عملکرد شناختی در سوگ و داغداری پیچیده

Abstract Complicated grief (CG) is increasingly recognized as a debilitating outcome of bereavement. Given the intensity of the stressor, its chronicity, and its association with depression, it is important to know the impact CG may have on cognitive functioning. This exploratory and descriptive study examined global and domain-specific cognitive functioning in a help-seeking sample of individuals with CG (n = 335) compared to a separately ascertained control sample (n = 250). Cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA). Controlling for age, sex and education effects, CG participants had lower total MoCA, visuospatial and attention scores relative to control participants. The two groups did not differ significantly in the domains of executive function, language, memory or orientation. Age, sex, and education accounted for much of the variance in MoCA scores, while CG severity and chronicity accounted for a very small percentage of MoCA score variance. Major depression was not a significant predictor of MoCA scores. This study is consistent with previous work demonstrating lower attention and global cognitive performance in individuals with CG compared to control participants. This study newly identifies the visuospatial domain as a target for future studies investigating cognitive functioning in CG.

Introduction Bereavement and the experience of grief are among life's most stressful events (Holmes and Rahe, 1967). Despite this stress, most individuals come to accept the finality of the death, its consequences, redefine their life goals and adjust to life without their loved one (Shear and Shair, 2005). However, for some, the acute grief process is stalled, leading to prolonged or complicated grief (CG). Symptoms of CG include intense sorrow, guilt, deep yearning for the deceased; preoccupation for the loved one or events surrounding the death; avoidance of reminders of the loss; bitterness, and difficulty trusting or caring for others (American Psychiatric Association, 2013 and Shear et al., 2011). Much evidence suggests that CG is a disorder distinct from conditions with overlapping symptomatology such as post traumatic stress disorder (PTSD) and depression (Prigerson et al., 1996, Boelen and van den Bout, 2005 and Simon et al., 2007). The American Psychiatric Association (APA) has included provisional criteria for the diagnosis of CG, designated “Persistent Complex Bereavement Disorder (PCBD)”, in Section III of the DSM-5 (American Psychiatric Association, 2013). Early studies have estimated the prevalence of CG to be 4–5% in the general population and 7–25% among bereaved individuals (Newson et al., 2011 and Kersting et al., 2011). The impact of CG on society and among bereaved individuals and their families is profound. Comorbidity with other psychiatric disorders such as depression tends to be significantly higher in individuals with CG compared to the general public. In a clinical study, a concurrent major depressive disorder (MDD) was present in 55% of individuals with CG (Simon et al., 2007). Given the intensity of the stressor and its association with depression, understanding the impact CG may have on cognition is important. Previous studies have suggested that individuals with CG have greater neurocognitive deficits compared to both normally bereaved and non-bereaved control participants in community based samples (O'Connor and Arizmendi, 2014 and Newson et al., 2011). This study represents an exploratory and descriptive analysis. It builds on previous work by exploring the association of CG with cognitive function in a sample of participants in a multisite NIMH-sponsored clinical trial researching treatment for CG and describing what may be an associated feature of the disorder. We examined cognitive functioning both globally and across six neurocognitive domains. After accounting for variables associated with cognitive functioning such as age, education, and depression, we examined whether variance in cognitive dysfunction might be explained by the presence of, severity or chronicity of CG symptoms.

Results 3.1. Participant descriptors CG participants included both men and women between the ages of 19–89. CG participants had a mean (SD) age of 53 (±15 years), were predominantly female (80%) and white (85%). The control sample was half female. Years of formal aging were comparable in the two groups (Table 1). Table 1. Demographic measures. Complicated grief (CG) [n if reduced sample] N = 335 Control [n if reduced sample] N = 250 Age 53.01 (14.57) Median = 55 Range = 19–89 54.42 (19.81) Median = 57 Range = 20–89 t (583) = −0.99, p = 0.32 %Female 79.70 (n = 267) 53.60 (n = 134) chisq (1) = 45.24, p < 0.0001 Race [n = 326] [n = 185] Fisher exact p = 0.01 (White vs. other: Fisher exact p = 0.42) % American Indian or Alaska Native 1.84 (n = 6) 0.54 (n = 1) %Asian 1.84 (n = 6) 5.95 (n = 11) %Black 10.43 (n = 34) 5.41 (n = 10) %Native Hawaiian or Other Pacific Islander 0.61 (n = 2) 0.00 (n = 0) %White 85.28 (n = 278) 88.11 (n = 163) Education Level chisq (3) = 2.60, p = 0.46 % ≤ 12 yrs 12.54 (n = 42) 14.80 (n = 37) % 13–15yrs 34.03 (n = 114) 33.60 (n = 84) % 16 yrs 21.79 (n = 73) 25.20 (n = 63) % > 16 yrs 31.64 (n = 106) 26.40 (n = 66) Site – – %San Diego 28.85 (n = 100) %Boston 27.46 (n = 92) %New York 11.04 (n = 37) %Pittsburgh 31.64 (n = 106) Table options Regarding clinical characteristics (Table 2) the mean score on the Inventory of Complicated Grief (ICG) was 43 (±9). The mean time since the death of a loved one was 5 (±7) years with median time of 2 years. 67% (n = 223/335) of CG participants had a diagnosis of current MDD. The mean total QIDS score was 13 (±4) indicating a mild to moderate level of depression. The mean total CIRS score for medical comorbidity was 6 (±4), with the mean number of organ systems affected, 5 (±3). Table 2. Clinical measures. Complicated grief (CG) N = 335 Time Since Loss 4.74 (7.19) Median = 2.37 Range = 0.50–58.67 Inventory Complicated Grief (ICG score) 43.05 (8.96) Quick Inventory of depressive symptomatology self-report (QIDS-SR) 13.46 (4.22) %Current MDD 66.57 (n = 223) Cumulative Illness Rating Scale (CIRS) Total 6.27 (4.31) Number of affected organ systems 4.70 (2.75) Heart + Vascular 0.93 (1.15) Neurological 0.44 (0.64) Table options 3.2. Global cognition The mean (SD) MoCA score in CG was 26.8 (±2.2) compared with 27.1 (±2.2) in control participants. The median MoCA score was 27 in CG and 28 in control participants (Table 3). Table 3. MoCA scores. Complicated grief (CG) N = 335 Controls (CTRL) N = 250 Age F, p/χ2, p Sex F, p/χ2, p Education F, p/χ2, p CG F, p/χ2, p MoCA totala (range = 0–30) 26.79 (2.20) Median = 27 Range = 21–30 27.12 (2.24) Median = 28 Range = 21–30 57.42, p < 0.001 5.39, p = 0.02 9.78, p < 0.0001 9.11, p = 0.003 Domains Executive Functioning (range = 0–4) 3.46 (0.76) Median = 4 Range = 1–4 3.53 (0.66) Median = 4 Range = 1–4 13.21, p = 0.0003 2.89, p = 0.09 31.51, p < 0.0001 2.46, p = 0.12 Visuospatial (range = 0–4) 3.41 (0.74) Median = 4 Range = 1–4 3.63 (0.59) Median = 4 Range = 2–4 20.38, p < 0.0001 3.74, p = 0.05 7.32, p = 0.06 12.52, p = 0.0004 Language (range = 0–5) 4.65 (0.59) Median = 5 Range = 2–5 4.55 (0.72) Median = 5 Range = 2–5 6.01, p = 0.01 3.95, p = 0.05 9.35, p = 0.03 0.62, p = 0.43 Short term memory (range = 0–5) 3.79 (1.18) Median = 4 Range = 0–5 3.74 (1.34) Median = 4 Range = 0–5 47.61, p < 0.0001 12.61, p = 0.0004 1.79, p = 0.62 2.41, p = 0.12 Attention/Concentration (range = 0–6) 5.56 (0.76) Median = 6 Range = 2–6 5.72 (0.62) Median = 6 Range = 2–6 3.80, p = 0.05 2.06, p = 0.15 13.66, p = 0.003 6.39, p = 0.01 Orientation (range = 0–6) 5.92 (0.31) Median = 6 Range = 4–6 5.95 (0.24) Median = 6.00 Range = 4–6 1.23, p = 0.27 0.03, p = 0.86 3.14, p = 0.37 1.99, p = 0.16 F statistic reported for ANCOVA (df = 1578) and χ2 (df = 1) reported for the domains scores. a No point added for participants with ≤High School education. Table options Results of ANCOVA showed that an increased age was associated with decrease in MoCA score (F(1,578) = 57.42, p < 0.0001, explained variance = 9.3%). Being female and having more education were both associated with higher scores (F(1,578) = 5.39, p = 0.02, explained variance = 0.3) and (F(3,578) = 9.78, p < 0.0001, explained variance = 4.1%) respectively. Controlling for age, sex and education effects, control participants had higher MoCA scores than CG participants (F(1,578) = 9.11, p = 0.003, explained variance = 1.3%, least square means: CG = 26.5 vs. CTRL = 27.1). Age, sex, education and group membership (CG vs. Control) explained 15% variance in MoCA total scores, while group membership alone explained 1.3% of variance above and beyond what was explained by demographic measures. In a sub-analyses examining only participants ≥60 years of age, group was no longer significant (F(1,210) = 3.12, p = 0.08). Total MOCA scores did not differ in sub-analyses comparing CG participants on psychotropic medications vs. CG participants not on psychotropic medications (F(6,328) = 0.01, p = 0.91, LSMEANS adjusting for age, gender and education: 26.61 vs. 26.58 respectively). Among potential participants with an ICG score of 30 or higher and at least 6 months elapsed since the death of a loved one, none had MOCA scores less than 21. 3.3. Domain specific cognition Table 3 displays the mean, median and range of both CG and control participants for each of the six neurocognitive domains. Results of the ordered logistic regression show that increased age was significantly associated with lower scores in all domains except attention and orientation (at p < 0.05). Females had higher MoCA scores than males in the language and memory domains. Higher education was associated with higher scores in the executive, language and attention domains. Controlling for age, sex and education effects, control participants were more likely to have higher visuospatial and attention scores than CG participants (odds ratios [95%CI]: 1.92 [1.34–2.75] and 1.68 [1.12–2.51] respectively.) The two groups did not differ significantly in the domains of executive function, language, memory or orientation. 3.4. Cognitive changes attributed to depression and severity of CG In the multiple linear regression models using only the CG sample, age and education, but not gender, were significant predictors of total MoCA score. Increased age was associated with lower MoCA scores, and higher levels of education, with higher MoCA scores. There was a site difference such that the NY site had lower MoCA scores than the other sites. We controlled for this site related difference in the analyses. The demographic variables explained 12.1% of variance seen in total MoCA scores. Current MDD diagnosis was not a significant predictor and neither was time since loss (explained variance <0.01%). ICG severity explained approximately 1% of total MoCA scores above and beyond demographic measures, diagnosis of depression and time since loss (Table 4). Table 4. Results from linear regression looking at effects of depression and CG severity. Model: F(9,325) = 5.57, p < 0.0001, R-square = 0.1337 Parameter estimate Standard error t Value p-Value Standardized estimate %Variance explained Intercept 29.77 0.77 38.87 <0.001 0 – Age −0.03 0.02 −3.61 <0.001 −0.20 3.4 Female 0.28 0.28 0.99 0.32 0.05 0.2 ED: ≤12 yrs −1.54 0.39 −3.92 <0.001 −0.23 4.0 ED: 13–15 yrs −0.93 0.28 −3.27 0.001 −0.20 2.8 ED: 16 yrs −0.35 0.32 −1.10 0.27 −0.07 0.3 Site: NY −1.00 0.39 −2.60 0.01 −0.14 1.8 Current MDD Dx 0.16 0.26 0.61 0.54 0.03 0.0 Time since loss 0.01 0.02 0.77 0.44 0.04 0.1 ICG score −0.03 0.01 −1.93 0.06 −0.11 1.0