An evolutionary approach to grief-related rumination: Construction and validation of the Bereavement Analytical Rumination Questionnaire

There has been little evolutionarily oriented empirical research on the intense, repetitive thoughts—ruminations—that often occur during grief. We used evolutionary theory to develop a new instrument for evaluating grief-related rumination titled the Bereavement Analytical Rumination Questionnaire (BARQ) operationalized by two dimensions: root cause analysis (RCA), the analysis of the cause of the loss; and reinvestment analysis (RIA), the analysis of how to reinvest time and effort in meaningful (presumably fitness enhancing) activities. We administered the BARQ to a sample of people seeking help for grief from non-profit organizations (619 completers) and tested several evolutionary predictions about grief-related rumination. The sample had several signs of severe grief, making it clinically relevant (sleep disturbances, chronicity, psychotropic drug use). Rumination was higher among antidepressant users, suggesting that rumination is related to depression. We also found evidence that grief-related rumination is modulated by circumstances (e.g., type of loss, age and gender of the participant, age of the deceased, traumatic death), which suggests adaptive regulation. Our most important results are consistent with inclusive fitness theory. Specifically, the pattern suggests that as people grow older, they spend less time ruminating about the causes of direct fitness losses (the loss of their own children), and they spend more time ruminating about the causes of indirect fitness losses (e.g., the loss of young non-parental, non-offspring relatives). We also found a sex or gender difference in grief-related rumination that is consistent with other evidence that women have a greater impact on the survival of close relatives (particularly, children and grandchildren), as well as evidence that women have more to lose with the loss of a close social partner. Overall, we found little support for the hypothesis that grief-related rumination is disordered.     

A randomized controlled effectiveness trial of cognitive behavior therapy for post-traumatic stress disorder in terrorist-affected people in Thailand

Although cognitive behaviour therapy (CBT) is the treatment of choice for post-traumatic stress disorder (PTSD), there is no evidence of its success with PTSD patients still under direct threat of terrorist attacks. This study reports the first randomized controlled trial of CBT for PTSD terrorist-affected people. Twenty-eight survivors of terrorist attacks in southern Thailand were randomized to 8 sessions of either CBT or treatment as usual (TAU). CBT was modified to accommodate the realistic threats facing patients. There were independent assessments conducted before, immediately after, and 3 months following treatment. Main outcome measures included symptoms of PTSD (PTSD Symptom Scale Interview), depression (Beck Depression Inventory) and complicated grief (Inventory of Complicated Grief). CBT resulted in significantly greater reduction in symptoms, including PTSD, depression, and complicated grief, at follow-up than TAU. Relative to TAU, CBT had stronger effect sizes at follow-up for PTSD, depression, and complicated grief. More patients in the CBT condition (75%) achieved high end-state functioning than participants in the TAU (33%). This preliminary evidence suggests that PTSD, depression, and complicated grief can be effectively treated despite ongoing threats of terrorism. Further, it demonstrates that non-specialist mental health workers in a non-western setting can be efficiently trained in using CBT, and this training can translate into successful treatment gains in trauma-affected individuals.     

Exploring the Grief Experience Among Callers to a Pet Loss Support Hotline

The present study explored the grief experience among callers to the Ontario Veterinary College Pet Loss Support Hotline (PLSH). Summary notes (n = 75) of the conversations between callers and PLSH volunteers were qualitatively analyzed using content analysis. Major content categories emerging from the analysis include personal pet narrative; perceived support sources; grief experiences; relationship with pet; memorialization; grief coping strategies; grief triggers; decision to euthanize; and veterinary interaction. Findings support that pet loss grief is a broad, complex construct, which can be complicated by a pet owner’s perceptions that they have minimal social support sources and negative veterinary interactions. Pet owners involved in the current study appeared comfortable sharing personal stories about their pet’s death when asked. In addition, memorialization appeared to be widely used by PLSH callers and may have helped them cope with their loss. Importantly, the interaction with veterinary staff was identified to potentially aggravate or alleviate a pet owner’s grief experience. Implications for mental health counselors and veterinary staff are that asking pet owners to tell their pet’s story and explore their support network may have value following the loss of a pet. Also, effectively communicating about memorialization and grief coping strategies may be beneficial when talking to owners experiencing grief. Finally, there continues to be a need for curricula and continuing professional training courses for veterinarians and mental health counselors to address topics such as the human–animal bond, grief, euthanasia, and memorialization practices.     

Pet Loss: Understanding Disenfranchised Grief,Memorial Use,and Posttraumatic Growth

The growing body of literature exploring pet loss suggests that many bereaved pet owners experience disenfranchised grief. Disenfranchised grief occurs when a loss is unacknowledged and the bereaved are unable to express their grief. When grief is considered illegitimate, the bereaved may experience a variety of adverse psychological outcomes, including increased distress and reduced quality of life. Additionally, when grief is inhibited, the individual may be less likely to experience positive changes such as posttraumatic growth. Few studies have considered the relationship between disenfranchisement and posttraumatic growth following the loss of a companion animal. This study investigated the relationship between disenfranchised grief, memorialization, and posttraumatic growth in bereaved pet owners. Grief severity was assessed as a moderator. Using an online survey, respondents (n?=?133) completed standardized measures, including the Pet Bereavement Questionnaire, the Loss of Social Support subscale from the Grief Experience Questionnaire, and the Posttraumatic Growth Inventory-Short Form (PTGI-SF). As hypothesized, there was a significant interaction between disenfranchised grief, grief severity, and posttraumatic growth, suggesting that disenfranchised grief inhibits posttraumatic growth when grief severity is high. Contrary to the hypothesis, there was no relationship between memorial quantity or type and posttraumatic growth. Overall, this study shows that disenfranchised grief can inhibit posttraumatic growth following the loss of a pet, highlighting the complicated relationship between posttraumatic growth, grief intensity, and disenfranchised grief.     

Pet Loss and Grief: Identifying At-risk Pet Owners during the Euthanasia Process

Pet owners often experience complex and profound grief reactions when their animals are euthanized. Veterinary staff are increasingly being called upon to be aware of and to respond to the grief reactions of pet owners at this critical time. The objectives of this study were to identify pet owners who are most at risk of grief and to suggest veterinary interventions during the euthanasia process. A convenience sample of 409 pet owners whose animals had been euthanized in the past year took part in a survey. Variables of interest included pet and pet-owner demographics, pet-death characteristics, attachment to pet, and bereavement reactions. Stepwise multiple regression analyses were conducted to identify factors related to the three grief reaction subtypes: sorrow, anger, and guilt. Results indicated that attachment to pets was a strong predictor of feelings of grief/sorrow (p < 0.001) and anger (p < 0.001). Sudden death was also related to feelings of anger (p < 0.05). Cancer diagnosis was negatively related to feelings of anger (p < 0.05) and guilt (p < 0.01). The findings from this study provide additional insight into the complexity of grief following pet euthanasia. For veterinary staff, anticipating the needs of pet owners and supporting them through the grief process is an integral role. Understanding which pet owners are at greatest risk of grief is an important initial step, followed by empathic communications, sensitive interactions, and the provision of grief support.     

“Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief”, are one and the same diagnostic entity: an analysis of data from the Yale Bereavement Study

There exists a general consensus that prolonged grief disorder (PGD), or some variant of PGD, represents a distinct mental disorder worthy of diagnosis and treatment. Nevertheless, confusion remains over whether different names and proposed symptom criteria for this disorder identify the same or different diagnostic entities. This study aimed to determine whether PGD, complicated grief (CG), and persistent complex bereavement disorder (PCBD) as described by the DSM‐5 are substantively or merely semantically different diagnostic entities. Data were derived from the Yale Bereavement Study, a longitudinal community‐based study of bereaved individuals funded by the US National Institute of Mental Health, designed explicitly to evaluate diagnostic criteria for disordered grief. The results suggested that the difference between PGD and PCBD is only semantic. The level of agreement between the original PGD test, a new version of the PGD test proposed for ICD‐11 and the PCBD test was high (pairwise kappa coefficients = 0.80‐0.84). Their estimates of rate of disorder in this community sample were similarly low (～10%). Their levels of diagnostic specificity were comparably high (95.0‐98.3%). Their predictive validity was comparable. In contrast, the test for CG had only moderate agreement with those for PGD and PCBD; its estimate of rate of disorder was three‐fold higher (～30%); its diagnostic specificity was poorer, and it had no predictive validity. We conclude that PGD, PCBD and proposed ICD‐11, but not CG, symptom‐diagnostic tests identify a single diagnostic entity. Ultimately, brief symptom‐diagnostic tests, such as the one proposed here for ICD‐11, may have the greatest clinical utility.     

Neuropsychological Outcome and Diffusion Tensor Imaging in Complicated versus Uncomplicated Mild Traumatic Brain Injury

This study examined whether intracranial neuroimaging abnormalities in those with mild traumatic brain injury (MTBI) (i.e., “complicated” MTBIs) are associated with worse subacute outcomes as measured by cognitive testing, symptom ratings, and/or diffusion tensor imaging (DTI). We hypothesized that (i) as a group, participants with complicated MTBIs would report greater symptoms and have worse neurocognitive outcomes than those with uncomplicated MTBI, and (ii) as a group, participants with complicated MTBIs would show more Diffusion Tensor Imaging (DTI) abnormalities. Participants were 62 adults with MTBIs (31 complicated and 31 uncomplicated) who completed neurocognitive testing, symptom ratings, and DTI on a 3T MRI scanner approximately 6-8 weeks post injury. There were no statistically significant differences between groups on symptom ratings or on a broad range of neuropsychological tests. When comparing the groups using tract-based spatial statistics for DTI, no significant difference was found for axial diffusivity or mean diffusivity. However, several brain regions demonstrated increased radial diffusivity (purported to measure myelin integrity), and decreased fractional anisotropy in the complicated group compared with the uncomplicated group. Finally, when we extended the DTI analysis, using a multivariate atlas based approach, to 32 orthopedic trauma controls (TC), the findings did not reveal significantly more areas of abnormal DTI signal in the complicated vs. uncomplicated groups, although both MTBI groups had a greater number of areas with increased radial diffusivity compared with the trauma controls. This study illustrates that macrostructural neuroimaging changes following MTBI are associated with measurable changes in DTI signal. Of note, however, the division of MTBI into complicated and uncomplicated subtypes did not predict worse clinical outcome at 6-8 weeks post injury.     

Psychiatry in the Soviet Union

The services for chronically handicapped people with psychiatric disorders in the Soviet Union are described. The system is based upon a network of community units, each of which includes a day centre, a follow-up clinic, and a sheltered workshop. British services could profitably learn from the experience of these units. The diagnostic system used by many Soviet psychiatrists is different from that incorporated in the International Classification of Diseases. In particular, the term “schizophrenia” is used to describe conditions which British psychiatrists would label in other ways.This clinical difference partly explains the different concept of “criminal responsibility,” but another large component of the difference is political rather than medical. There are also variations from British practice in certain juridical procedures. These differences together make Soviet psychiatric practice in the case of political dissenters unacceptable to most British psychiatrists. It is too soon to say that frank discussions of these matters could not lead to improvement. British and Soviet psychiatrists still have something to learn from each other.     

Lactic Acidosis in Diabetes

Lactic acidosis is occasionally responsible for metabolic acidosis in diabetics. It may occur in the presence of normal blood levels of the ketone bodies, and such cases are often described as having “non-ketotic diabetic acidosis.” Lactic acid may contribute to the metabolic acidosis in patients with true diabetic ketoacidosis, but the blood lactate concentrations in these patients are not usually very high. In some patients the ketoacidosis is replaced by a lactic acidosis during treatment. This usually occurs in association with a serious underlying disorder and is associated with a poor prognosis. A transient increase in blood lactate concentration was in fact observed in most patients after the beginning of treatment, but the significance of this finding is uncertain.     

Development of the Pet Bereavement Questionnaire

Abstract

The death of a pet can be a significant stressor for some people and is a known risk factor for depression. The Pet Bereavement Questionnaire (PBQ) was developed to fill the need for a brief, acceptable, well-validated instrument for use in studies of the psychological impact of losing a pet. Initial results suggest that the PBQ has good internal reliability (Cronbach's α = 0.87), as well as good construct validity, with three distinct factors reflecting grief, anger and guilt. Grief was found to correlate strongly with pet attachment. The anger and guilt scales, however, correlated with depressive symptoms. The PBQ discriminated between individuals seeking support after pet loss (who would be expected to show higher levels of bereavement) and those who simply acknowledge the recent loss of a pet. We suggest that future research into pet bereavement use this new questionnaire so that the results of different studies can be compared, normative scores can be developed and researchers in this area can use a single instrument with established construct validity. In particular, we hope the PBQ will be used in treatment outcome research to identify high-risk individuals and test the effectiveness of both existing and novel interventions. Moreover, the PBQ could also be used in clinical settings, such as tertiary care veterinary hospitals, to identify pet owners in need of clinical support services.     

Texas-Revised Inventory of Grief: Validierung der deutschen Version TRIG-D

The loss of a loved person has often yearlong consequences for the bereaved. The Texas-Revised Inventory of Grief was developed by Faschingbauer and coworkers to measure the grief-specific distress. Up to now, no German translation of this instrument existed. An adapted German version of the TRIG is presented and results of a validation study with parents who lost a child are reported. The TRIG-D shows good internal consistency (Cronbach’s a =.87) Correlations of grief-intensity of the TRIG-D with stress-related symptoms and depression were high. These predictors explained 55% of the total variance of grief intensity. The TRIG-D measures reliably the intensity of grief related distress; however, there exist no cut-off-values for complicated grief.     

Diagnosis and Treatment of Delirium

Delirium is not a clinical entity but a symptom-complex of manifold etiology. Its presence signifies acute cerebral insufficiency and often represents a medical and/or psychiatric emergency.Though some forms of delirium have distinctive features, the fundamental phenomena are common to all, with clouding of consciousness the sine qua non. The condition has two major components: (1) the basic “acute brain syndrome” and (2) associated release phenomena.Clinicians must first make the vital differentiation between delirium and “functional” mental disorder, then proceed with the elucidation of the underlying diagnosis and the concurrent organization of symptomatic and etiologic treatment.Proper treatment combines management of the acute brain syndrome with general and specific procedures for control of the underlying condition. Dealing with the symptom-complex itself involves the principles and practice of sedation, hydration, and nutrition, nursing care and supportive measures. Provided the basic organic condition is treatable, the prognosis today is usually good.     

Diagnostic Criteria for Depression in Type 2 Diabetes: A Data-Driven Approach

BackgroundWhile depression is a frequent psychiatric comorbid condition in diabetes and has significant clinical impact, the syndromal profile of depression and anxiety symptoms has not been examined in detail.AimsTo determine the syndromal pattern of the depression and anxiety spectrum in a large series of patients with type 2 diabetes, as determined using a data-driven approach based on latent class analysis (LCA).MethodType 2 diabetes participants from the observational community-based Fremantle Diabetes Study Phase II underwent assessment of lifetime depression using the Brief Lifetime Depression Scale, the Patient Health Questionnaire 9-item version (PHQ-9) for current depression symptoms, and the Generalized Anxiety Disorder Scale that was specifically developed and validated for this study. The main outcome measure was classes of patients with a specific syndromal profile of depression and anxiety symptoms based on LCA.ResultsLCA identified four classes that were interpreted as “major anxious depression”, “minor anxious depression”, “subclinical anxiety”, and “no anxious depression”. All nine DSM-IV/5 diagnostic criteria for major depression identified a class with a high frequency of major depression. All symptoms of anxiety had similar high probabilities as symptoms of depression for the “major depression-anxiety” class. There were significant differences between classes in terms of history of depression and anxiety, use of psychoactive medication, and diabetes-related variables.ConclusionsPatients with type 2 diabetes show specific profiles of depression and anxiety. Anxiety symptoms are an integral part of major depression in type 2 diabetes. The different classes identified here provide empirically validated phenotypes for future research.     

Ketamine Decreases Resting State Functional Network Connectivity in Healthy Subjects: Implications for Antidepressant Drug Action

Increasing preclinical and clinical evidence underscores the strong and rapid antidepressant properties of the glutamate-modulating NMDA receptor antagonist ketamine. Targeting the glutamatergic system might thus provide a novel molecular strategy for antidepressant treatment. Since glutamate is the most abundant and major excitatory neurotransmitter in the brain, pathophysiological changes in glutamatergic signaling are likely to affect neurobehavioral plasticity, information processing and large-scale changes in functional brain connectivity underlying certain symptoms of major depressive disorder. Using resting state functional magnetic resonance imaging (rsfMRI), the „dorsal nexus “(DN) was recently identified as a bilateral dorsal medial prefrontal cortex region showing dramatically increased depression-associated functional connectivity with large portions of a cognitive control network (CCN), the default mode network (DMN), and a rostral affective network (AN). Hence, Sheline and colleagues (2010) proposed that reducing increased connectivity of the DN might play a critical role in reducing depression symptomatology and thus represent a potential therapy target for affective disorders. Here, using a randomized, placebo-controlled, double-blind, crossover rsfMRI challenge in healthy subjects we demonstrate that ketamine decreases functional connectivity of the DMN to the DN and to the pregenual anterior cingulate (PACC) and medioprefrontal cortex (MPFC) via its representative hub, the posterior cingulate cortex (PCC). These findings in healthy subjects may serve as a model to elucidate potential biomechanisms that are addressed by successful treatment of major depression. This notion is further supported by the temporal overlap of our observation of subacute functional network modulation after 24 hours with the peak of efficacy following an intravenous ketamine administration in treatment-resistant depression.     

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD‐11

The diagnostic concepts of post‐traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro‐ and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD‐11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non‐specific symptoms; a new complex PTSD category that comprises three clusters of intra‐ and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of “adjustment disorder” involving increased specification of symptoms; and a conceptualization of “acute stress reaction” as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low‐ and high‐income countries.     

Design and Implementation of an fMRI Study Examining Thought Suppression in Young Women with,and At-risk,for Depression

Ruminative brooding is associated with increased vulnerability to major depression. Individuals who regularly ruminate will often try to reduce the frequency of their negative thoughts by actively suppressing them. We aim to identify the neural correlates underlying thought suppression in at-risk and depressed individuals. Three groups of women were studied; a major depressive disorder group, an at-risk group (having a first degree relative with depression) and controls. Participants performed a mixed block-event fMRI paradigm involving thought suppression, free thought and motor control periods. Participants identified the re-emergence of “to-be-suppressed” thoughts (“popping” back into conscious awareness) with a button press. During thought suppression the control group showed the greatest activation of the dorsolateral prefrontal cortex, followed by the at-risk, then depressed group. During the re-emergence of intrusive thoughts compared to successful re-suppression of those thoughts, the control group showed the greatest activation of the anterior cingulate cortices, followed by the at-risk, then depressed group. At-risk participants displayed anomalies in the neural regulation of thought suppression resembling the dysregulation found in depressed individuals. The predictive value of these changes in the onset of depression remains to be determined.     

State and Trait Olfactory Markers of Major Depression

Nowadays, depression is a major issue in public health. Because of the partial overlap between the brain structures involved in depression, olfaction and emotion, the study of olfactory function could be a relevant way to find specific cognitive markers of depression. This study aims at determining whether the olfactory impairments are state or trait markers of major depressive episode (MDE) through the study of the olfactory parameters involving the central olfactory pathway. In a pilot study, we evaluated prospectively 18 depressed patients during acute episodes of depression and 6 weeks after antidepressant treatment (escitalopram) against 54 healthy volunteers, matched by age, gender and smoking status. We investigated the participants’ abilities to identify odors (single odors and in binary mixture), to evaluate and discriminate the odors’ intensity, and determine the hedonic valence of odors. The results revealed an “olfactory anhedonia” expressed by decrease of hedonic score for high emotional odorant as potential state marker of MDE. Moreover, these patients experienced an “olfactory negative alliesthesia”, during the odor intensity evaluation, and failed to identify correctly two odorants with opposite valences in a binary iso-mixture, which constitute potential trait markers of the disease. This study provides preliminary evidence for olfactory impairments associated with MDE (state marker) that are persistent after the clinical improvement of depressive symptoms (trait marker). These results could be explained by the chronicity of depression and/or by the impact of therapeutic means used (antidepressant treatment). They need to be confirmed particularly the ones obtained in complex olfactory environment which corresponds a more objective daily life situation.     

Is Rumination after Bereavement Linked with Loss Avoidance? Evidence from Eye-Tracking

Rumination is a risk factor in adjustment to bereavement. It is associated with and predicts psychopathology after loss. Yet, the function of rumination in bereavement remains unclear. In the past, researchers often assumed rumination to be a maladaptive confrontation process. However, based on cognitive avoidance theories of worry in generalised anxiety disorder (GAD) and rumination after post-traumatic stress disorder (PTSD), others have suggested that rumination may serve to avoid painful aspects of the loss, thereby contributing to complicated grief. To examine if rumination is linked with loss avoidance, an eye-tracking study was conducted with 54 bereaved individuals (27 high and 27 low ruminators). On 24 trials, participants looked for 10 seconds at a picture of the deceased and a picture of a stranger, randomly combined with negative, neutral or loss-related words. High ruminators were expected to show initial vigilance followed by subsequent disengagement for loss stimuli (i.e., picture deceased with a loss word) in the first 1500 ms. Additionally, we expected high ruminators to avoid these loss stimuli and to show attentional preference for non-loss-related negative stimuli (i.e., picture stranger with a negative word) on longer exposure durations (1500–10000 ms). Contrary to expectations, we found no evidence for an effect of rumination on vigilance and disengagement of loss stimuli in the first 1500 ms. However, in the 1500–10000 ms interval, high ruminators showed shorter gaze times for loss stimuli and longer gaze times for negative (and neutral) non-loss-related stimuli, even when controlling for depression and complicated grief symptom levels. Effects of rumination on average fixation times mirrored these findings. This suggests that rumination and loss avoidance are closely associated. A potential clinical implication is that rumination and grief complications after bereavement may be reduced through the use of exposure and acceptance-based therapeutic techniques.