Contents
1. Introduction …... 1.1 Complicated Grief ... 1.2 Adult Separation Anxiety Disorder ... 1.3 Separation anxiety and grief...
2 3 7 10
2. Aim of the study …... 13
3. Methods ... 3.1 Participants ... 3.2 Assesment ... 3.3 Statystical analyses ... 14 14 14 16 4. Results ... 18 5. Discussion …... 20 6. Limitations ... 24 7. Conclusion... 25 8. References... 26 9. Tables …... 36
1. Introduction
“The mourner is in fact ill, but because this state of mind is common and seems so natural to us, we do not call mourning an illness”.
Melanie Klein, 1940
As interestingly noted by Parkes and Prigerson1, the assertion that grief cannot be said to be an illness because it will be experienced by most of us sooner or later it is not valid.
As many common diseases follow a physical injury, grief can be considered the consequence of a psychological trauma. Just like for other illnesses, many people go to their doctor for help after a bereavement and a large proportion of their complaints are expressions of grief. As illnesses are characterized by discomfort, pain and impairment of functioning, bereaved people experience unpleasant and painful emotions and are normally expected to miss work and to have others taking over responsibility of making decisions and acting on their behalf for some time.
This said, it has also to be said that grief usually heals, as several physical injuries do. Nevertheless, sometimes healing is delayed, complications arise and symptoms of grief are so severe, so lasting and so disabling that it's to the patient's advantage to consider them ill and to provide them with the treatments and
1.1 Complicated Grief
In western culture mourning usually takes place over a period of weeks to months of acute grief. During this time the loss is gradually integrated into the person's ongoing life. This integration process, which Bowlby referred to as a successful mourning, consists of acknowledgment of the finality of the loss and its consequences, revision of the internal representation of the deceased person, and redefinition of life goals. Even though bereaved people actually keep on longing and feeling a sense of connection to the deceased, painful thoughts of the loved one cease to dominate their mind and they usually regain interest and engagement in ongoing life.
Yet for about 10% to 20% of bereaved persons, this progression from acute to integrated grief does not occur 2, 3. Complicated grief (CG), also referred to as traumatic grief or prolonged grief disorder, is the condition which arise when acute grief persists indefinitely, bringing about significant distress and impairment of functioning.
The current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM IV-R) 4 mentions “bereavement” among a group of “Other conditions that may be the focus of clinical attention”. Although not yet included in official diagnostic manuals, increasing evidence suggest that CG constitutes a unique disorder, with clinical features distinct from that of PTSD, anxiety and depression 5, 6, 7.
Despite the absence of official status, a growing body of data draws a reliable picture of key features of CG, which can be reliably identified by administering the Inventory of Complicated Grief (ICG) 8 more than 6 months after the death of a loved one.
Persons suffering from CG have a general sense of disbelief and feelings of anger and bitterness regarding the death. They are preoccupied with the deceased, and may have recurrent, intrusive images or thoughts of the death. They are also prone to rumination in the kind of repetitive thoughts focusing on guilt over having been unable to prevent the death or accompanying suffering, or on the idea that it is not right for the bereaved person to enjoy her life because the deceased cannot. Anger or disappointment with others or with the unfairness of the world is also frequently a focus of rumination. Pangs or painful emotions are recurrent as well, with intense yearning and longing for the deceased.
At the same time, the bereaved people eschew reminders that the person is gone. They may stay away from the final resting place, shun activities once shared with the deceased, refrain from disposing of possessions, or avoid other reminders 9. Rumination and avoidance prevent the mourner from coming to terms with the finality and consequences of the loss. Instead of finding a way to integrate the painful information, they remain caught in a cycle in which the death seems to have been wrong, unfair, or even preventable. Often, their emotions remain as intense as when the death first occurred.
gender, education, and race as risk factors for CG are very inconsistent, and evidence for caregiver burden before a death as a risk factor is also mixed. However, studies conducted with caregivers of terminally ill people, showed that factors consistently associated with negative bereavement outcomes include being married to the person who died, deriving benefit from the caregiving experience, and having a higher level of depression before the loss 11, 12, 13, 14, 15; 16, 17. Moreover, attachment issues, such as insecure attachment styles and Separation anxiety, have been recently found linked to an higher risk of developing CG 18, 19,
20, 21, 22, 23
.
Several studies indicate that bereavement impacts physical and mental health, with evidence that bereavement may increase mortality rates 24 and be associated with long term functional impairment 25. CG in particular appears to be associated with unique physical and mental issues 26. CG symptoms have been shown to predict worsened health outcomes such as hypertension, heart trouble, cancer, immunological dysfunction and smoking 27. The impact of CG on mental health seems to include higher rates of both passive and active suicidality, poorer functioning, poorer general status and reduced quality of life 26, 28. In a series of studies, Prigerson and colleagues found that high symptom levels of CG assessed at 6 months post-loss predicted poor sleep quality, depressed mood, and low self-esteem at 18 months after the death of the spouse, even after adjusting for high baseline levels of depressive symptoms 8, 27, 29.
researchers begun to develop standardized assessment and specific treatments. Nevertheless the association between CG and long-term mental and physical health impairment, highlights the importance of accurately diagnosing CG and identifying potential risk factors and treatments.
Since CG symptoms do not appear to be reduced by standard treatments for depression 30, 31 or PTSD 32, as expected in the perspective of CG as a unique clinical entity, some specific treatments was recently developed. Whereas pharmacological treatments, as tricyclic antidepressants, showed to be ineffective in reduction of CG symptoms 33, at least two psychotherapy specifically designed for CG showed to reduce CG symptoms 9, 34. One of the only effective treatments of CG tested in an Randomized Clinical Trial with a larger sample has been Shear et al.’s Complicated Grief Treatment (CGT)9. CGT arose out of strategies developed in Interpersonal Therapy (IPT) for depression, modified to improve IPT for grief-specific cases. Given the overlap between CG and PTSD (in particular the reexperiencing and avoidance components), Shear et al. enhanced IPT with techniques based on Dr. Edna Foa’s highly effective exposure therapy for PTSD
32
. In the RCT, CGT showed a significantly greater decrease in mean grief scores compared to IPT.
1.2 SEPAD
Separation anxiety disorder (SEPAD) is a well-established diagnostic category in the DSM-IV-TR and is generally considered a disorder of childhood. However, recent epidemiological data show that this disorder may also occur during adulthood with a lifetime prevalence in the general population of 6.6% 35. The essential feature of SEPAD in children is excessive anxiety concerning separation, actual or imagined, from home or from those to whom the person is attached causing clinically significant distress or impairment in functioning. Although many youth who suffer from SEPAD appear to make a good recovery, some authors have hypothesized that early onset SEPAD is either specifically linked to risk of panic disorder in adulthood 36, 37 or generally linked to several adult anxiety and mood disorders 38, 39. Moreover, many adult patients show symptoms of SEPAD, characterized by extreme anxiety about separations, actual or imagined, from major attachment figures or family environment and fears that harm would befall those close to them 40, 41, 42, 43.
Anxieties might include parents but more often involve intimate partners and children 40, 44. Somatic symptoms which are usually prominent in juvenile SEPAD, such as nausea and stomachaches 4, seem to be less frequent in adults who instead show more cognitive and emotional symptoms 44. Moreover, as a way to deal with their fears and ensure a contact with attachment figures, adults with SEPAD might make frequent phone calls, adher to rigid routines or talk
excessively.
Thus, some authors hypothesize that SEPAD might be a primary condition in adulthood and determine serious anxiety symptoms, including panic attacks, and depression 40.
Recent epidemiological data (National Comorbidity Survey, NCS-R) 35 show that lifetime prevalence estimate of adult SEPAD is 6.6%, consistently with a previous study showing a prevalence of 6% among elderly subjects recruited from a primary medical care setting 43. In NCS-R, adult SEPAD is significantly more common among women than men, people in the age range 18-59, and in the never married and previously married (compared to the currently married or cohabiting). Moreover, adult SEPAD is highly co-morbid with other psychiatric disorders and associated with substantial impairment in role functioning that persists even after controlling for co-morbidity.
As for clinical samples, a recent study conducted in a large cohort of patients with mood and anxiety disorders 45 found a prevalence of adult SEPAD of 40%, quite consistently with previous data showing a prevalence of 46% in patients with panic disorder or generalized anxiety 46.
In another recent study conducted on a large sample of anxiety patients, the estimate prevalence of adult SEPAD was 23% 47 with an overrepresentation of females in the SEPAD group. Interestingly, in both studies people with adult SEPAD, with respect to those without, showed higher co-morbidity with panic
showing higher co-morbidity with Major Depression.
As for co-morbidity with mood disorders, SEPAD has been found to be associated with bipolar disorder 35 and earlier onset of bipolar disorder has been correlated to juvenile SEPAD 48. Major depression seems instead not to be linked to SEPAD 45,
47, 49
. Nevertheless, depressive symptoms have been shown to be more severe while associated with SEPAD 45, 47 and depressed patients with adult SEPAD and a history of juvenile SEPAD showed a greater number of affective episodes compared with those in whom SEPAD was absent.
1.3 SEPAD and CG
In the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R) bereavement is said to be likely to present with symptoms of a Major Depressive Episode. Nevertheless, as interestingly noted by Parkes and Prigerson 1, the most characteristic feature of grief is not prolonged depression but acute and episodic “pangs”. In the way that infants separated from their mothers show a phase of yearning and protest 50, grieving adults go through a phase of “yearning and searching for the lost figure” which is characterized by episodes of severe anxiety and psychological pain. In this perspective, grief consists of a special kind of anxiety, phenomenologically close to separation anxiety, rather than of depressive symptoms 1.
On the other hand, since Bowlby started his work on attachment, separation and loss have always been treated together and attachment theory has offered insight into both separation anxiety and grief. As a matter of fact, some studies have reported a link between insecure attachment styles and both CG symptoms 18, 20 and SEPAD symptoms 50. Moreover, it has been proposed that exposure to a traumatic event, as a loss, may trigger symptoms associated with adult SEPAD 40,
49
and recent data found childhood SEPAD to be linked to a higher risk of developing CG in adulthood 23.
Adult SEPAD was recently evaluated among trauma-affected subjects 49 and was found to be associated with PTSD, but not with depression or CG. On the other hand, traumatic loss seemed to be correlated to SEPAD symptoms. Moreover, among PTSD dimensions, adult SEPAD was specifically linked to avoidance and hyperarousal, but not to reexperiencing. A similar, strong pattern of association between SEPAD and PTSD was found by National Co-morbidity Survey as well
35
. As hypothesized by Manicavasagar 51, fear for personal safety might represent a common factor underlying PTSD and SEPAD while trauma might act as a trigger for both disorders.
As adult SEPAD is still unexplored among CG patients, its possible impact on CG treatments is still unknown as well.
One of the only effective treatments of CG tested in a Randomized Clinical Trial with a larger sample has been Complicated Grief Treatment (CGT) 9, which arose from IPT tecniques for depression modified to include CBT–based techniques for addressing trauma. In the randomized clinical trial the authors found no statistically significant differences in CG treatment response based upon race, age, sex, time since the loss, or relationship to the deceased, but did not examine adult SEPAD as a moderator of treatment response.
It is noteworthy that recent studies have pointed out that the presence of adult SEPAD affects treatment outcomes in patients treated with psychotherapy. Aaronson and colleagues found that, compared to patients with panic disorder alone, those with co-morbid SEPAD were more likely to experience poor
treatment response to CBT 52. Additionally, Kirsten and colleagues 53 reported that the presence of SEPAD predicted poor recovery from general symptoms of anxiety and depression amongst patients receiving CBT. Yet based on these researchers' findings, Separation Anxiety might be expected to act as a moderator of response to CG treatment in bereaved people.
2 Aim of the study
The proposed research attempts to explore the prevalence of adult SEPAD among CG patients, its pattern of co-morbidity with PTSD, depression and panic disorder and its possible association with specific dimensions of traumatic loss.
3. Method
The study involves a secondary data analysis from a 16 session randomized controlled trial 9 that compared the effectiveness of Complicated Grief Treatment (CGT) to that of Interpersonal Therapy (IPT) among adults with complicated Grief (CG).
Participants
Bereaved individuals were recruited via media advertisement, professional referral and self-referral to an university-based clinic in Pittsburgh, Pennsylvania, between April 2001 and April 2004. A subgroup of the sample was recruited from a clinic which had predominantly low income African American patients. Inclusion required a death of a loved one occurred at least 6 months previously, a score of at least 30 on the ICG and judgment by the independent evaluator that complicated grief was the most important clinical problem. Exclusion criteria were a current substance abuse or dependence (past 3 months), history of psychotic disorder or bipolar I disorder, suicidality requiring hospitalization, pending lawsuit or disability claim related to the death, or concurrent psychotherapy.
posttreatment.
The 19-item Inventory of Complicated Grief (ICG) was used to assess symptoms of CG. This scale has been utilized previously in various studies of CG 8, and has good internal validity and consistency and six-month test-retest reliability. This measure was administered at baseline, at treatment and at 6 months post-treatment and has been used as the primary outcome measure in the study. The Structured Clinical Interview for the DSM-IV (SCID-I) 54 was administered at baseline to determine the absence of diagnostic exclusion criteria and to assess co-occurring Axis-I disorders. The Hamilton Rating Scale for Depression (HRSD) 55 was administered at baseline and post-treatment to assess the severity of depressive symptoms.
Separation anxiety
The Separation Anxiety Symptoms Questionnaire (ASA-27) 56 is a 27-item self-report inventory which explores symptoms of Separation Anxiety in adulthood, including, but not limited to, adult variants of DSM-IV criteria for Separation Anxiety in childhood. This scale has been shown to display good internal and test-retest reliability as well as concurrent validity with clinical assessments of adult Separation anxiety 56. The ASA-27 was administered at baseline; according to the literature suggesting a cut-off of 22 in clinical samples 56, people who scored 22 or greater on the ASA-27 were given a diagnosis of adult SEPAD.
Three instruments were administered at baseline to assess specific grief-related dimensions: the Grief Related Avoidance Questionnaire, the Peri-traumatic Dissociative Experiences Questionnaire and the Impact of Events Scale. The Grief Related Avoidance Questionnaire (GRAQ) is a 6-item self-report scale which measures avoidance behavior through 15 situations that bereaved individuals frequently refrain from doing. The measure has good internal validity and reliability. The Peritraumatic Dissociative Experiences Questionnaire (PDEQ) 58 is a 10-item self-report scale which assesses dissociative experiences occurring during a traumatic event, including derealization, depersonalization, amnesia, altered time perception, confusion, reduced awareness. The Impact of Events Scale (IES) 59 is a 15-item self-report scale measuring current stress related to a specific event. The scale consists of two subscales: intrusion and avoidance. The scale has adequate internal consistency and high test-retest reliability.
Grief related impairment
The Work and Social Adjustment Scale (WSAS) 60 was used to assess the interference of grief symptoms with five areas of daily functioning: work, home management, private leisure, social leisure, and family relationships. It is a well-validated, widely used measure.
Statistical analyses
Statistical differences between people with and without adult SEPAD were reported using chi-square test for categorical variables (such as
socio-test for continuous variables, such as Ham-D score. T-socio-test was also used to report statistical differences in ASA-27 score on the basis of the presence/absence of Axis I diagnoses.
All tests were two-tailed and a p value <0.05 was considered statistically significant.
Statistical tests were performed with STATA (Rel. 10. 2007. College Station, TX: StataCorpLP) for Windows.
4. Results
Socio-demographic and grief correlates
Out of 216 patients participating in the CGT study, 151 filled out the ASA-27 scale. Out of these 151, 104 (68,9%) were given a diagnosis of adult SEPAD as having a score of 22 or greater on the ASA-27.
Socio-demographic correlates are shown in table 1. People with and without SEPAD did not differ significantly for gender distribution, age, education and marital status. A significant difference was found with respect to race (P=0.002). With respect to grief measures (tab.2), there were no differences between people with adult SEPAD and those without in terms of total number of losses and type of loss (violent/non violent loss). However, a weak trend to significance was found with respect to the relationship to the deceased (P=0.065).
As shown in table 2, people with adult SEPAD showed higher scores on the ICG (P<0.001), the PDEQ (P=0.004), the GRAQ (P<0.001), the IES intrusion (P<0.001) and IES avoidance (P<0.001).
People with adult SEPAD, compared with people without, showed a greater grief-related impairment as evaluated with the WSAS (P=0.006).
Co-morbidity with other DSM-IV disorders
P=0.01; lifetime: P=0.01). Particularly, the co-morbidity between estimated adult SEPAD and PD appeared to be very strong, with all people with current PD and the vast majority with lifetime PD having also adult SEPAD.
On the other hand, adult SEPAD was not significantly associated with MDD, either current or lifetime. Nevertheless, HAM-D total score was significantly higher among people with adult SEPAD than those without P<0.001).
Regarding the mean scores on the ASA-27 on the basis of the presence or absence of other Axis I disorders (tab.4), people with PTSD (either current or lifetime) showed significantly higher scores than people without PTSD (current: P=0.02; lifetime: P=0.002), as well as people with PD (current: P<0.001; lifetime: P <0.001). On the opposite, people with MDD, either current or lifetime, did not show a different mean score on the ASA-27 from people without MDD.
5. Discussion
To the best of our knowledge, the present study is the first to explore adult separation anxiety disorder (SEPAD) among people with complicated grief (CG).
We found that adult SEPAD is highly frequent among CG patients, with a prevalence of about 69%. Compared with prevalence estimates from other clinical samples, we are reporting the highest prevalence of adult SEPAD, as previous studies found prevalences ranging from 23% to 54% 45-47, 51.
We found two studies in the literature evaluating the relationship between CG and adult SEPAD. In a large cohort of patients with mood and anxiety disorders CG was recently shown to be associated with adult SEPAD (Muti et al. in press). Nevertheless, a previous study conducted in war-affected refugees failed to find an association between adult SEPAD and CG, the only association being between adult SEPAD and PTSD 49.
As attachment theory has given insight into both adult SEPAD and CG, one possible explanation for such a high prevalence of adult SEPAD among CG patients could be that the two disorders are linked on the ground of attachment. Indeed, some studies have found an association between insecure attachment styles and both adult SEPAD and CG 18, 51.
specifically associated to traumatic loss 49. As long as both adult SEPAD and CG, which is also referred to as traumatic grief, are likely to follow a traumatic loss, the high prevalence of adult SEPAD among CG patients may be not surprising. Nevertheless, it has to be noted that the diagnosis of adult SEPAD was made using a cut-off instrument instead of a criteria-based instrument. Interestingly, studies using the same cut-off instrument, yielded the highest prevalence estimates that we found in the literature (54%) 62.
People with and without adult SEPAD did not differ in terms of gender, marital status and age, nor for any of the loss measures. Interestingly, the only loss measure showing a weak trend to significance was “relationship to the deceased” (P=.065). Specifically, the 88% (n=22) of people who developed CG after the death of a friend or a relative beyond the first degree had co-morbid adult SEPAD, whereas just the 12% (n=3) did not.
Prevalence estimates of CG among different populations of bereaved people do not clearly differ in the literature 63. Nevertheless, some data have shown that closely related people have higher levels of complicated grief 64. Larger samples could help to elucidate whether adult SEPAD might identify a subpopulation of bereaved people prone to experience CG symptoms after the loss of a not close relative.
Our data indicated that adult SEPAD is correlated to PTSD. This finding is not new in the literature. Silove and colleagues 49 found a strong association between
SEPAD and PTSD in trauma-affected refugees, with almost all individuals with SEPAD having co-morbid PTSD. Consistently, the NCS-R study 35 found PTSD showing one of the strongest pattern of co-morbidity with SEPAD among Axis I disorders. It has been proposed that the intense personal insecurity might be the common factor underlying both PTSD and SEPAD 49. This fear for personal safety may drive the need to maintain proximity to attachment figures, as well as increase the likelihood of experiencing PTSD symptoms after a traumatic event.
The relationship between SEPAD and Panic Disorder (PD) has long been a matter of debate. Separation sensitivity is considered a dimension of PD and it is included in the panic-agoraphobic spectrum41, 65, 66. On the other hand, some authors have been hypothesizing that adult SEPAD is a unique disorder, independent from PD, and that panic attacks might be secondary to separation anxiety 61. Our data showed that adult SEPAD and PD are strongly correlated. Particularly, almost all individuals with PD had co-morbid adult SEPAD, but just one third of people with adult SEPAD had also PD. Certainly, SEPAD symptoms are rather common among PD patients. One could speculate that the agoraphobic-like dimension of SEPAD might account for the high co-morbidity between SEPAD and PD. Nevertheless, our clinical impression is that adult SEPAD may also present as an independent disorder. Moreover, in our sample just one third of people with adult SEPAD had PD as well. Although in epidemiological studies up
more than 95% of individuals with Agoraphobia meet also criteria for PD 4, 67.
Interestingly, adult SEPAD was not correlated with Major Depression, either current or lifetime. Recent data from a large sample of subjects with mood and anxiety disorders showed that people with or without SEPAD (respectively juvenile and adult) do not differ significantly for the frequency of mood disorders, either major depression or bipolar disorder 45.
Similarly, Silove and colleagues 47 found no differences in depression rates between people with adult SEPAD and people with 2 or more different anxiety diagnoses as a control group. The same authors 49 found that adult SEPAD was not associated with Major depression in a sample of war-affected refugees. Consistently with our results, in all cited studies people with adult SEPAD showed more severe symptoms of depression.
Some data in the literature showed that SEPAD, both the juvenile and the adult form, are significantly more frequent in patients with bipolar disorder and panic disorder co-morbidity than in patients with major depression48, 68. Due to the exclusion criteria for enrollment in our study, the co-morbidity with bipolar disorder could not be evaluated. Nevertheless, our results might stand for the hypothesis that SEPAD may be linked to bipolar disorder rather than unipolar depression.
6. Limitation
One of the main limitation of this study is that we used a dimensional instrument to assess the presence of adult SEPAD. A score of 22 or greater on ASA-27 has been suggested as a reliable cut-off for diagnosis in clinical samples. Although this cut-off showed good sensitivity and specificity (respectively 81% and 84%) with respect to a diagnosis yielded by a semisctructured clinical interview (SCI-SAS) 56, a certain rate of misclassification could have occurred. Moreover, most of the epidemiological and clinical studies used a clinical interview to give a diagnosis of adult SEPAD, which has to be taken into account while comparing our results with epidemiological and clinical data from the literature. Thus, the discrepancy between our prevalence of adult SEPAD and prevalence estimates from other studies may be at least in part due to a less stringent threshold for assigning the diagnosis used in our study.
A further limitation is the lack of patients with more heterogeneous mood diagnoses. For bipolar disorder being among exclusion criteria for enrollment in the study, we were unable to investigate the relationship between adult SEPAD and bipolar disorder. Even though some interesting data came up with respect unipolar depression, we could not comprehensively evaluate the relationship between adult SEPAD and mood disorders.
7. Conclusion
Adult Separation Anxiety (SEPAD) is highly frequent among patients with complicated grief (CG). As to other anxiety disorders, adult SEPAD is strongly associated with post traumatic stress disorder and panic disorder. Even though there is a correlation between adult SEPAD symptoms and the severity of depressive symptoms, adult SEPAD is not significantly co-morbid with unipolar depression.
Further studies will be necessary in order to confirm and generalize our results and to elucidate whether adult SEPAD might affect the course of CG and treatment response.
8. References
1 Parkes CM, Prigerson H. Bereavement, studies of grief in adult life. Routledge 2010.
2 Jacobs SC. Pathologic Grief: Maladaptation to Loss. Washington DC: American Psychiatric Press;1993
3 Middleton W, Burnett P, Raphael B, Martinek N. The bereavement response: a cluster analysis. Br J Psychiatry. 1996;169:167-171
4 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington (DC): American Psychiatric Association; 2000.
5 Prigerson HG, Frank E, Kasl SV, et al. Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. Am J Psychiatry. 1995;152:22-30
6 Prigerson HG, Bierhals AJ, Kasl SV, Reynolds et al. Complicated Grief as a disorder distinct from bereavement-related depression and anxiety:a replication study. Am J Psychiatry.1996;153:1484-6
7 Prigerson HG, Shear MK, Jacobs S, et al. Grief and its relation to posttraumatic stress disorder. In: Nutt D, Davidson JR, Zohar J, eds. Posttraumatic Stress Disorders: Diagnosis, Management and Treatment. New York, NY: Martin Dunitz Publishers; 2000:163-177
8 Prigerson HG, Maciejewski PK, Reynolds CF 3rd, et al. Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss.
Psychiatry Res. 1995;59:65-79
9 Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA. 2005;293:2601-2608
10 Schulz R, Boerner K, Shear K, Zhang S, Gitlin LN. Predictors of complicated grief among dementia caregivers: a prospective study of bereavement. Am J Geriatr Psychiatry. 2006;14:650-8
11 Bass DM, Bowman K. The transition from caregiving to bereavement: the relationship of care-related strain and adjustment to death. Gerontologist 1990; 30:35–42
12 Bernard LL, Guarnaccia CA. Two models of caregiver strain and bereavement adjustment: a comparison of husband and daughter caregivers of breast cancer hospice patients. Gerontologist 2003; 43:808–816
13 Boerner K, Schulz R, Horowitz A. Positive aspects of caregiving and adaptation to bereavement. Psychol Aging 2004; 19:668–675
14 Gitlin L, Belle SH, Burgio L, et al: Effect of multicomponent interventions on caregiver burden and depression: the REACH multisite initiative at 6-month follow-up. Psychol Aging 2003;18:361–374
15 Li LW. From caregiving to bereavement: trajectories of depressive surviving caregivers: Does length of hospice enrollment matter? symptoms among wife and daughter caregivers. J Gerontol B Psychol Sci Soc Sci 2005; 60:P190–198
to death of a spouse: findings from the Caregiver Health Effects Study. JAMA 2001; 285:3123–3129
17 Aneshensel CS, Botticello AL, Yamamoto-Mitani N. When caregiving ends: the course of depressive symptoms after bereavement. J Health Soc Behav 2004; 45:422–440
18 van Doorn C, Kasl SV, Beery LC, Jacobs SC, et al. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis. 1998;186:566-73
19 Prigerson HG, Maciejewski PK, Rosenheck RA. Preliminary explorations of the harmful interactive effects of widowhood and marital harmony on health, health service use, and health care costs. Gerontologist. 2000;40:349-57
20 Fraley RC, Bonanno GA. Attachment and loss: A test of three competing models on the association between attachment-related avoidance and adaptation to bereavement. Pers Soc Psychol Bull. 2004;30:878 – 890
21 Johnson JG, Zhang B, Greer JA, Prigerson HG. Parental Control, Partner Dependency and Complicated Grief among Widowed Adults in the Community. Journal of Nervous and Mental Disease. 2007;195: 26-30
22 Silverman GK, Johnson JG, Prigerson HG Preliminary explorations of the effects of prior trauma and loss on risk for psychiatric disorders in recently widowed people. Isr J Psychiatry Relat Sci. 2001;38:202–215
grief in later life. J Nerv Ment Dis. 2006;194:121-3
24 Bowlinget A. Mortality after bereavement: a review of the literature on
survival periods and factors affecting survival. Soc Sci Med. 1987;24:117-124
25 Lee M, Carr D. Does the context of spousal loss affect the physical functioning of older widowed persons? Res Aging. 2007;29:457-487
26 Silverman GK, Jacobs SC, Kasl SV, et al. Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychol Med. 2000;30:857-862
27 Prigerson HG, Bierhals A J, Kasl SV, et al. Complicated grief as a risk factor for mental and physical morbidity. Am J Psychiatry. 1997; 154:616 – 623.
28 Szanto K, Shear MK, Houck PR, et al. Indirect self-destructive behavior and overt suicidality in patients with complicated grief. J Clin Psychiatry. 2006;67:233-239
29 Prigerson HG, Bierhals AJ, Kasl SV, et al. Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study. Am J Psychiatry. 1996;153:1484-1486
30 Pasternak RE, Reynolds CF, 3rd, Frank E, Miller M. The temporal course of depressive symptoms and grief intensity in late-life spousal bereavement. Depression. 1993;1:45-49
31 Reynolds CF, 3rd, Miller MD, Pasternak RE, et al. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute
and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry. 1999;156:202-208
32 Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 1991;59:715-723
33 Zygmont M, Prigerson HG, Houck PR, et al. A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief. J Clin Psychiatry. 1998; 59:241-245
34 Boelen PA, de Keijser J, van den Hout MA, van den Bout J. Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 2007;75:277-84
35 Shear K, Jin R, Ruscio AM, et al. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:1074-83
36 Shear MK. Factors in the etiology and pathogenesis of panic disorder: revisiting the attachment-separation paradigm. Am J Psychiatry. 1996;153:125-36
37 Silove D, Manicavasagar V, Curtis J, Blaszczynski A. Is early separation anxiety a risk factor to adult panic disorder? A critical review . Compr Psychiatry.1996;37:1-14.
38 Lewinsohn PM, Zinbarg R, Seeley JR, et al. Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders
39 Lipsitz JD, Martin LY, Mannuzza S, et al. Childhood separation anxiety disorder in patients with adult anxiety disorders. Am J Psychiatry. 1994;151:927-929
40 Manicavasagar V, Silove D, Curtis J. Separation anxiety in adulthood: a phenomenological investigation. Compr Psychiatry. 1997;38:274-82
41 Fagiolini A, Shear MK, Cassano GB, Frank E. Is lifetime separation anxiety a manifestation of panic spectrum? CNS Spectr. 1998;3:63-72
42 Cyranowski JM, Shear MK, Rucci P et al. Adult separation anxiety:
psychometric properties of a new structured clinical interview. J Psychiatr Res. 2002;36:77-86
43 Wijeratne C and Manicavasagar V. Separation anxiety in the elderly. J Anxiety Disord. 2003;17:695-702
44 Manicavasagar V, Silove D, Curtis J. Separation anxiety in adulthood: a phenomenological investigation. Compr Psychiatry. 1997 Sep-Oct;38(5):274-82.
45 Pini S, Abelli M, Shear KM, Cardini A, Lari L, Gesi C, Muti M, Calugi S Galderisi S, Troisi A, Bertolino A, Cassano GB. Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatr Scand. 2010 Jul;122(1):40-6.
46 Manicavasagar V, Silove D, Curtis J, Wagner R. Continuities of separation anxiety from early life into adulthood. J Anxiety Disord. 2000; 4: 1–18
prevalence and correlates of adult separation anxiety disorder in an anxiety clinic. BMC Psychiatry. 2010 Mar 10;10:21.
48 Pini S, Abelli M, Mauri M, Muti M, Iazzetta P, Banti S, Cassano GB. Clinical correlates and significance of separation anxiety in patients with bipolar disorder. Bipolar Disord. 2005 Aug;7(4):370-6.
49 Silove D, Momartin S, Marnane C, Steel Z, Manicavasagar V. Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma. J Trauma Stress. 2010 Feb;23(1):169-72.
50 Bowlby J. Attachment and Loss, Vol. 2: Separation. New York: Basic Books. 1973
51 Manicavasagar V, Marnane C, Pini S, Abelli M, Rees S, Eapen V, Silove D. Adult separation anxiety disorder: a disorder comes of age. Curr Psychiatry Rep. 2010 Aug;12(4):290-7.
52 Aaronson CJ, Shear MK, Goetz RR, et al. Predictors and time course of response among panic disorder patients treated with cognitive-behavioral therapy. J Clin Psychiatry. 2008;69:418-24
53 Kirsten LT, Grenyer BF, Wagner R, Manicavasagar V: Impact of separation anxiety on psychotherapy outcomes for adults with anxiety disorders. Counselling & Psychotherapy Research 2008, 8(1):36-42.
54 First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM IV axis I disorders. New York State Psychiatric Institute; New
55 Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;25: 56-67
56 Manicavasagar V, Silove D, Wagner R, Drobny J. A self-report questionnaire for measuring separation anxiety in adulthood. Compr Psychiatry 2003; 44: 146–153
57 Shear K, Monk T, Houck P, et al. An attachment-based model of complicated grief including the role of avoidance. Eur Arch Psychiatry Clin Neurosci. 2007;257:453-61
58 Marmar CR, Metzler TJ, Otte C. The Peritraumatic Dissociative Experiences Questionnaire. In J. P. Wilson & T. M. Keane (Eds.) Assessing
psychological trauma and PTSD (2nd ed.) 2004;144–167. New York, NY: Guilford Press
59 Chung MC, Werrett J, Easthope Y, Farmer S. Coping with post-traumatic stress: young, middle-aged and elderly comparisons. Int J Geriatr Psychiatry. 2004;19:333-343
60 Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002;180:461-464
61 Manicavasagar V, Marnane C, Pini S, Abelli M, Rees S, Eapen V, Silove D. Adult separation anxiety disorder: a disorder comes of age. Curr Psychiatry Rep. 2010 Aug;12(4):290-7.
62 Manicavasagar V, Silove D, Marnane C, Wagner R. Adult attachment styles in panic disorder with and without comorbid adult separation anxiety
disorder. Aust N Z J Psychiatry 2009;43:167–172.
63 McCarthy MC, Clarke NE, Ting CL, Conroy R, Anderson VA, Heath JA. Prevalence and predictors of parental grief and depression after the death of a child from cancer. J Palliat Med. 2010 Nov;13(11):1321-6.
64 Mitchell AM, Kim Y, Prigerson HG, Mortimer-Stephens M. Complicated grief in survivors of suicide. Crisis. 2004;25(1):12-8.
65 Shear MK, Cassano GB, Frank E, Rucci P, Rotondo A, Fagiolini A. The panic-agoraphobic spectrum: development, description, and clinical significance. Psychiatr Clin North Am. 2002 Dec;25(4):739-56.
66 Rucci P, Miniati M, Oppo A, Mula M, Calugi S, Frank E, Shear MK, Mauri M, Pini S, Cassano GB. The structure of lifetime panic-agoraphobic spectrum. J Psychiatr Res. 2009 Jan;43(4):366-79.
67 Wittchen HU, Gloster AT, Beesdo-Baum K, Fava GA, Craske MG.
Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety. 2010 Feb;27(2):113-33.
68 Toni C, Perugi G, Frare F, Tusini G, Fountoulakis KN, Akiskal KK, Akiskal HS. The clinical-familial correlates and naturalistic outcome of panic-disorder agoraphobia with and without lifetime bipolar II comorbidity. Ann Gen Psychiatry. 2008 Nov 13;7:23.
Bowlby J. Attachment and Loss, Vol 3: Loss: Sadness and Depression. New York: Basic Books. 1980;153:1484 –1486
separation anxiety: relevance to risk of adult anxiety disorders. J Affect Disord. 1998; 48: 181–190
Melhem NM, Day N, Shear MK, Day R, Reynolds CF 3rd, Brent D. Traumatic grief among adolescents exposed to a peer's suicide. Am J Psychiatry. 2004 Aug;161(8):1411-6.
9. Tables Table 1
Socio-demographic correlates of adult SEPAD among patients with CG
No ASAD (n=47) ASAD (n=104) N (%) N (%) Chi-square P Age 18-29 30-44 45-59 60+ 3 (6) 13 (28) 22 (47) 9 (19) 9 (9) 41 (39) 41 (39) 13 (13) 2.9 0.41 Gender Male Female 11 (23) 36 (77) 15 (14) 89 (86) 1.8 0.18 Race Caucasian African American Other 35 (75) 10 (21) 2 (4) 66 (65) 34 (33) 2 (2) 2.7 0.02 Education 0-11 12 13-15 16 or more years 1 (2) 8 (19) 14 (33) 20 (47) 13 (13) 26 (25) 33 (32) 31 (30) 6.3 0.1 Marital status Never Married Married Divorc./Widow. 13 (28) 16 (34) 18 (38) 30 (29) 24 (23) 50 (48) 2.2 0.34
Tab.2 Grief correlates of adult SEPAD among patients with CG
No SEPAD (n=47) SEPAD (n=104) n (%) or Mean (SD) n (%) or Mean (SD) Chi-square or T value P Relationship of deceased Spouse/partner Parent Child Other 14 (29) 14 (29) 16 (34) 3 (6) 27 (26) 33 (32) 21 (20) 22 (22) 7.0 0.065 Type of loss violent not violent 8 (28) 21 (72) 16 (34) 31 (66) 0.4 0.56 Number of losses 0 1 2 3 0 (0) 19 (40) 18 (38) 10 (21) 1 (1) 37 (35) 33 (32) 33 (32) 2.3 0.51 Ham-D tot 17.43 22.46 -3.7 <0.001 ICG 42.49 (7.16) 48.26 (10.25) -3.94 <0.001 PDEQ 28.36 ( 33.61 -2.90 0.004 GRAQ 17.82 (11.04) 27.73 (11.94) -4.14 <0.001 IES Intrusion Avoidance 18.30 (8.13) 15.87 (8.45) 22.88 (7.27) 21.60 (8.98) -3.45 -3.68 <0.001 <0.001 WSAS 18.26 (9.36) 23.25 (10.52) -2.79 0.006
Tab.3
Co-morbidity of ASAD with Post Traumatic Stress disorder (PTSD), Panic Disorder (PD) and Major Depressive Disorder (MDD), current and lifetime respectively. No SEPAD (n=44) SEPAD (n=92) P n (%) n (%) PTSD current lifetime 18 (40.91) 21 (47.73) 54 (58.70) 61 (66.30) 0.06 0.04 PD current lifetime 0 2 (4.55) 19 (20.65) 27 (29.35) 0.01 0.01 MD current lifetime 22 (50.00) 33 (75.00) 58 (62.37) 74 (79.57) 0.20 0.66
Tab.4
Mean Scores on the ASA-27, among the total sample, based on the presence or absence of Post Traumatic Stress disorder (PTSD), Panic Disorder (PD) and Major Depressive Disorder (MDD) current and lifetime respectively.
ASA-27 Mean (SD) T Value P PTSD current present absent 32,38 (14,95) 26,41 (14,48) -2,36 0.02 PTSD lifetime present absent 32,59 (15,81) 24,99 (12,40) -3,13 0.002 PD current present absent 42,21 (12,54) 27,51 (14,36) -4,64 <0.001 PD lifetime present absent 38,24 (14,37) 27,22 (14,31) -3,67 <0.001 MDD current present absent 31,86 (15,78) 26,88 (13,83) -1,96 0.051 MDD lifetime present absent 30,52 (15,38) 27,17 (14,25) -1,12 0.27
