Maja O’Connor

Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis

BACKGROUND Prolonged grief disorder (PGD) is a bereavement-specific syndrome expected to be included in the forthcoming ICD-11. Defining the prevalence of PGD will have important nosological, clinical, and therapeutic implications. The present systematic review and meta-analysis aimed to estimate the prevalence rate of PGD in the adult bereaved population, identify possible moderators, and explore methodological quality of studies in this area. METHODS A systematic literature search was conducted in PubMed, PsycINFO, Embase, Web of Science, and CINAHL. Studies with non-psychiatric, adult populations exposed to non-violent bereavement were included and subjected to meta-analytic evaluation. RESULTS Fourteen eligible studies were identified. Meta-analysis revealed a pooled prevalence of PGD of 9.8% (95% CI 6.8-14.0). Moderation analyses showed higher mean age to be associated with higher prevalence of PGD. Study quality was characterized by low risk of internal validity bias but high risk of external validity bias. LIMITATIONS The available studies are methodologically heterogeneous. Among the limitations are that only half the studies used registry-based probability sampling methods (50.0%) and few studies analyzed non-responders (14.3%). CONCLUSIONS This first systematic review and meta-analysis of the prevalence of PGD suggests that one out of ten bereaved adults is at risk for PGD. To allocate economic and professional resources most effectively, this result underscores the importance of identifying and offer treatment to those bereaved individuals in greatest need. Due to heterogeneity and limited representativeness, the findings should be interpreted cautiously and additional high-quality epidemiological research using population-based designs is needed.

A confirmatory factor analysis of combined models of the Harvard Trauma Questionnaire and the Inventory of Complicated Grief-Revised: Are we measuring complicated grief or posttraumatic stress?

The aim of this study was to assess the factorial structure of complicated grief (CG) and investigate the relationship between CG and posttraumatic stress disorder (PTSD) through the assessment of models combining both constructs. The questionnaire was completed by elderly, married respondents with a history of at least one significant, interpersonal loss (145 males and 147 females, 60-81 years). Confirmatory factor analysis (CFA) supported a two-factor model of separation and traumatic distress in CG. To investigate the relationship between CG and PTSD three combined models were specified and estimated using CFA. A model where all five factors, the two factors of CG and the three factors of PTSD, as defined by the DSM-IV, were allowed to correlate provided the best fit. The results indicated a considerable overlap between the dimensions of CG and PTSD, and complicated grief is construct that appears to be largely accounted for by especially the intrusive component of PTSD.

Efficacy of Mindfulness-Based Cognitive Therapy on Late Post-Treatment Pain in Women Treated for Primary Breast Cancer: A Randomized Controlled Trial

PURPOSE To assess the efficacy of mindfulness-based cognitive therapy (MBCT) for late post-treatment pain in women treated for primary breast cancer. METHODS A randomized wait list-controlled trial was conducted with 129 women treated for breast cancer reporting post-treatment pain (score ≥ 3 on pain intensity or pain burden assessed with 10-point numeric rating scales). Participants were randomly assigned to a manualized 8-week MBCT program or a wait-list control group. Pain was the primary outcome and was assessed with the Short Form McGill Pain Questionnaire 2 (SF-MPQ-2), the Present Pain Intensity subscale (the McGill Pain Questionnaire), and perceived pain intensity and pain burden (numeric rating scales). Secondary outcomes were quality of life (World Health Organization-5 Well-Being Index), psychological distress (the Hospital Depression and Anxiety Scale), and self-reported use of pain medication. All outcome measures were assessed at baseline, postintervention, and 3-month and 6-month follow-up. Treatment effects were evaluated with mixed linear models. RESULTS Statistically significant time × group interactions were found for pain intensity (d = 0.61; P = .002), the Present Pain Intensity subscale (d = 0.26; P = .026), the SF-MPQ-2 neuropathic pain subscale (d = 0.24; P = .036), and SF-MPQ-2 total scores (d = 0.23; P = .036). Only pain intensity remained statistically significant after correction for multiple comparisons. Statistically significant effects were also observed for quality of life (d = 0.42; P = .028) and nonprescription pain medication use (d = 0.40; P = .038). None of the remaining outcomes reached statistical significance. CONCLUSION MBCT showed a statistically significant, robust, and durable effect on pain intensity, indicating that MBCT may be an efficacious pain rehabilitation strategy for women treated for breast cancer. In addition, the effect on neuropathic pain, a pain type reported by women treated for breast cancer, further suggests the potential of MBCT but should be considered preliminary.

A longitudinal study of PTSD in the elderly bereaved: Prevalence and predictors

Complicated grief reactions are relatively common following spousal bereavement. Old-age spousal loss qualifies as a possible traumatic stressor; however, posttraumatic stress disorder (PTSD) as a possible complication of the loss has rarely been explored in this population. This study aimed to investigate the frequency of PTSD in elderly bereaved people across the first 18 months of bereavement. Additionally, risk factors for the prediction of bereavement outcome in relation to four domains of the bereavement process were investigated. Data were collected via self-report questionnaires measuring traumatic stress (Harvard Trauma Questionnaire (HTQ)), coping style (Coping Style Questionnaire (CSQ)), crisis support (Crisis Support Scale (CSS)), and personality (e.g., NEO-five factor inventory (NEO-FFI)). Elderly bereaved people (N = 296, Mean = 73 years) participated at 2, 6, 13, and 18 months post loss. The comparison group consisted of married elderly people who had experienced at least one significant loss (N = 276, mean = 70 years). The frequency of PTSD within the spousal bereaved group was high (16%) compared to the comparison group (4%) and remained stable across time. Each individual domain included in the current analysis was a predictor of PTSD 18 months post loss. Most predictors remained stable across time. A hierarchical regression analysis of the four domains predicted 49% of the variance, indicating a considerable overlap between the domains. Only one predictor, early posttraumatic distress, remained significant. The results confirm that loss of a spouse in old age is traumatic for some and that the effects of the loss remain over the first 18 months post loss. The results therefore underline the importance of further investigation into PTSD in the elderly bereaved.

Assessing posttraumatic stress disorder's latent structure in elderly bereaved European trauma survivors: evidence for a five-factor dysphoric and anxious arousal model.

Abstract The three-factor structure of posttraumatic stress disorder (PTSD) specified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, is not supported in the empirical literature. Two alternative four-factor models have received a wealth of empirical support. However, a consensus regarding which is superior has not been reached. A recent five-factor model has been shown to provide superior fit over the existing four-factor models. The present study investigated the fit of the five-factor model against the existing four-factor models and assessed the resultant factors’ association with depression in a bereaved European trauma sample (N = 325). The participants were assessed for PTSD via the Harvard Trauma Questionnaire and depression via the Beck Depression Inventory. The five-factor model provided superior fit to the data compared with the existing four-factor models. In the dysphoric arousal model, depression was equally related to both dysphoric arousal and emotional numbing, whereas depression was more related to dysphoric arousal than to anxious arousal.

The self-efficacy in patient-centeredness questionnaire – a new measure of medical student and physician confidence in exhibiting patient-centered behaviors

BackgroundPatient-centered communication is a core competency in modern health care and associated with higher levels of patient satisfaction, improved patient health outcomes, and lower levels of burnout among physicians. The objective of the present study was to develop a questionnaire assessing medical student and physician self-efficacy in patient-centeredness (SEPCQ) and explore its psychometric properties.MethodsA preliminary 88-item questionnaire (SEPCQ-88) was developed based on a review of the literature and medical student portfolios and completed by 448 medical students from Aarhus University. Exploratory Principal Component analysis resulted in a 27-item version (SEPCQ-27) with three underlying self-efficacy factors: 1) Exploring the patient perspective, 2) Sharing information and power, and 3) Dealing with communicative challenges. The SEPCQ-27 was completed by an independent sample of 291 medical students from 2 medical schools and 101 hospital physicians.ResultsInternal consistencies of total and subscales were acceptable for both students and physicians (Cronbach’s alpha (range): 0.74–0.95). There were no overall indications of gender-related differential item function (DIF), and a Confirmatory Factor Analysis (CFA) indicated good fit (CFI = 0.98; NNFI = 0.98; RMSEA = 0.05; SRMR = 0.07). Responsiveness was indicated by increases in SEPCQ scores after a course in communication and peer-supervision (Cohen’s d (range): 0.21 to 0.73; p: 0.053 to 0.001). Furthermore, positive associations were found between increases in SEPCQ-scores and course-related motivation to learn (medical students) and between SEPCQ scores and years of clinical experience (physicians).ConclusionsThe final SEPCQ-27 showed satisfactory psychometric properties, and preliminary support was found for its construct validity, indicating that the SEPCQ-27 may be a valuable measure in future patient centered communication training and research.

PTSD in older bereaved people

Late life bereavement has been associated with psychological problems, mainly depression. A few studies indicated that posttraumatic stress disorder (PTSD) was an important issue in late life bereavement reactions. This study aimed to assess the prevalence of PTSD in recently bereaved older people compared with married controls and to investigate whether the loss of a spouse in old age, in contrast with earlier assumptions, could lead to PTSD. Two hundred and ninety-six Danish older bereaved people (mean age 73 years, 113 males) were chosen from national registers and assessed two months postbereavement. They were compared with a control group of 276 married older people. The prevalence of PTSD and depression were measured through a self-report questionnaire. Results showed that 16% of the bereaved and 4% of the control group had a PTSD diagnosis (ES = 0.35; Cohens d = 0.74). Additionally, 37% of the bereaved and 22% of the control group had mild to severe depression (ES = 0.19; Cohens d = 0.37). The results suggested that late life spousal bereavement result in PTSD with equal frequency to general samples of bereaved persons. Furthermore, the prevalence of PTSD in the first months after bereavement was more elevated than the level of depression. This makes PTSD an important factor when studying late life bereavement reactions.

The impact of different diagnostic criteria on PTSD prevalence

The diagnostic criteria for PTSD have undergone several changes in the last two decades. This may in part explain the great variance in PTSD prevalence found in existing research. The objective of this study is to investigate the influence of different diagnostic criteria and different combinations of criteria on PTSD prevalence. A sample of 242 Danish social work students (M =29.2 years) completed a list of potentially traumatizing events, major life events and the Harvard Trauma Questionnaire. A considerable difference in PTSD prevalence as a result of different diagnostic criteria of PTSD was found. Future meta-analyses and reviews of PTSD prevalence must take into account the impact of changing criteria on prevalence. Clinicians also need to address this issue when assessing PTSD.

Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer – explorative analyses from a randomized controlled trial

Abstract Background: Mindfulness-based intervention has been found efficacious in reducing persistent pain in women treated for breast cancer. Little, however, is known about possible moderators of the effect. We explored clinical and psychological moderators of the effect on pain intensity previously found in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) with women treated for breast cancer with persistent pain. Material and methods: A total of 129 women treated for breast cancer reporting persistent pain were randomized to MBCT or a wait-list control. The primary outcome of pain intensity (11-point numeric rating scale) was measured at baseline, post-intervention, three, and six months follow-up. Proposed clinical moderators included age, axillary lymph node dissection (ALND), radiotherapy, and endocrine treatment. Psychological moderators included psychological distress [the Hospital Anxiety and Depression Scale (HADS)], the adult attachment dimensions anxiety and avoidance [the Experiences in Close Relationships Short Form (the ECR-SF)], and alexithymia [the Toronto Alexithymia Scale (TAS-20)]. Multi-level models were used to test moderation effects over time, i.e. time × group × moderator. Results: Only attachment avoidance (p = 0.03, d = 0.36) emerged as a statistically significant moderator. Higher levels of attachment avoidance predicted a larger effect of MBCT in reducing pain intensity compared with lower levels attachment avoidance. None of the remaining psychological or clinical moderators reached statistical significance. However, based on the effect size, radiotherapy (p = 0.075, d = 0.49) was indicated as a possible clinical moderator of the effect, with radiotherapy being associated with a smaller effect of MBCT on pain intensity over time compared with no radiotherapy. Conclusion: Attachment avoidance, and potentially radiotherapy, may be clinically relevant factors for identifying the patients who may benefit most from MBCT as a pain intervention. Due to the exploratory nature of the analyses, the results should be considered preliminary.

Prolonged grief reactions after old age spousal loss and centrality of the loss in post loss identity

BACKGROUND The loss of a spouse is a major life event. Previous research found that centrality of the loss to ones identity using Centrality of Event Scale (CES) is related to complicated bereavement reactions, such as depression, posttraumatic stress symptoms (PTS), and prolonged grief symptoms (PGS). This study aims to examine loss-centrality in elderly bereaved people up to 4 years post loss, to determine the relation of loss-centrality to complicated bereavement reactions, such as PGS, depression, and PTS, and to identify early predictors of loss-centrality. METHOD Self-reported data were collected from 208 elderly bereaved people (mean age 72 years, 63.9% women), who completed measures of psychological distress (PTS, depression, PGS) as well as intra- and interpersonal factors (coping-style, crisis support, satisfaction with life, and NEO-PI-R) at 2, 6, and 48 months post spousal loss. CES was measured 48 months post spousal loss. RESULTS In line with previous findings (Boelen, 2012a), loss-centrality 4 years following the loss was significantly related to depression, PTS, and PGS. Additionally, early PGS and gender predicted later loss-centrality. LIMITATIONS Self-repport data was used rather than clinical interviews. CES was only measured 48 months post loss. PGS was first measured 6 months post. CONCLUSIONS The results support the link between loss-centrality and post loss psychopathology in a population particularly vulnerable to complicated bereavement reactions. The close link between prolonged grief and CES may be relevant in developing treatments for PGS, especially considering the potential relationship between high CES, high PGS, and possibly lack of acceptance of the loss.