Anxious and Depressive Avoidance and Symptoms of Prolonged Grief, Depression, and Post-Traumatic Stress Disorder

Abstract

Following loss, people can develop symptoms of depression, Post-Traumatic Stress Disorder (PTSD), or Complicated Grief (CG) -also termed Prolonged Grief Disorder (PGD). A recent cognitive-behavioural model has proposed that avoiding confrontation with the reality of the loss (called "anxious avoidance" [AA]) and refraining from activities that could foster adjustment (called "depressive avoidance" [DA]) both play a critical role in CG/ PGD. The present study examined this assumption, using self-reported data from 161 mourners. Findings showed that items constituting AA and DA represented two distinct factors. Both factors were strongly correlated with other measures of bereavement-related avoidance and both accounted for a unique part of the explained variance in CG/PGD severity, beyond relevant background variables, negative cognitions, and concomitant symptom-levels of depression and PTSD. DA also explained unique variance in depression beyond these variables. Moreover, AA and DA mediated the linkages of neuroticism, attachment anxiety, and attachment avoidance with symptomlevels of CG/PGD. IntroductionThere is increasing evidence that in an estimated 5 to 20% of bereaved people a loss gives rise to serious mental health problems such as depression, Post-Traumatic Stress Disorder (PTSD), or Complicated Grief (CG;Forstmeier & Maercker, 2007;Prigerson & Jacobs, 2001). CG, or Prolonged Grief Disorder (PGD) as it is recently termed, entails chronic, intense grief-reactions including separation distress, difficulties accepting the loss, preoccupation, and recurrent images of the lost person that cause significant impairments in functioning for at least 6 months (Prigerson, Horowitz, Jacobs, Parkes, Aslan, Goodkin et al., 2009;Prigerson, Vanderwerker, & Maciejewski, 2008). Parallel to the development of validated criteria for CG/PGD, there is increasing attention for the treatment of this condition. For instance, Shear, DOI: http://dx.doi.org/10.5334/pb-50-1-2-49 50 ANXIOUS AND DEPRESSIVE AVOIDANCE IN GRIEF, Frank, Houck, and Reynolds III (2005) found "complicated grief treatment" -a novel treatment containing elements of interpersonal therapy and cognitive-behavioural therapy (CBT) -to be effective in the reduction of CG/PGD symptoms. Boelen, de Keijser, van den Hout, and van den Bout (2007) found evidence for the effectiveness of brief cognitive-behavioural therapy for CG/ PGD. Although these findings are encouraging, not all patients included in these studies improved, leaving room to further improve and refine treatments. For the refinement of effective treatments for CG/PGD, it is essential to have more knowledge about intrapersonal processes that are involved in the development and maintenance of this condition.Recently, we developed a cognitive-behavioural (CB) conceptualisation of CG/PGD that was designed to offer a framework for the generation of hypotheses about processes involved in this condition and to inform efficacious treatment for it . This model proposes that CG/PGD develops and persists under t...

Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial

“…Therefore, systematically confronting a bereaved person with the most painful aspects of the reality of the loss could increase acceptance of the loss and facilitate adjustment to bereavement. Behavioral activation, on the other hand, is founded on the observation that individuals experiencing grief complications may become more inactive and withdraw social, occupational, and recreational activities (Boelen et al, 2006;Boelen & Eisma, in press;Boelen & van den Bout, 2010). This results in reduced opportunities to challenge negative cognitions that are common after loss, which fuels negative feelings and grief complications.…”

“…(e.g., Boelen & van den Bout, 2010;Bonanno, Papa, Lalande, Zhang, & Noll, 2005;Eisma et al, 2013). Such avoidance strategies are hypothesized to block integration of the loss in the autobiographical knowledge base (Boelen, van den Hout, & van den Bout, 2006) and/or acceptance of the loss (Stroebe, Boelen, van den Hout, Stroebe, Salemink and van den Bout, 2007;Worden, 2009).…”

Grief rumination mediates the association between self-compassion and psychopathology in relatives of missing persons

“…Exposure to loss-related stimuli is a critical ingredient of effective grief treatment (Bryant et al, 2014). Similarly, theoretical (Boelen, van den Hout, & van den Bout, 2006; Maccallum & Bryant, 2013; Stroebe & Schut, 1999) and empirical work (Boelen, de Keijser, & Smid, 2015; Boelen & van den Bout, 2010; Eisma et al, 2013; Schnider, Elhai, & Gray, 2007) emphasized that strategies to avoid and minimize engagement with painful feelings and thoughts associated with the loss are key to the onset and maintenance of psychopathology following the loss of a loved one.…”

Cognitive therapy and eye movement desensitization and reprocessing for reducing psychopathology among disaster-bereaved individuals: study protocol for a randomized controlled trial

“…Participants rate their agreement with each item on a 8-point scale with 0 = not at all true for me and 7 = completely true for me. Psychometric properties of the subscales are adequate (Boelen & van den Bout, 2010). …”

“…‘Since he/she is not here anymore, I feel less worthy’), and catastrophic misinterpretations about one’s own reactions to the loss (‘If I would allow myself to really experience the grief, I will lose control’) have shown to be related to increased PG, PTS, and depression levels concurrently and longitudinally (Boelen, van den Bout, & van den Hout, 2006b; Boelen, van Denderen, & de Keijser, 2016). Avoidance behaviour is also associated with psychopathology following loss (Boelen & Eisma, 2015; Boelen & van den Bout, 2010), including depressive avoidance (i.e. withdrawal from previous fulfilling activities because of the belief that these activities are pointless since the loss) and anxious avoidance (i.e.…”