About ISTSS
Traumatic Loss and Grief SIG

Traumatic Loss and Grief Special Interest Group

Update - Spring 2013

Dear SIG Members,

Thank you for joining the Traumatic Loss and Grief Special Interest Group (TLG-SIG). We hope to see you at the annual SIG meeting at the ISTSS Annual Meeting. At these meetings, we have had important dialogue about the proposed DSM-V diagnosis for bereavement, traumatic loss and grief theory, measurement and current treatments. On this webpage you will find summaries of some of these TLG-SIG discussions including a list of current measures and treatment manuals. Please feel free to use the ISTSS Groups Discussion Board to share information related to traumatic grief and loss with other TLG-SIG members. We will look forward to seeing you at the next ISTSS conference.

Regards,

Alison Salloum, Ph.D.
University of South Florida

Mission Statement (Updated 2013)

Treatment Manuals for Traumatic Grief and Loss (Updated 2013)

Update - Fall 2011

Dear SIG Members,

Thank you for joining the Traumatic Loss and Grief Special Interest Group. We hope to see you at the annual SIG meeting at the ISTSS 27th Annual Meeting. This year there will be three Traumatic Grief and Loss SIG Endorsed Presentations. Having three presentations on traumatic loss and grief is consistent with our SIG goal to promote increased knowledge about theory, research and practice related to children and adults who are experiencing traumatic loss and grief. We look forward to continuing the dialogue about the proposed DSM-V diagnosis for bereavement. For more information please see the proposed DSM-V Adjustment Disorder Related to Bereavement and the Bereavement Related Disorder http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=367

In addition, we want to promote interdisciplinary dialogue and sharing of current studies, instruments, and practice methods. Please see the preliminary list of adult and child bereavement related measures recently posted on our site.

Regards,

Alison Salloum, Ph.D.
Assistant Professor
University of South Florida

Inventory of Grief and Loss Measures (PDF)

Fall 2010
Dear SIG Members,

Delineating the type of complicated grief (CG) or the combinations of factors that may complicate grieving is important to the nature and effectiveness of interventions. PDFs are provided that discuss several types of CG. References are provided that discuss issues of grief and its complication. Reference lists have been updated and are now divided by category. It is clear that more study is needed to examine mixed findings for several variables and their associations to CG under varying circumstances.

Attached are the following PDFs for your information. They represent the final update for 2010.

Please let us know if there are any missing references or topics that should be represented here. In November of 2010, Alison Salloum will be taking over as chairperson of the Loss and Grief SIG. Congratulations, Alison. We look forward to your leadership.

Sincerely,
Kathleen Nader

Table 1. A brief look at separate aspects of two forms of complicated grief
Preliminary Draft (12/15/08)

	Prolonged Grief Disorder	Traumatic Grief
Foci	The relationship with the deceased Issues of personal identity in the absence of the deceased	The traumatic event or experience The nature and/or circumstances of the death
Descriptions of inability to move through or out of grief	stuck in a state of chronic mourning (Prigerson, 2004) (Prigerson et al., 2008, p. 170)	stuck on the traumatic aspects of the death (NCTSN, 2004)
Role of Trauma	May occur without a traumatic event, when the loss is personally devastating The loss of the deceased may be experienced as traumatic	The death occurred under traumatic circumstances The survivor may or may not have had direct exposure to the event Perception by a child (not necessarily shared by others) that the death was sudden, shocking, or frightening may result in traumatic grief
Relationship to Normal Bereavement	Failure of the transition from acute grieving to integrated grief (or the beginnings of integration) by 6 months after the death Symptoms of normal bereavement may be intense, prolonged, and undermine the ability to function	Tasks of normal grieving may not be possible until after aspects of the traumatic experience and response are resolved The occurrence of symptoms of grief may trigger traumatic symptoms and undermine the ability to grieve normally as well as undermine the ability to function The interplay between trauma and grief may intensify symptoms common to each
Reexperiencing	May experience recurrent intrusive, distressing thoughts and images of the deceased Intensely emotional intrusions fail to diminish over time -Immune function may be diminished and health disturbed over time May continue to frequent places frequented by the deceased, misperceive others for the deceased, and interpret specific perceptual clues as related to the deceased beyond the normal period of acute grief; these deliberate imaginal and behavioral forms of continuing the bond with the deceased may impede integration of the loss	Grief reexperiencing may occur in addition to event-specific PTSD reexperiencing -May repeatedly experience intrusions of observed or imagined images of the manner of the death - Thoughts of the deceased trigger traumatic memories and reexperiencing, avoidance, and/or arousal May reenact in behaviors, activities, or play the circumstances of the death or other death-related repetitions (e.g., for children, repeated death-related rhymes, talking repeatedly about death and dying) May experience physiological reactions and/or psychological reactivity to reminders of the deceased -Immune function may be diminished and health disturbed over time
Avoidance	May avoid reminders of the absence of the deceased May persistently avoid reminders of the loss -May avoid places and things that are reminders of the death, activities that are reminders of the loss (e.g., the deceased persons frequent, enjoyed or anticipated activities), and/or situations related to illness or death that ordinarily evoke sympathy (e.g., attending a funeral or visiting an ill person) in order to regulate strong emotions such as intensifying sadness and yearning (painful longing) for the deceased and/or to avoid confronting the painful reality of the death Avoidance may become excessive and thus hinder both loss-related and restoration related processes The inhibition of competence motivation may produce a continuing sense of estrangement from the world	May avoid reminders of the deceased to avoid reminders of the traumatic nature of the death and/or avoid traumatic reexperiencing and arousal May avoid people, things, places and activities that remind of the deceased because remembering the deceased reminds of the manner of death and triggers cue-conditioned fear and other trauma symptoms (for children, rule out avoidance related to superstitious thinking about the contagion of death) Avoidance may be related to the intensity of reactions to combined trauma and grief. For example, a sense of estrangement may be intensified because of trauma and grief-influenced withdrawal and other symptoms.
Arousal	Sleep disturbance Cortisol levels may be elevated with persistent intense grief	May experience arousal symptoms associated with PTSD and/or acute grief (e.g., sleep disturbance) Coritsol levels may vary with time since the trauma and with age
Functioning	Impaired social, occupational, or other important areas of functioning (e.g., domestic responsibilities) Competence motivation (mastery) and exploration behaviors are inhibited Additional examination is needed to assess the skill disruption for children replacement-attachment seeking may additionally disrupt life-trajectory	Impaired social, academic, occupational, or other important areas of functioning Loss of goal motivation and mastery -For children, skill development (e.g., self-control, learning) may be disrupted and/or impaired
Identified Risk Factors	Pronounced avoidance; African American race; intense negative affect in the initial grief period	Children: parental psychopathology; increased traumatic exposures in combination with a traumatic death; specific coping such as venting anger, fighting, avoiding people, using a creative outlet, and doing volunteer work; increased media exposure to the traumatic event Boys' oppositional behaviors Girls' anxiety & depression
Identified Protective Factors	A reducing magnitude of oscillations between attention away from and attention toward the deceased; positive emotions during bereavement	Children: early treatment seeking; preexisting good mental health; good parental mental health; preexisting in tact family; a good support system; good parental coping skills
Comorbidity	May co-occur with full or subthreshold PTSD and/or Depression	May co-occur with full or subthreshold PTSD and/or Depression, general anxiety

Nader, 2008 Sources: Boelen et al., 2006; Bonanno, 2004; Brown & Goodman, 2005; Brown, Pearman & Goodman, 2004; Cohen et al., 2002, 2004; DeBellis, 2001; Goldsmith et al., 2008; Jacobs, 1999; Layne et al., 2001; Nader, 1994, 1997; 2008; Nader et al., 1993; National Child Traumatic Stress Network (NCTSN), 2004; Pfefferbaum et al., 1999, 2000; Prigerson, 2004; Prigerson et al., 1999; Prigerson et al., 2008; Pynoos et al., 1987 (both articles); Rafael et al., 2004; Shear et al., 2006; Shear et al., 2007; Shear & Shair, 2005

Prolonged Grief Disorder pdf
Traumatic Grief pdf

Spring 2009
Dear SIG members,

Thank you to Judith Cohen, Christopher Layne, Alison Salloum, and Holly Prigerson for their input. Their suggestions and comments are among the revisions that have been or will be put into the pdfs. Some references have been added and additional references and findings will be added periodically.

The table above was based on both theory and findings. It is a working effort to distinguish the two types of maladaptive grieving discussed at the 2008 ISTSS meeting. As indicated on the revision of the TG pdf, the table presented in that pdf is intended as something to revise and test. Chris has reminded me that we are talking about grief reactions that range from adaptive to maladaptive. Although the TG pdf may focus on deaths that occur in relationship to traumatic events, you may have observed other forms of maladaptive grief in addition to those represented in the two pdfs.

All of the items offered on the website are for your additional discussion and suggestions for revision. There will be ongoing updates and revisions.

Questions
If you are aware of any study (not included on the pdfs), in progress or published, that addresses any of the following questions, please let me know. If you have observations of multiple patients that suggest answers, please let me know. Some of the questions are the results of discussions with those who have provided feedback to the original tables in addition to those questions engendered by studies.

General

Given that formal disorders may not cover all possible combinations of symptoms that may result in functional impairment, has anyone observed or demonstrated forms of complicated/maladaptive grief in addition to those described as PGD and TG (see pdfs). Have you observed important variations in these forms
How do researchers assess the differences among normal grief-related symptoms, traumatic grief-related symptoms, and trauma-related symptoms For example, is the length and intensity of symptoms what distinguishes maladaptive grief from adaptive grief For example, how are trauma-related bad dreams distinguished from grief-related bad dreams How are authors distinguishing between the hyperaroused sleep of PTSD and grief related sleep disturbances
Given that some studies have used adult scales to assess adolescents and others have used child scales, has anyone compared the use of child vs. adult scales to assess adolescents
Are there larger studies in progress or being planned that compare individuals from the same location/group who have lost loved ones (1 & 2) in non-traumatic circumstances (1—with and 2—without the attachment issues assessed for PDG), (3 & 4) under traumatic circumstances (3—with and 4—without direct exposures to the event), and (5) with both traumatic and attachment issues at play Have they assessed different age groups Have they included measures that assess normal bereavement as well as maladaptive bereavement Have they assessed a link between the manner of death and the nature of grief as well as other symptoms
Will these studies be done using measures that assess all of the symptoms proposed for different forms of maladaptive grief
At least for children, whose development may be impaired by symptoms as well as disorders, should we be looking at the range from adaptive to maladaptive grief and the mediating and moderating variables that influence where someone falls on the continuum rather than using classifications of complicated grief
Has anyone assessed race and ethnicity controlling for SES
Have additional studies examined the use of creative outlets or volunteer work as risk or protective factors

Prolonged Grief Disorder (PGD)

Have the grief responses of those who experienced a traumatic death been compared to the grief responses of those in the same local who experienced a nontraumatic death If yes, was it determined whether some respondents were reacting both to the loss of the attachment figure and to the traumatic nature of the death What differences are found in course and presentation
Are there completed studies comparing child and adult PGD

Traumatic Grief (TG)

Have any studies included questionnaires of normal bereavement and the symptoms of TG as well as of PG
Are there studies that address age differences among children in the manifestation of TG Have they distinguished these differences from those associated with traumatic reactions
Have any studies assessed for all of the symptoms of PGD and TG (as described in the pdfs and in the literature)
-What symptoms would you add to the list
-Have studies determined the distinctness of TG, PTSD, PG, depression and grief using scales that address symptoms that address each of these disorders
Given evidence suggesting that individuals who experience the least distress have the most benign course of grief, has the relationship of that finding to the distress experienced in addressing a trauma been studied

Thank you.
Kathleen

References that Compare Types of Grief
Neria, Y. & Litz, Brett T. (2004). Bereavement by traumatic means: The complex synergy of trauma and grief. Journal of Loss and Trauma, 9(1), 73 – 87.
Raphael, B., Martinek, N., & Wooding, S. (2004). Assessing traumatic bereavement. In Wilson, J. & Keane, T. (eds.) Assessing Psychological Trauma & PTSD, (2nd edition, pp. 492-510). New York: Guilford Press.