Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Abstract

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected.Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.bereavement, identity confusion, inclusion of other in the self, interpersonal closeness, prolonged grief disorder, self-other fusion | INTRODUCTIONGrief is a normal, natural and very individual process consisting of different experiences, trajectories and time courses (Stroebe et al., 2007; Zisook et al., 2014). Initially, grief very often presents itself in an 'acute' form, where bereaved individuals are intensively yearning for the deceased and often report exhaustive thoughts and memories of the deceased, which often entail negative emotions such as guilt, anxiety or anger (Shear, 2015; Zisook et al., 2014). While a majority of bereaved individuals are able to adapt to their loss after a certain period of time, and do not need clinical intervention, about 10% experience long-term difficulties and develop a pathological form of grief (Lundorff et al., 2017;Shear et al., 2011). Over the years, different terminologies and definitions of pathological grief have been promoted, i.e., traumatic grief, complicated grief, prolonged grief or persistent complex bereavement disorder, resulting in the development of different criteria sets and also measures (

Interpersonal problems and cooperative behavior in patients suffering from prolonged grief disorder as compared to bereaved healthy controls

“…Combined with the results obtained from the IIP-D, it could be argued that the cooperation behavior in the FIPD is the result of warm-submissive behavior and the underlying will to please others, however, interpreting the group × repeated measures interaction, which demonstrated that the number of shared tokens tended to be distributed differently across the 30 trials for the two groups, could also indicate a lack of social flexibility (Nelson & Guyer 2011) due to deficient valuation, inhibition, or rule use. Without further evidence, we suggest that valuation may be most deficient in PGD, leading to stronger commitment, higher dependency, and a higher than normal tendency to feel fused with the bereaved, as shown by other studies (Harrison et al 2021). Hence, in persistently over-valuating the other, they might lack the capability to adapt to changes in the relationship.…”

“…However, studies have shown that PGD is associated with insecure attachment and that PGD patients often have formed a very close, almost dependent relationship with the deceased, which makes it difficult for them to form new relationships (Burke & Neimeyer 2013;Maccallum & Bryant 2018;Mancini et al 2015). In fact, PGD patients have been found to feel significantly closer to the deceased than to their closest living friend, and to experience higher than normal identity fusion with the deceased (Harrison et al 2021). Such higher self-other fusion is associated with more empathy and altruism (Cialdini et al 1997).…”

“…We were interested not only in the degree of cooperation the patients would show but also in the interactive dynamics of their game-playing. Given their predisposition towards insecure attachment and high self-other fusion (Burke & Neimeyer 2013;Harrison et al 2021), we hypothesized that patients might show social perseveration in their cooperation behavior; that is, they would maintain other-concerned, cooperative behaviors, regardless of the partner's actions, thus showing a reduced willingness to negatively reciprocate any experienced defections. In a final step, we combine the first and the second approaches by showing that interpersonal problems mediate the behavioral peculiarities of PGD patients.…”

Do early symptoms of prolonged grief disorder lead to symptoms of posttraumatic stress disorder and depression? A longitudinal register-based study of the two first years of bereavement.

“…Correspondingly, recent studies found that perceived interpersonal closeness to the deceased was an important risk factor across bereaved spouses and adult children, and both subgroups show similar patterns of decreasing symptoms over time (C. B. Harris et al, 2023;Harrison et al, 2022). Thus, perceived interpersonal closeness and merged identity with the deceased may increase the risk of developing PGD rather than the factual relationship to the deceased.…”

A network analysis of posttraumatic stress symptoms and quality of relationship with deceased in COVID-19 bereaved adults.

“…On the other hand, psychoanalytic theory suggests that a conflicted relationship before death is also linked to loss-related psychopathology, presumably because it complicates resolving attachment issues with the deceased and completing the decathexis (i.e., emotional withdrawal of one's attachment to the deceased; Freud, 1917;Parkes, 1991;Worden, 2015). Empirical studies confirmed that predeath closeness to and conflict with the deceased was positively associated with postdeath pathological grief, depressive symptoms, and psychological distress (Coelho et al, 2022;Harrison et al, 2022;Keser et al, 2022;Lee et al, 2022;Sekowski & Prigerson, 2022;Smigelsky et al, 2020;Tang et al, 2021). When taking closeness and conflict into consideration simultaneously, however, the two dimensions seem to contribute differently to psychopathological symptoms.…”