Bereavement is one of the most distressing life-events and the loss of a loved one has been associated with significant morbidity and mortality (Schaefer et al., 1995, Schultz et al., 2001, Li et al., 2003 and Stroebe et al., 2007) and with mood and anxiety disorders (Bruce et al., 1990, Onrust and Cuijpers, 2006, Kristensen et al., 2009 and Dell'Osso et al., 2011a). There is considerable evidence that a minority of bereaved individuals experience symptoms of complicated grief (CG) that are associated with significant distress and impairment (Horowitz et al., 1997, Shear et al., 2007, Boelen and van den Bout, 2008, Prigerson et al., 2009 and Dell'Osso et al., 2011b).
CG is currently under consideration for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), and the Internal Statistical Classification of Diseases and Related Health Problems, eleventh revision (ICD-11). One issue related to inclusion in DSM-V is whether or not CG can be differentiated from its “nearest neighbours”, in this case major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) (Prigerson et al., 1995a, Lichtenthal et al., 2004, Boelen et al., 2010 and Shear et al., 2011). CG frequently co-occurs with MDD, with rates of MDD comorbidity ranging from 52 to 70% (Melhem et al., 2001 and Simon et al., 2007). High rates (24%) of CG comorbidity have also been found in individuals with bipolar disorder (Simon et al., 2005 and Simon et al., 2007) with the presence of CG associated with additional psychiatric comorbidity, greater bipolar disorder severity and functional impairment, and lifetime suicide attempts. These observations could raise the question of the nosologic independence between CG and mood disorders. In this respect the study of the relationships between lifetime mood symptomatology and CG may provide useful information.
CG is characterized by continued severe separation distress and by dysfunctional thoughts, feelings or behaviours that are related to the loss that complicate the grief process (Prigerson et al., 2009, Zisook and Shear, 2009 and Shear et al., 2011). In particular, CG differs from MDD and PTSD in having prominent symptoms of separation distress (e.g., preoccupation with thoughts and images of the deceased, yearning and searching behaviours, excessive loneliness and frequent intense pangs of grief and sadness) (Shear and Shair, 2005 and Shear et al., 2007). Other complicating features include feelings of disbelief, ruminating about circumstances or consequences of the loss, intense physical or emotional reactivity to reminders, intrusive images, avoidance behaviour and loss of sense of security and trust, anger or bitterness, social estrangement, feeling lost and unfocused. Although the latter resemble some of the symptoms of PTSD, the separation distress component is unique. In more recent conceptualizations of CG, the original distinction suggested between symptoms of separation and traumatic distress is no longer made and increasing effort has been devoted to identifying the core symptoms of CG loaded into a single construct (Prigerson et al., 2009, Zisook et al., 2010 and Shear et al., 2011).
Traumatized individuals are typically anxious about the threat related to the traumatic event; whereas individuals with CG experience separation anxiety and the hallmark of CG is sadness and yearning (Lichtenthal et al., 2004, Prigerson et al., 2009 and Shear et al., 2011). Recent studies have suggested that the vulnerability to CG may be rooted in insecure attachment styles developed in childhood (Vanderwerker et al., 2006), while previous work showed an association between insecure attachment styles and elevated traumatic grief symptoms but not depression in bereaved spouses (Van Doorn et al., 1998). Adult separation anxiety and CG are phenomenologically alike and therefore it is relevant to examine their distinctiveness. Assuming the perspective of insecure attachment (as a trait) to be a vulnerability factor, adult separation anxiety and CG might be different aspects of the same psycho(patho)logical dimension. In a previous study, we first reported significantly higher adult separation anxiety symptoms in patients with CG with respect to healthy control subjects (Dell'Osso et al., 2011c).
The purpose of the current study is to explore the distinctiveness vs. overlap between CG and PTSD in terms of clinical correlates. In particular, our aim is to compare patients with CG with those with PTSD and CG + PTSD paying attention to symptoms of adult separation anxiety and lifetime mood spectrum comorbidity.
