEs is a stable trajectory of healthy functioning or resilience. We review research showing that resilience is not the result of a few dominant factors, but rather that there are multiple independent predictors of resilient outcomes. Finally, we critically evaluate the question of whether resilience-building interventions can actually make people more resilient, and we close with suggestions for future research on resilience.

The Human Capacity to Thrive in the Face of Potential Trauma

For decades, researchers have documented remarkable levels of resilience in children who were exposed to corrosive early environments, such as those in which poverty or chronic maltreatment were present; however, relatively little research has examined resilience in children or adults who were exposed to isolated and potentially traumatic events. The historical emphasis on psychological and physiologic dysfunction after potentially traumatic events has suggested that such events almost always produce lasting emotional damage. Recent research, however, has consistently shown that across different types of potentially traumatic events, including bereavement, serious illness, and terrorist attack, upward of 50% of people have been found to display resilience. Research has further identified substantial individual variation in response to potentially traumatic events, including 4 prototypical and empirically derived outcome trajectories: chronic dysfunction, recovery, resilience, and delayed reactions. Factors that promote resilience are heterogeneous and include a variety of person-centered variables (eg, temperament of the child, personality, coping strategies), demographic variables (eg, male gender, older age, greater education), and sociocontextual factors (eg, supportive relations, community resources). It is surprising that some factors that promote resilience to potentially traumatic events may be maladaptive in other contexts, whereas other factors are more broadly adaptive. Given the growing evidence that resilience is common, psychotherapeutic treatment should be reserved for those in genuine need.

Is There More to Complicated Grief Than Depression and Posttraumatic Stress Disorder? A Test of Incremental Validity

There is growing interest in complicated grief reactions as a possible new diagnostic category for inclusion in the Diagnostic and Statistical Manual of Mental Disorders. However, no research has yet shown that complicated grief has incremental validity (i.e., predicts unique variance in functioning). The authors addressed this issue in 2 studies by comparing grief, depression, and posttraumatic stress disorder (PTSD) symptoms with different measures of functioning (interviewer ratings, friend ratings, self-report, and autonomic arousal). The 1st study (N = 73) used longitudinal data collected at 4 and 18 months postloss, and the 2nd study (N = 447) used cross-sectional data collected 2.5-3.5 years postloss. With depression and PTSD controlled, grief emerged as a unique predictor of functioning, both cross-sectionally and prospectively. The findings provide convergent support for the incremental validity of complicated grief as an independent marker of bereavement-related psychopathology.

Psychopathology and Resilience Following Traumatic Injury: A Latent Growth Mixture Model Analysis

OBJECTIVE To investigate trajectories of PTSD and depression following traumatic injury using latent class growth curve modeling. METHOD A longitudinal study of 330 injured trauma survivors was conducted and participants were assessed during hospitalization, and at 1, 3, and 6 months follow-up. Acute Stress Disorder (ASD) was assessed during hospitalization using the Acute Stress Disorder Interview (ASD-I), PTSD was measured at all follow-up with the Post-Traumatic Stress Diagnostic Scale (PDS) and depression was measured at hospitalization with the (BSI) and at follow-up with the Center for Epidemiologic Studies Depression Scale (CESDS). Covariates were explored, including coping self-efficacy, anger, education level, and mechanism of injury. RESULTS Four latent classes were identified for PTSD and Depression symptoms: chronic distress, delayed distress, recovered, and resilience. When compared to the resilient group, individuals with chronic distress were more likely to have been assaulted, had higher levels of anger, and had less coping self-efficacy. The delayed distress group had lower education levels, higher levels of coping self-efficacy, and higher levels of anger. Individuals in the recovered group had fewer years of education, and higher levels of anger. CONCLUSION The majority of the injured trauma sample demonstrated resiliency, with those exhibiting distress doing so as a delayed, chronic, or recovered trajectory. Coping self efficacy, education, assaultive trauma type, and anger were important covariates of depression and PTSD trajectories. These results are similar to studies of individuals who experienced a major health threat and with survivors from the World Trade Center attacks in the U.S.

Trajectories of trauma symptoms and resilience in deployed US military service members: prospective cohort study

BACKGROUND Most previous attempts to determine the psychological cost of military deployment have been limited by reliance on convenience samples, lack of pre-deployment data or confidentiality and cross-sectional designs. AIMS This study addressed these limitations using a population-based, prospective cohort of U.S. military personnel deployed in support of the operations in Iraq and Afghanistan. METHOD The sample consisted of U.S. military service members in all branches including active duty, reserve and national guard who deployed once (n = 3393) or multiple times (n = 4394). Self-reported symptoms of post-traumatic stress were obtained prior to deployment and at two follow-ups spaced 3 years apart. Data were examined for longitudinal trajectories using latent growth mixture modelling. RESULTS Each analysis revealed remarkably similar post-traumatic stress trajectories across time. The most common pattern was low-stable post-traumatic stress or resilience (83.1% single deployers, 84.9% multiple deployers), moderate-improving (8.0%, 8.5%), then worsening-chronic post-traumatic stress (6.7%, 4.5%), high-stable (2.2% single deployers only) and high-improving (2.2% multiple deployers only). Covariates associated with each trajectory were identified. CONCLUSIONS The final models exhibited similar types of trajectories for single and multiple deployers; most notably, the stable trajectory of low post-traumatic stress preto post-deployment, or resilience, was exceptionally high. Several factors predicting trajectories were identified, which we hope will assist in future research aimed at decreasing the risk of post-traumatic stress disorder among deployers.

Trajectories of psychological distress among Chinese women diagnosed with breast cancer.

Background: The distinct trajectories of psychological distress over the first year of the diagnosis with breast cancer (BC) and its determinants have not been explored.

Predictors and Parameters of Resilience to Loss: Toward an Individual Differences Model

Although there is marked variation in how people cope with interpersonal loss, there is growing recognition that most people manage this extremely stressful experience with minimal to no impact on their daily functioning (G. A. Bonanno, 2004). What gives rise to this resilient capacity? In this paper, we provide an operational definition of resilience as a specific trajectory of psychological outcome and describe how the resilient trajectory differs from other trajectories of response to loss. We review recent data on individual differences in resilience to loss, including self-enhancing biases, repressive coping, a priori beliefs, identity continuity and complexity, dismissive attachment, positive emotions, and comfort from positive memories. We integrate these individual differences in a hypothesized model of resilience, focusing on their role in appraisal processes and the use of social resources. We conclude by considering potential cultural constraints on resilience and future research directions.

The limits of resilience: Distress following chronic political violence among Palestinians

We examined posttraumatic stress disorder (PTSD) and depression symptom trajectories during ongoing exposure to political violence, seeking to identify psychologically resilient individuals and the factors that predict resilience. Face-to-face interviews were conducted with a random sample of 1196 Palestinian adult residents of the West Bank, Gaza, and East Jerusalem across three occasions, six months apart (September 2007-November 2008). Latent growth mixture modeling identified PTSD, and depression symptom trajectories. Results identified three PTSD trajectories: moderate-improving (73% moderate symptoms at baseline, improving over time), severe-chronic (23.2% severe and elevated symptoms over the entire year); and severe-improving (3.5% severe symptoms at baseline and marked improvement over time). Depression trajectories were moderate-improving (61.5%); severe-chronic (24.4%); severe-improving (14.4%). Predictors of relatively less severe initial symptom severity, and improvement over time for PTSD were less political violence exposure and less resource loss; and for depression were younger age, less political violence exposure, lower resource loss, and greater social support. Loss of psychosocial and material resources was associated with the level of distress experienced by participants at each time period, suggesting that resource-based interventions that target personal, social, and financial resources could benefit people exposed to chronic trauma.

Assertive community treatment: facilitators and barriers to implementation in routine mental health settings.

OBJECTIVE This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. METHODS As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. RESULTS Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. CONCLUSIONS State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures.