Manik Djelantik Toward an integrated understanding of traumatic grief Connecting prolonged grief, posttraumatic stress, and depression symptoms in traumatically and non-traumatically bereaved individuals Toward an integrated understanding of traumatic grief Manik Djelantik © 2020, A.A.A.M.J. Djelantik All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission from the author. Cover: hollandse meesters, Utrecht Cover image: Jenna Postma Printing / binding: Gildeprint, Enschede ISBN 978-94-640-2071-7 Traumatic grief: Connecting prolonged grief, posttraumatic stress, and depression symptoms in traumatically and non-traumatically bereaved individuals Traumatische rouw: De samenhang tussen symptomen van gecompliceerde rouw, posttraumatische stress en depressie bij nabestaanden na traumatische en niet-traumatische verliezen (met een Nederlandse samenvatting) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. H.R.B.M. Kummeling, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op vrijdag 6 maart 2020 des middags te 12.45 uur door Anak Agung Ayu Manik Jantine Djelantik geboren op 21 januari 1984 te Utrecht Promotiecommissie Promotoren: Prof. dr. P. A. Boelen Prof. dr. R. J. Kleber Prof. dr. G. E. Smid (Universiteit voor Humanistiek) Voor mijn dochters Table of contents Chapter 1 General introduction 11 Section 1 Traumatic loss 27 Chapter 2 The prevalence of prolonged grief disorder in bereaved 29 individuals following unnatural losses: Systematic review and meta-regression analysis Chapter 3 Symptoms of prolonged grief, posttraumatic stress, and 57 depression after loss in a Dutch community sample: A latent class analysis Section 2 Traumatic grief 75 Chapter 4 Early indicators of problematic grief trajectories following 77 bereavement Chapter 5 Do prolonged grief disorder symptoms predict posttraumatic 91 stress disorder symptoms following bereavement? A cross-lagged analysis Chapter 6 Symptomatology following loss and trauma: 107 Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample Chapter 7 Post-migration stressors and their association with 139 symptom reduction and non-completion during treatment for traumatic grief in refugees Chapter 8 Prolonged grief disorder, posttraumatic stress disorder, and 159 depression following traffic accidents among bereaved Balinese family members: Latent class analyses and cultural correlates Chapter 9 General discussion 183 Samenvatting (Dutch summary) 197 References 209 Dankwoord (Acknowledgements) 233 About the author & list of publications 241 Chapter 1 General introduction Chapter 1 General introduction ŚŝƐƚŽƌŝĐĂůĞǀĞŶƚ͗dŚĞŽĐŽĂŶƵƚ'ƌŽǀĞĮƌĞ It was a lively Saturday night 28 November 1942. More than a thousand ƉĞŽƉůĞǁĞƌĞĞŶũŽLJŝŶŐĂĚĞƐĞƌǀĞĚŶŝŐŚƚŽƵƚŝŶŽŶĞŽĨŽƐƚŽŶ͛ƐŚŽƩĞƐƚĐůƵďƐ͕ ǁŚŝĐŚǁĂƐĚĞĐŽƌĂƚĞĚŝŶĂƚƌŽƉŝĐĂůƚŚĞŵĞǁŝƚŚƉĂůŵƚƌĞĞƐ͘/ŶƚŚĞŵŝĚĚůĞŽĨƚŚĞ ƉĂƌƚLJ͕ĂĮƌĞƐƚĂƌƚĞĚĂŶĚƚŚĞĐůƵďƋƵŝĐŬůLJďĞĐĂŵĞĮůůĞĚǁŝƚŚŇĂŵĞƐĂŶĚƚŽdžŝĐ 12 ŐĂƐƐĞƐ͘'ƵĞƐƚƐƉĂŶŝĐŬĞĚĂŶĚƚƌŝĞĚƚŽĞƐĐĂƉĞ͘hŶĨŽƌƚƵŶĂƚĞůLJ͕ƚŚĞĞŵĞƌŐĞŶĐLJ ĞdžŝƚƐǁĞƌĞůŽĐŬĞĚĂŶĚŵĂŶLJŐƵĞƐƚƐĚŝĞĚŝŶƚŚĞŝƌĂƩĞŵƉƚƚŽŐĞƚŽƵƚ͘/ŶƚŚĞ ĨŽůůŽǁŝŶŐĚĂLJƐ͕ŶĞǁƐƐƉƌĞĂĚƚŚĂƚƚŚŝƐĚŝƐĂƐƚĞƌŚĂĚĐŽƐƚϰϵϮůŝǀĞƐ͘DĂŶLJŽĨƚŚĞ ƐƵƌǀŝǀŽƌƐŚĂĚůŽƐƚĂůŽǀĞĚŽŶĞŝŶƚŚĞĮƌĞ;ŽƐƚŽŶ&ŝƌĞ,ŝƐƚŽƌŝĐĂů^ŽĐŝĞƚLJ͕ϮϬϭϲ͖ &ƌƵŵŬŝŶΘZŽďŝŶĂƵŐŚ͕ϮϬϭϴͿ Problem definition: Grief or traumatic stress? Historical perspective Psychiatrist Erich Lindemann, based at the Massachusetts General Hospital (MGH) in Boston, became interested in how people would cope with such a shocking experience. He initiated a study in which he interviewed survivors who had lost a loved one in the fire and asked them about their psychological symptoms. He found a surprisingly common reaction of distress among the participants, characterised by ‘intense emotional pain’, ‘preoccupation with thoughts about the death’, ‘avoidance of grief-related emotions’, and ‘feelings of guilt and social isolation’ (Lindemann, 1944). The publication of his findings has been the starting point for further studies. The reaction he described has been found in many other bereaved populations. Also, theories, have been derived to explain the development of this reaction e.g., Bowlby (1980) and Parkes (1965). Over the decades, this has resulted in a scientific discussion about the existence of a disorder characterized by complicated grief symptoms such as ‘prolonged yearning’, ‘avoidance of reminders of the loss’, ‘difficulty accepting the death’, and functional impairment (Prigerson, Shear, et al., 1999; Shear, Ghesquiere, & Glickman, 2013). Currently, the criteria sets of symptoms that have been included under the name of prolonged grief disorder (PGD) in the International Classification of Diseases 11th Revision (ICD- 11) and persistent complex bereavement disorder (PCBD) in the fifth edition of the Diagnostic and Statistical Manual (DSM-5) show strong similarities with the descriptions in the study of Lindemann (American Psychiatric Association, 2013; Killikelly & Maercker, 2017; World Health Organization, 2018). General introduction At the same time and independent from Erich Lindemann, a second psychiatrist named Alexandra Adler also started a mental health research among the survivors of the Cocoanut Grove Disaster. She interviewed more than 100 survivors who were treated at the Boston City Hospital. Half of them had lost a loved one in the fire. Like Lindemann, she found a common psychological reaction among the survivors. However, unlike the psychological reaction of disturbed grief postulated by Lindemann, the reaction she described was characterised by ‘traumatic distress and anxiety’, ‘terrifying nightmares’, ‘preoccupying thoughts about the event’, ‘irritability’, 13 ‘depressed mood’ and ‘feelings of guilt’ (Adler, 1943). Her work was also highly influential for further research. It is known as one of the first studies systematically describing the symptoms of the later developed diagnosis of posttraumatic stress disorder (PTSD) in a civilian population (American Psychiatric Association, 1980). The disturbances described by Lindemann and Adler include partly the same symptoms, but also seem to reflect two different perspectives on psychological distress following war, disaster or violence, and loss; the first perspective focused on loss (and consequently grief and separation distress) and the second perspective focused on the confrontation with extreme stress (trauma). Since then, many more scientists have written about the relationship between grief and posttraumatic distress. In the 1970s, Mardi Horowitz, introduced the theory of stress response syndromes (Horowitz, 1976). In this theory, he stated that a stressor on itself may evoke mental health issues, regardless of pre-existing factors like personality features or prior mental health issues. Remarkably, Horowitz initially mentioned loss of a loved one as one type of stressor which could cause this general stress response syndrome without specifying grief as a distinct form of traumatic distress. Later, he developed criteria for pathological grief as a distinct syndrome (Horowitz, 1986; Horowitz, Bonanno, & Holen, 1993). Several scholars (Raphael & Martinek, 1997; van den Bout & Kleber, 2013) have argued that trauma and bereavement are in nature related events with relatively similar psychological reactions, while other researchers, e.g., Stroebe and Schut (1999), have emphasised the differences between the two phenomena. However, in the case of loss due to war, disaster and other extreme experiences, researchers found evidence that a mixture of pathological grief and traumatic distress may occur (Green, 2000; Rando, 2000). Stroebe, Schut, and Finkenauer (2001) introduced a conceptual framework and research agenda to conduct empirical studies to define the differences and similarities between PTSD and normal and pathological grief considering different characteristics such as the type of event, the impact intensity, the disturbances, and assessment. Recently, Frumkin and Robinaugh (2018) published an elaborate overview of reviews written Chapter 1 about the intersection of grief and trauma. They concluded that a comprehensive understanding for this intersection was not yet available and made a call for more research on this subject. In addition, other researchers and clinicians have considered the disturbances after traumatic and non-traumatic losses in terms of major depressive disorder, e.g., Galatzer-Levy and Bonanno (2012), Clayton (1990) and Hensley (2006). This seems logical, because depression symptoms like ‘depressed mood’, ‘feeling worthless’, and ‘suicidal ideation’ are also commonly present in the bereaved individual in the first 14 period after losing a loved one (Prigerson, Frank, et al., 1995). While reading about this scientific debate, the following questions arose in our minds. How do posttraumatic and prolonged grief influence each other over time? And how are depressive symptoms connected with these two types of distress? Is a traumatic loss the only risk factor to develop both types of distress? Is it possible to identify bereaved individuals at risk for psychopathology? And what does this mean for clinicians and researchers working with individuals affected by bereavement and trauma? Should psychological assessment and treatment focus more on grief or