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BMC Psychiatry

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Open Access 01-12-2017 | Research article

Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder

Authors: Carina Heeke, Nadine Stammel, Manuel Heinrich, Christine Knaevelsrud

Published in: BMC Psychiatry | Issue 1/2017

Abstract

Background

Exposure to trauma and bereavement is common in conflict-affected regions. Previous research suggests considerable heterogeneity in responses to trauma and loss with varying symptom representations. The purpose of the current study was to (1) identify classes of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptom profiles among individuals who were exposed to both trauma and loss due to the Colombian armed conflict and (2) to examine whether sociodemographic, loss and trauma-related characteristics could predict class membership.

Methods

Three hundred eight victims of internal displacement who had experienced trauma and loss were assessed through measures of PGD (PG-13), PTSD (PCL-C), and social support (DUKE-UNC). Latent class analysis (LCA) was performed to analyze differential profiles by symptoms of PGD and PTSD and multinomial logistic regression was used to analyze predictors of class membership.

Results

LCA revealed a four-class solution: a resilient class (23.6%), a PTSD-class (23.3%), a predominately PGD class (25.3%) and a high distress-class with overall high values of PGD and PTSD (27.8%). Relative to the resilient class, membership to the PGD class was predicted by the loss of a close family member and the exposure to a higher number of assaultive traumatic events, whereas membership to the PTSD class was predicted by the perception of less social support. Compared to the resilient class, participants in the high distress-class were more likely to be female, to have lost a close relative, experienced more accidental and assaultive traumatic events, and perceived less social support.

Discussion

Specific symptom profiles emerged following exposure to trauma and loss within the context of the Colombian armed conflict. Profiles were associated with distinct types of traumatic experiences, the degree of closeness to the person lost, the amount of social support perceived, and gender. The results have implications for identifying distressed subgroups and informing interventions in accordance with the patient’s symptom profile.

Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–49. doi:10.1001/jama.2009.1132.CrossRefPubMed

Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Raphael B, Marwit SJ, Wortman C, Neimeyer RA, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e10000121. doi:10.1371/journal.pmed.1000121.CrossRef

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington: American Psychiatric Publishing; 2013.CrossRef

Maercker A, Brewin CR, Bryant RA, Cloitre M, Ommeren M, Jones LM, Humayan A, Kagee A, Llosa AE, Rousseau C. Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry. 2013;12(3):198–206. doi:10.1002/wps.20057.CrossRefPubMedPubMedCentral

Kersting A, Braehler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord. 2011;131(1-3):339–43. doi:10.1016/j.jad.2010.11.032.CrossRefPubMed

Fujisawa D, Miyashita M, Nakajima S, Ito M, Kato M, Kim Y. Prevalence and determinants of complicated grief in general population. J Affect Disord. 2010;127(1-3):352–8. doi:10.1016/j.jad.2010.06.008.CrossRefPubMed

Bonanno GA, Kaltman S. The varieties of grief experience. Clin Psychol Rev. 2001;21(5):705–34. doi:10.1016/S0272-7358(00)00062-3.CrossRefPubMed

Kristensen P, Weisaeth L, Heir T. Bereavement and mental health after sudden and violent losses: a review. Psychiatry. 2012;75(1):76–97. doi:10.1521/psyc.2012.75.1.76.CrossRefPubMed

Boelen PA, de Keijser J, Smid G. Cognitive–behavioral variables mediate the impact of violent loss on post-loss psychopathology. Psychol Trauma. 2015;7(4):382. doi:10.1037/tra0000018.CrossRefPubMed

10.

Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319–45. doi:10.1016/S0005-7967(99)00123-0.CrossRefPubMed

11.

Boelen PA, van den Hout MA, van den Bout J. A cognitive-behavioral conceptualization of complicated grief. Clin Psychol-Sci Pract. 2006;13(2):109–28. doi:10.1111/j.1468-2850.2006.00013.x.CrossRef

12.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn, revised) (DSM-IV-TR). Washington, DC: APA; 2001.

13.

Stammel N, Heeke C, Bockers E, Chhim S, Taing S, Wagner B, Knaevelsrud C. Prolonged grief disorder three decades post loss in survivors of the Khmer rouge regime in Cambodia. J Affect Disord. 2013;144(1-2):87–93. doi:10.1016/j.jad.2012.05.063.CrossRefPubMed

14.

Morina N, von Lersner U, Prigerson HG. War and bereavement: consequences for mental and physical distress. PLoS One. 2011;6(7):e22140. doi:10.1371/journal.pone.0022140.CrossRefPubMedPubMedCentral

15.

Schaal S, Jacob N, Dusingizemungu JP, Elbert T. Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors. BMC Psychiatry. 2010;10(55). doi:10.1186/1471-244x-10-55.

16.

Morina N, Rudari V, Bleichhardt G, Prigerson HG. Prolonged grief disorder, depression, and posttraumatic stress disorder among bereaved Kosovar civilian war survivors: a preliminary investigation. Int J Soc Psychiatry. 2010;56(3):288–97. doi:10.1177/0020764008101638.CrossRefPubMed

17.

Schaal S, Elbert T, Neuner F. Prolonged grief disorder and depression in widows due to the Rwandan genocide. Omega (Westport). 2009;59(3):203–19. doi:10.2190/OM.59.3.b.CrossRef

18.

Galatzer-Levy IR, Bryant RA. 636,120 ways to have posttraumatic stress disorder. Perspect Psychol Sci. 2013;8(6):651–62. doi:10.1177/1745691613504115.CrossRefPubMed

19.

Nickerson A, Liddell BJ, Maccallum F, Steel Z, Silove D, Bryant RA. Posttraumatic stress disorder and prolonged grief in refugees exposed to trauma and loss. BMC Psychiatry. 2014;14(1):106. doi:10.1186/1471-244X-14-106.CrossRefPubMedPubMedCentral

20.

Boelen PA, Reijntjes A, J. Djelantik AAAM, Smid GE. Prolonged grief and depression after unnatural loss: Latent class analyses and cognitive correlates. Psychiatry Res. 2016;240:358–363. doi:10.1016/j.psychres.2016.04.012.

21.

Internal Displacement Monitoring Center. Global overview 2015: people internally displaced by conflict and violence. In: . Geneva: Internal Displacement Monitoring Center. p. 2015.

22.

Centro Nacional de Memoria Histórica. Basta ya! Colombia: Memorias de guerra y dignidad. Bogotá: Imprenta Nacional; 2013.

23.

Neria Y, Gross R, Litz B, Maguen S, Insel B, Seirmarco G, Rosenfeld H, Suh EJ, Kishon R, Cook J, et al. Prevalence and psychological correlates of complicated grief among bereaved adults 2.5-3.5 years after September 11th attacks. J Trauma Stress. 2007;20(3):251–62. doi:10.1002/jts.20223.CrossRefPubMed

24.

Kolassa I-T, Ertl V, Eckart C, Kolassa S, Onyut LP, Elbert T. Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychol Trauma. 2010;2(3):169. doi:10.1037/a0019362.CrossRef

25.

Breslau N, Peterson E, Poisson L, Schultz L, Lucia V. Estimating post-traumatic stress disorder in the community: lifetime perspective and the impact of typical traumatic events. Psychol Med. 2004;34(05):889–98. doi:10.1017/S0033291703001612.CrossRefPubMed

26.

Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol. 2000;68(5):748. doi:10.1037/0022-006X.68.5.748.CrossRefPubMed

27.

Burke LA, Neimeyer RA, McDevitt-Murphy ME. African American homicide bereavement: aspects of social support that predict complicated grief, PTSD, and depression. Omega-J Death Dying. 2010;61(1):1–24. doi:10.2190/OM.61.1.a.CrossRef

28.

Heeke C, Stammel N, Knaevelsrud C. When hope and grief intersect: rates and risks of prolonged grief disorder among bereaved individuals and relatives of disappeared persons in Colombia. J Affect Disord. 2015;173(0):59–64. doi:10.1016/j.jad.2014.10.038.CrossRefPubMed

29.

Powell S, Butollo W, Hagl M. Missing or killed: the differential effect on mental health in women in Bosnia and Herzegovina of the confirmed or unconfirmed loss of their husbands. Eur Psychol. 2010;15(3):185–92. doi:10.1027/1016-9040/a000018.CrossRef

30.

Lenferink LI, von Denderen M, de Keijser J, Wessel I, Boelen P. Prolonged grief and post-traumatic stress among relatives of missing persons and homicidally bereaved individuals: a comparative study. J Affect Disord. 2017;209(1-2). doi:10.1016/j.jad.2016.11.012.

31.

Stammel N, Heeke C, Díaz Gómez MT, Ziegler M, Knaevelsrud C. We don't want to be left behind: attitudes and experiences of internally displaced persons within the context of the armed conflict and the reparation process in Colombia. Berlin: Behandlungszentrum für Folteropfer; 2012.

32.

Prigerson HG, Vanderwerker LC, Maciejewski PK. A case for inclusion of prolonged grief disorder in DSM-V. In: Stroebe MS, Hansson RO, Schut H, Stroebe W, Van den Blink E, editors. Handbook of bereavement research and practice: advances in theory and intervention. Washington, DC: American Psychological Association; 2008. p. 165–86.CrossRef

33.

Weathers FW, Litz BT, Huska JA, Keane TM. PTSD checklist - civilian version. Boston: National Center for PTSD; 1994.

34.

Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress Anxiety. 2011;28(7):596–606. doi:10.1002/da.20837.CrossRefPubMedPubMedCentral

35.

Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD checklist (PCL). Behav Res Ther. 1996;34(8):669–73. doi:10.1016/0005-7967(96)00033-2.CrossRefPubMed

36.

Miles JNV, Marshall GN, Schell TL. Spanish and English versions of the PTSD checklist – civilian version (PCL-C): testing for differential item functioning. J Trauma Stress. 2008;21(4):369–76. doi:10.1002/jts.20349.CrossRefPubMedPubMedCentral

37.

Cairo JB, Dutta S, Nawaz H, Hashmi S, Kasl S, Bellido E. The prevalence of posttraumatic stress disorder among adult earthquake survivors in Peru. Disaster Med Public Health Prep. 2010;4(01):39–46. doi:10.1016/j.socscimed.2013.11.012.CrossRefPubMed

38.

Mollica RF, Caspiyavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard trauma questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic-stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992;180(2):111–6. doi:10.1097/00005053-199202000-00008.CrossRefPubMed

39.

Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9(4):445–51.CrossRef

40.

Nickerson A, Bryant RA, Schnyder U, Schick M, Mueller J, Morina N. Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees. J Affect Disord. 2015;173:185–92. doi:10.1016/j.jad.2014.10.043.CrossRefPubMed

41.

Broadhead W, Gehlbach SH, De Gruy FV, Kaplan BH. The Duke-UNC functional social support questionnaire: measurement of social support in family medicine patients. Med Care. 1988;26(7):709–723. doi:10.1097/00005650-198807000-00006.

42.

Bellón Saameño J, Delgado Sánchez A, Luna del Castillo J, Lardelli Claret P. Validez y fiabilidad del cuestionario de apoyo social funcional Duke-UNC-11. Aten Primaria. 1996;18(4):153–63.PubMed

43.

Nylund KL, Asparouhov T, Muthén BO. Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Struct Equ Model. 2007;14(4):535–69. doi:10.1080/10705510701575396.CrossRef

44.

Geiser C. Datenanalyse mit Mplus. Wiesbaden: VS Verlag für Sozialwissenschaften; 2011.CrossRef

45.

Muthén L, Muthén B. Mplus User's Guide (Version 7). Muthén & Muthén: Los Angeles; 2015.

46.

Asparouhov T, Muthén B: Auxiliary variables in mixture modeling: Using the BCH method in Mplus to estimate a distal outcome model and an arbitrary secondary model. Mplus Web Notes. 2014; 21(2).

47.

Vermunt JK. Latent class modeling with covariates: two improved three-step approaches. Polit Anal. 2010;18(4):450–69. doi:10.1093/pan/mpq025.CrossRef

48.

Asparouhov T, Muthén B. Auxiliary variables in mixture modeling: three-step approaches using Mplus. Struct Equ Model. 2014;21(3):329–41. doi:10.1080/10705511.2014.915181.CrossRef

49.

Masyn KE. Latent class analysis and finite mixture modeling. In: Little TD, Little TD, editors. The Oxford handbook of quantitative methods (Vol 2): statistical analysis. New York, NY, US: Oxford University Press; 2013. p. 551–611.

50.

Laurie A, Neimeyer RA. African Americans in bereavement: grief as a function of ethnicity. Omega (Westport). 2008;57(2):173–93. doi:10.2190/OM.57.2.d.CrossRef

51.

Tsai W-I, Prigerson HG, Li C-Y, Chou W-C, Kuo S-C, Tang ST. Longitudinal changes and predictors of prolonged grief for bereaved family caregivers over the first 2 years after the terminally ill cancer patient’s death. Palliat Med. 2016;30(5):495–503. doi:10.1177/0269216315603261.CrossRefPubMed

52.

Klasen F, Oettingen G, Daniels J, Post M, Hoyer C, Adam H. Posttraumatic resilience in former Ugandan child soldiers. Child Dev. 2010;81(4):1096–113. doi:10.1111/j.1467-8624.2010.01456.x.CrossRefPubMed

53.

Burke LA, Neimeyer RA. Prospective risk factors for complicated grief. In: Stroebe MS, Schut H, van den Bout J, editors. Complicated grief: scientific foundations for health care professionals. New York: Routledge; 2013. p. 145–61.

54.

Porter M, Haslam N. Predisplacement and Postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294(5):602–12. doi:10.1001/jama.294.5.602.CrossRefPubMed

55.

Boelen PA, Reijntjes A, Smid GE. Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement. J Anxiety Disord. 2016. doi:10.1016/j.janxdis.2016.03.004.

56.

Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol. 2004;72(4):579. doi:10.1037/0022-006X.72.4.579.CrossRefPubMed

57.

Lambert JE, Alhassoon OM. Trauma-focused therapy for refugees: meta-analytic findings. J Couns Psychol. 2015;62(1):28–37. doi:10.1037/cou0000048.CrossRefPubMed

58.

Nickerson A, Bryant RA, Silove D, Steel Z. A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev. 2011;31(3):399–417. doi:10.1016/j.cpr.2010.10.004.CrossRefPubMed

59.

Kersting A, Dölemeyer R, Steinig J, Walter F, Kroker K, Baust K, Wagner B. Brief internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial. Psychother Psychosom. 2013;82(6):372–81. doi:10.1159/000348713.CrossRefPubMed

60.

Layne CM, Saltzman WR, Poppleton L, Burlingame GM, Pašalić A, Duraković E, Mušić M, Ćampara N, Ðapo N, Arslanagić B, et al. Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1048–62. doi:10.1097/CHI.0b013e31817eecae.CrossRefPubMed

Title: Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder
Authors: Carina Heeke
Nadine Stammel
Manuel Heinrich
Christine Knaevelsrud
Publication date: 01-12-2017
Publisher: BioMed Central
Published in: BMC Psychiatry / Issue 1/2017
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-017-1286-2

At a glance: The STEP trials

Springer Medicine

Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder

Abstract

Background

Methods

Results

Discussion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Discussion

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