اضطراب جدایی بزرگسالان، بیماران مبتلا به غم و اندوه پیچیده و / یا افسردگی اساسی را متمایز می کند و مربوط به علائم طیفی خلق و خوی طول عمر است

Background Increasing literature has been focused on complicated grief (CG) and its distinctiveness from other potentially loss related mental disorders such as major depression (MD). In this regard, symptoms of separation distress seem to play a key role. The aim of this study was to compare the clinical features of CG to those of MD and of CG + MD, with particular attention to separation anxiety. Methods Fifty patients with CG (26 with and 24 without MD) and 40 with MD were consecutively recruited. Assessments included: SCID-I/P, Inventory of Complicated Grief (ICG), Adult Separation Anxiety Symptom Questionnaire (ASA-27), Work and Social Adjustment Scale (WSAS), Mood Spectrum-Self Report (MOODS-SR)-lifetime version. Results Patients with MD reported significantly higher ASA-27 scores than patients with CG either alone or with MD. In all groups, ASA-27 total scores were significantly correlated with the MOODS-SR total scores and with those of its depressive component and rhythmicity domain. No significant differences were reported in the WSAS scores. Limitations Major limitations are the small sample size and the use of lifetime instruments. Conclusions Our results suggest a correlation between adult separation anxiety symptoms and lifetime mood spectrum symptoms both in patients with CG and MD. Further studies are needed to better understand the role of adult separation anxiety in the development of these disorders and for their nosographic autonomy as well.

Increasing literature has been focused on bereavement related conditions with particular attention to a new, unique syndrome variously referred to as “complicated grief”, “prolonged grief disorder” or “traumatic grief”. In the recently released DSM-5 [1], this syndrome has been classified in Section III (Conditions Requiring Further Research) as “Persistent Complex Bereavement-Related Disorder”. However, we will use “complicated grief” (CG) in this paper because this definition is more widely used in the existing literature. CG is characterized by a specific onset after the loss of a significant other and includes dysfunctional thoughts, feelings or behaviors that are related to the loss that complicate the grief process, including disbelief and preoccupation with the deceased, intense yearning and searching, distressing memories and difficulties moving on [2], [3], [4] and [5]. CG is typically associated with significant distress, impairment and a heightened risk of suicide beyond concomitant depression and anxiety [2], [6], [7], [8], [9], [10], [11] and [12]. Despite consistent evidence in support of a unique syndrome of CG as an independent diagnosis, the lack of consensus regarding the best diagnostic criteria led to the inclusion of CG among disorders requiring further study in DSM-5. In order to acknowledge CG as a distinct syndrome, several studies have examined the distinctiveness from its “nearest neighbors” that can also occur in the wake of a loss, in particular major depression (MD) and post-traumatic stress disorder (PTSD) [7], [13], [14], [15], [16], [17], [18], [19], [20] and [21]. Severe grief increases the risk of major depressive episodes [22] and there is evidence that CG frequently co-occurs with mood disorders [23]. Rates of MD comorbidity ranging from 52 to 70% have been reported in CG patients [24] and [25]. Conversely, two recent studies found high prevalence of CG (respectively 18.6% and 25%) in bereaved patients with depression [23] and [26]. Similarly, CG comorbidity has been detected in about 24% of patients with a diagnosis of bipolar disorder facing a loss [25] and [27]. These observations suggested the potential usefulness of exploring the relationships between lifetime mood symptomatology and CG [28]. Studies investigating the differential clinical correlates of CG and MD highlighted the former to be characterized by prominent symptoms of separation distress (e.g., preoccupation with thoughts and images of the deceased, yearning and searching behaviors, excessive loneliness and frequent intense pangs of grief and sadness) with respect to the latter [8], [29], [30] and [31]. Recently, insecure attachment styles have also been suggested as potential risk factors for CG [32], [33] and [34]. Previous work showed an association between insecure attachment style and elevated traumatic grief symptoms but not depression in bereaved spouses [35]. If so, separation anxiety may be uniquely associated with CG, however there are little data to examine this possibility [28], [36] and [37]. The purpose of the current study was to explore the distinctiveness vs. overlap between CG and MD in terms of clinical correlates. In particular, our aim was to compare patients with CG with those with MD and CG + MD paying attention to symptoms of adult separation anxiety and lifetime mood spectrum comorbidity.

Patients with CG, either alone or with MD, and with MD were mostly females. Details on the demographic characteristics of the study sample are reported in Table 1. Table 1. Demographic characteristics of the study samples. MDD N = 40 CG + MDD N = 26 CG − MDD N = 24 F p Mean ± S.D. Mean ± S.D. Mean ± S.D. Agea 51.30 ± 16.38 51.69 ± 14.35 47.08 ± 14.75 1,01 n.s. N (%) N (%) N (%) ch p Female 30 (75%) 20 (76.9) 23 (95.8) 4.76 ns Marital status Single 16 (40.0) 4 (15.4) 8 (33.3) Married/living with partner 11 (27.5) 13 (46.1) 11 (45.9) Widows-ers 8 (20.0) 8 (30.8) 5 (20.8) Separated/divorced 5 (12.5) 2 (7.7) 0 (0) 9.09 ns Educational level University 0 (0) 13 (50) 12 (50.0) 38.01 0.0001 High school 20 (50) 10 (38.5) 12 (50.0) < 8 years of education 20 (50) 3 (11.5) 0 (0) Employed full/part time 24 (60) 15 (57.7) 14 (58.3) 0.30 ns a Post-hoc Scheffè. Table options Table 2 shows the clinical characteristics of the study sample. As expected CG patients reported significantly higher ICG total scores than patients with MD alone. These latter reported significantly higher scores (p < 0.001) on the ASA-27 with respect to patients with CG, both with and without MD. Moreover, a significantly (p = 0.009) higher proportion of patients with MD alone scored above the ASA-27 cut-off than patients with CG either alone or with MD. Table 2. Clinical characteristics of the study samples. MDD N = 40 CG + MDD N = 26 CG − MDD N = 24 f p Mean ± S.D. Mean ± S.D. Mean ± S.D. ICG total scorea 20.7 ± 16.7 37.1 ± 10.0 41.0 ± 10.5 19.14 0.000 ASA_27b 53.6 ± 15.1 26.1 ± 13.9 27.2 ± 16.7 32.95 0.000 MOODS-SR Depressive component 35.5 ± 13.3 29.3 ± 13.2 29.6 ± 12.2 2.42 n.s. Manic component 20.8 ± 12.5 15.7 ± 9.2 15.7 ± 10.3 2.33 n.s. Rhythmicity 12.6 ± 6.2 13.3 ± 5.0 11.5 ± 5.6 .655 n.s. WSAS 23.1 ± 10.2 17.0 ± 10.6 17.9 ± 10.0 2.87 n.s. N (%) N (%) N (%) χ2 p ASA_27 ≥ 22 36 (90.0) 17 (65.4) 14 (58.3) 9.48 0.009 Post-hoc Scheffè. a CG + MDD, CG − MDD > MDD. b MDD > CG + MDD, CG − MDD. Table options Significant positive correlations emerged between the ASA-27 total score and the ICG total score (r = 0.418, p = 0.003), and the MOODS-SR total score (r = 0.445, p = 0.001). Significant correlations were also found between the ASA-27 total score and the depressive component (r = 0.436, p = 0.002) and the rhythmicity domain (r = 0.361, p = 0.010) of the MOODS-SR.