“My heart still aches with sadness”: Epidemiological Relationships Between Perinatal Grief, Major Depressive Disorder, and Personality Disorders by Lisa Michelle Burke, BA(Hons), MHSt, FT Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Psychology (Clinical) College of Health and Biomedicine Victoria University 2017 ii Abstract The experience of perinatal bereavement can be devastating for women and their loved ones, and yet the experience has largely been overlooked by researchers. It is only recently that, along with changed sociocultural conditions, technological advances in neonatal care, and advanced understanding of maternal/fetal attachment, women’s experiences of perinatal loss have been empirically recognised. With an estimated 1 in 3 women experiencing perinatal loss, the profound sorrow that can accompany miscarriage, stillbirth, ectopic pregnancy, and terminations is now more readily acknowledged. Although some women accommodate perinatal loss in the longer-term, previous research has shown that approximately 20% continue to carry disabling symptoms in the years after perinatal loss. The challenge remains for researchers and practitioners alike to identify factors which influence longer-term perinatal grief trajectories. The present study aimed to examine perinatal grief experiences and mental health in a group of community-dwelling Australian women. One hundred and ninety- seven women participated in a clinical interview to assess perinatal history, depression, and personality disorders. It was hypothesised that previously-healthy women who developed de novo Major Depressive Disorder after experiencing perinatal loss would report more intense grief, with depression acting as a significant risk factor for complications in grief. Further, it was hypothesised that women with personality disorders would report more intense grief responses, with the presence of any personality disorder acting as a significant risk factor for greater complications in perinatal grief. These hypotheses were all supported. After an median 11 years post- loss, 6.5% of women continued to report clinically significant levels of perinatal grief. One in four women who were previously mentally healthy responded to perintal loss iii with the development of de novo depression. For women who did develop de novo depression, and for women with personality disorders, the risk of developing more problematic grief was between two and four times greater than women without such features. It may be that women with personality disorders are more at risk of developing a despair-related form of prolonged grief, whereas women with depression may be at risk of developing a form of prolonged grief associated with poorer coping. Such findings have theoretical and clinical implications whereby certain groups of women appear at greater risk of developing more complicated grief after perinatal loss. Further research should continue to identify these and other risk factors that modulate grief responses, so as to inform diagnosis and treatment of Persistent Complex Bereavement Disorder. iv Declaration I, Lisa Burke, declare that the Doctor of Psychology (Clinical) thesis entitled “My heart still aches with sadness”: Epidemiological Relationships Between Perinatal Grief, Major Depressive Disorder, and Personality Disorders” is no more than 40,000 words in length including quotes and exclusive of tables, figures, appendices, bibliography, references and footnotes. This thesis contains no material that has been submitted previously, in whole or in part, for the award of any other academic degree or diploma. Except where otherwise indicated, this thesis is my own work. Signature: Lisa Burke Date: 17 March 2017 v Acknowledgments Behind every final product, there’s a cast of unsung heroes. This dissertation is no different. To the participants first and foremost, the women who shared their stories, I thank you. You wore your hearts on their sleeves as you opened sometimes painful wounds. This research would not be without you. Thank you to my supervisors, Associate Professor Lana Williams and Professor Julie Pasco, for your wisdom in crafting this work. To Dr Carolyn Deans, thank you for stepping into the breach to smooth the waters. To the cast who supported me to kept me afloat, I thank you. Be it academic, intellectual, statistical, spiritual, emotional, psychological, or practical support – every moment you have offered has been a contribution to this final product. Thank you to all my family members, friends, school parents and teachers, child minders, book clubbers, wine drinkers, mothers group confidantes, Barwon Health and Deakin friends, and Monash colleagues… you all played a valued role. But there are four in particular. My Mum. A constant presence whether near or far. You are our role model for kindness, humour, patience, and persistence. You travelled each year to love, help, support, clean, and mend! Thank you Biddy, you were my rock ♥ My young man, Mitchell. Four years of age when this degree started, and now you are ten. You are loving, curious, and perceptive. Always the first to notice subtle shifts and offer something precious in word or deed, such as placing your Star Wars figurines on the edge of my desk with a gentle smile. Thank you Ditch, you were my comfort ♥ vi Mallory, my little lady. You were just eight months of age when I started this journey, and you screamed every time I left for university. I worried often and plentifully. As an infant, you sat at times patiently on the floor beside my desk, and at times impatiently, pulling tissues out of a box to keep yourself amused. You let me know when my decisions impacted on you and your brother. Thank you Mall, you were my accountability ♥ Gep, my Gep. What can I say? All the text messages you sent… “I miss you” and “Let me know how I can help you.” Well, now it is done and it’s my turn to ask, “How can I help you?” On the busy days and nights when our marriage was largely conducted via phone, you were so loving and caring of our family. And through it all, you changed careers and finished your own degree. You are amazing, you inspire me to be a better person. Under the guidance of Kevin near and far, you have become the personification of patience, love, kindness, and compassion. Thank you Gep, you are my stability ♥ This work is dedicated to the little girl who was so tiny she couldn’t stay. It is for the little girl so perfect, God gave her wings. For the little girl whose life and death changed us all. Chloe, when you died, everyone added something to your tribute box. Except me. I did not know what to add. It took me 15 years to realise that what I could add was knowledge and healing. And here it is. This is the work that this tiny girl inspired. This is the salve to pain. This is for Chloe and for Sharon ♥♥ vii Table of Contents Abstract ................................................................................................................. ii Declaration............................................................................................................iv Acknowledgments ................................................................................................. v Table of Contents ............................................................................................... vii List of Tables ......................................................................................................... x List of Figures ..................................................................................................... xii Chapter 1: Literature Review ................................................................................ 1 1.1 Theories of Grief ....................................................................................... 3 1.2 Grief as a Clinical Disorder ..................................................................... 14 1.3 Grief Trajectories ..................................................................................... 21 1.4 Perinatal Loss .......................................................................................... 26 1.5 Psychological Responses to Perinatal Loss ............................................. 41 1.6 Complicated Perinatal Grief .................................................................... 47 1.7 Personality, Personality Disorders, and Perinatal Grief .......................... 50 1.8 Rationale for the Present Research .......................................................... 58 1.9 Aims and Hypotheses .............................................................................. 61 Chapter 2: Method ............................................................................................... 63 2.1 Participants .............................................................................................. 63 2.2 Measures .................................................................................................. 66 2.3 Procedure ................................................................................................. 75 2.4 Design and Analysis ................................................................................ 76 Chapter 3: Results ................................................................................................ 77 3.1 Data Screening ......................................................................................... 77 viii 3.2 Perinatal Losses ......................................................................................