International Society for Traumatic Stress Studies

Persistent Complex Bereavement Disorder as a Call to Action

Posted 21 January 2014 in StressPoints by Julie B. Kaplow, PhD, ABPP, Christopher M. Layne, PhD, and Robert S. Pynoos, MD, MPH


Persistent Complex Bereavement Disorder (PCBD) is a newly proposed (i.e., candidate) diagnosis included in the appendix of DSM-5 as an invitation for further study and exploration (American Psychiatric Association, 2012). Many facets of this proposed disorder—ranging from the risk of pathologizing “normal” grief reactions, to the minimum required duration of symptoms, to the specific nature of PCBD criteria, to the added value of PCBD above and beyond other grief-related constructs—have been the subject of considerable debate that continues to persist (e.g., Wakefield, 2012).
 

Indeed, some grief researchers have advocated for the summary dismissal of PCBD and a return to previously studied grief constructs, construct names, related grief assessment tests, and associated lines of research (e.g., Boelen & Prigerson, 2012; Melhem, Porta, Payne, & Brent, 2013; Prigerson et al., 2009; Shear et al., 2011). Such spirited debate is not surprising given that the introduction of a candidate disorder into the appendix (instead of the main text of the DSM-5) denotes a body of empirical evidence that the DSM-5 reviewing committee has judged to be both sufficient to establish the likely existence of a new psychiatric disorder, yet nevertheless insufficient to unambiguously clarify its primary features. Indeed, the inclusion of PCBD as a candidate disorder constitutes a call to action to the grief field to “grow” the evidence base more vigorously and rapidly, giving careful attention to enhancing methodological rigor, valid assessment, and systematic theory-building.

Given the current status of PCBD as a candidate disorder, clinicians who rely on the DSM-5 to diagnose and bill for grief-related mental health services cannot formally diagnose PCBD, but instead may diagnose an adjustment disorder for which no formal grief-related criteria exist. Thus, a general aim of the DSM-5’s open invitation is to clarify primary features of PCBD as manifest across diverse populations and to explore the increased precision, specificity, and other “added value" benefits that PCBD might bring, if included, to the formal diagnostic lexicon.

More specifically, this call to action is intended to encourage research that rigorously evaluates whether the constellation of criteria making up PCBD is sufficiently valid, comprehensive, clinically useful, and empirically distinct from other established disorders as to merit its future “migration” (either as presently constituted or in an “evolved” form with additional, fewer, and/or re-worded criteria) from the appendix to the main text as a formal psychiatric disorder (Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012).

We propose that the choice to include a bereavement-related disorder in the appendix of DSM-5 in general, and PCBD as currently defined in particular, can provide much-needed impetus to addressing critically important research questions that have, to date, rarely been explored, particularly within the still-nascent field of childhood grief (see Nader & Layne, 2009).

In evaluating the origins of PCBD, it is important to bear in mind that PCBD is a “hybrid” disorder, the specific criteria for which can be traced back to several primarily adult schools of thought regarding the essential nature and distinguishing features of maladaptive grief. These schools of thought include “pathological grief” (Horowitz, Bonnano, & Holen, 1993), “prolonged grief disorder” (Prigerson et al., 2009), and “complicated grief” (Shear et al., 2011). The choice to include PCBD as an appendix disorder in DSM-5 is an acknowledgement of the important contributions made to date by these researchers in helping to map out the general landscape of grief and in identifying indicators of bereavement-related pathology. Nevertheless, a new name (Persistent Complex Bereavement Disorder) was selected for the candidate disorder instead of adopting the name of any previously studied grief construct (e.g., complicated grief, prolonged grief disorder, traumatic grief) to prevent the new candidate diagnosis from becoming conceptually confounded with—or misinterpreted as an alternative measure of—the products of any individual schools of thought that contributed to its formulation.

Accordingly, this invited editorial is intended to serve in part as a follow-up to a previous Traumatic Stress Points article published five years ago (Nader & Layne, 2009) that laid out specific recommendations for examining age-related differences in grief reactions in the interests of “growing” a more developmentally informed evidence base that will enhance theory-building, clinical assessment, and intervention. In our role as lead authors of an invited developmental review of proposed PCBD criteria (Kaplow, Layne, Pynoos, et al., 2013), we have also written this editorial in response to calls to summarily dismiss PCBD (e.g., Boelen & Prigerson, 2012; Melhem et al., 2013)—a move that would bring premature closure to the active exploration and debate that its inclusion in DSM-5 invites.

Pursuant to this aim, we pose a series of questions designed to encourage the pursuit of innovative research studies that will meaningfully advance the grief field in general and the child and adolescent grief subfield in particular. Such studies will not only allow for a more thorough evaluation of the scientific and clinical merits of PCBD, but will also lay the groundwork for the development of “next generation” assessment-driven interventions whose components, coupled with proper education and training, can be flexibly tailored to the diverse needs, strengths, and ecologies of bereaved youth (Kaplow et al. 2012; Layne, Strand, Popescu et al., 2014).

1. Is PCBD (or maladaptive grief more generally) unidimensional or multidimensional, and why does it matter?

To begin to address this question, it is first important to note that proposed PCBD criteria span four primary conceptual dimensions (American Psychiatric Association, 2012). These include:

  • Separation distress, including persisting intense yearning, longing, sorrow, emotional pain, and preoccupation with the deceased person.
  • Reactive distress and behavior in response to the death, including difficulty accepting the death, difficulty reminiscing about the deceased, and excessive avoidance of loss reminders connected to the deceased (e.g., photos, belongings, conversations about him/her).
  • Disruptions in personal and social identity, including feeling like part of oneself has died with the deceased. This disruption may begin as an acute personal existential crisis and develop over time into persisting impairment.
  • Preoccupation with the circumstances of the death, especially as evoked by loss reminders (e.g., hearing the name of one’s deceased father, or being in the company of his family or friends, evokes distressing recollections of the circumstances surrounding his death—see Layne et al., 2006).

A major challenge when attempting to differentiate between normal versus pathological grief lies in the potentially multidimensional nature of the underlying construct that PCBD criteria are presumed to reflect. For example, if grief as a latent construct is indeed multidimensional within a given population, then bereaved individuals may show elevations or “pathology” in one grief domain (e.g., separation distress) and not another (e.g., disruptions in personal identity). Issues surrounding the inherent dimensionality of grief reactions, and of tests purported to measure those reactions, are by no means simply a dry academic debate, given that they carry potentially far-reaching implications for valid clinical assessment, accurate diagnosis, intervention, and public policy (Kaplow et al., 2012; Kaplow, Layne, Saltzman, Cozza, & Pynoos, 2013).

Indeed, failure to adequately conceptualize, measure, and statistically model multidimensionality in underlying constructs, in cases where multidimensionality is truly present, can seriously undermine the validity of clinical assessment instruments to the extent that test results become ambiguous, uninterpretable, and misleading (Strauss & Smith, 2009). The admonition of Shear and colleagues (2011) to refrain from the use of data analytic procedures that presume—but do not rigorously test for—a single underlying dimension of grief is consistent with this view.

The issue of multidimensionality is especially salient in relation to the construction and/or use of assessment tests that purport to measure maladaptive grief. Restricted construct span can significantly reduce test content validity in ways that may lead to misleading or uninterpretable test scores and misinformed or erroneous conclusions. For example, Shear and colleagues (2011) have noted that the criteria set for complicated grief was derived from a widely used measure of grief, the Inventory of Complicated Grief (ICG; Prigerson et al., 1995; see also Inventory of Complicated Grief- Revised, ICG-R, Melhem, Moritz, Walker, Shear, & Brent, 2007; and Inventory of Complicated Grief- Revised for Children, ICG-RC, Melhem et al., 2013), and its “limited item pool” (Melhem et al., 2007, p. 498) and restricted range of item content (Shear et al., 2011, p. 107) may prohibit the identification of other potentially important domains of grief.

To our understanding, none of the measures cited above, as currently constituted, cover the entire construct span of PCBD. Similarly, the now-retired Extended Grief Inventory (Layne, Savjak, Saltzman, & Pynoos, 2001; cited in Brown et al., 2008; Brown & Goodman, 2005) lacks the construct span necessary to evaluate the diverse range of distress reactions that constitute PCBD and is thus an inadequate tool with which to participate in this new era of rigorous inquiry. We propose that the introduction of PCBD presents grief researchers with one of three primary options for continuing their work: (1) To repudiate, dismiss, or ignore PCBD and instead retain formerly-used constructs, construct names, measures, and research questions; (2) to modify formerly used (pre-PCBD) measures so that they adequately cover all content domains of PCBD, including the traumatic bereavement specifier; or (3) to “retire” previously created measures (e.g., Layne et al., 2001) and replace them with new measures specifically designed to comprehensively cover all PCBD domains (e.g., Layne, Kaplow, & Pynoos, 2013).  

Selecting a measure of grief that provides insufficient coverage of all proposed PCBD dimensions may introduce bias in the form of the assumption (either explicit or implicit) that any underrepresented or absent domain (e.g., circumstance-related distress) is irrelevant to the valid measurement and diagnosis of PCBD. Such presumptions run contrary to the aim of introducing PCBD as a candidate diagnosis in DSM-5 and risk premature and, in our opinion, unwarranted closure on a topic that the grief field has been invited to rigorously address as an open empirical question. It should be underscored that, in choosing to include criteria drawn from multiple schools of thought in its formulation of PCBD, the reviewing DSM-5 committee conveyed its judgment that each contributing perspective carried sufficient value as to merit further study as part of a proposed appendix disorder.

Accordingly, research studies that incorporate developmentally informed and comprehensive measures spanning all proposed PCBD domains are needed to rigorously examine the manifestations, phenomenology, clinical course, and clinical utility of PCBD in child and adolescent populations (e.g., see PCBD Checklist; Layne, Kaplow, & Pynoos, 2013).

2. Is PCBD distinct from, versus functionally interchangeable with, other grief-related constructs?

As previously discussed, reflecting the diverse perspectives and comparatively nascent state of the grief literature while DSM-5 was in development, PCBD diagnostic criteria represent a “hybrid” amalgamation of symptoms drawn from a variety of major conceptual perspectives that contributed to it. It is thus inaccurate to re-label PCBD as “complicated grief”, “prolonged grief disorder”, “prolonged grief reactions”, “traumatic grief”, “childhood traumatic grief”, or “problematic grief”. Instead, consistent with its status as a proposed psychiatric disorder, PCBD should be approached as a separate and distinct diagnostic construct whose signs and symptoms cover a broader spectrum of grief-related phenomena than any of the individual diagnostic entities or criteria sets that contributed to its formulation.

With respect to the research agenda that PCBD invites, studies of bereaved youth are needed that empirically evaluate whether various grief-related latent constructs and their proposed dimensions are meaningfully distinct from one another. Study designs (both cross-sectional and especially longitudinal) relevant to addressing empirical distinctiveness among diagnostic constructs include those that examine potential differential relations between specific grief dimensions and their theorized causal precursors (e.g., different postulated etiologic risk factors), correlates, and consequences (including indicators of impaired versus competent functioning) (Kaplow et al., 2012; Layne, Olsen, Kaplow, Shapiro, & Pynoos, 2011). Also of great value are longitudinal studies examining whether various domains or dimensions of grief manifest in similar ways and follow similar clinical courses over time and across developmental periods (Nader & Layne, 2009).

Given the already-confusing proliferation of grief-related constructs, schools of thought, terms, and measures, the grief field will benefit greatly from giving careful attention to enhancing conceptual, terminological, and methodological clarity (Layne, Warren, Watson, & Shalev, 2007). We thus encourage prospective grief test consumers to become informed concerning the theoretical roots of grief-related constructs and the roles that these constructs play in the construction and adaptation of tests purporting to measure them. Background information relevant to critiquing tests includes core theoretical assumptions concerning the etiology, essential features, and manifestations of grief-related diagnostic constructs, and the specific psychometric procedures used to construct tests (including descriptions of how guiding theory was used to generate and evaluate candidate test items; the test item pool; test validation population[s]; specific applications for which the test was designed; criteria used to exclude, retain, or modify candidate test items; procedures used to evaluate test reliability, validity, clinical utility, developmental appropriateness; see Layne, Kaplow, & Pynoos, 2012).

3. Does PCBD manifest differently in children compared to adults?

Although developmental capacities appear to act as key moderators or determinants of the ways in which children, adolescents, and adults grieve (Kaplow et al., 2012; Nader & Layne, 2009), the great majority of empirical studies focusing on maladaptive grief have involved adult samples only, thereby impeding efforts to accurately define and clarify the essential features of maladaptive (as well as adaptive) grief reactions in childhood. As noted by Nader & Layne (2009), our capacity as a field to identify and describe the range and nature of maladaptive grief reactions has also been hampered by a lack of consensus across studies of bereaved adults concerning the primary defining features of maladaptive versus adaptive grief reactions. For example, studies focusing on “complicated grief” have primarily emphasized qualitative distinctions (i.e., differences in specific types of grief reactions) between normal versus maladaptive grief (e.g., Boelen & van den Bout, 2005; Shear et al., 2007; Simon et al., 2007). In contrast, advocates of “prolonged grief” emphasize a more quantitative distinction by proposing that maladaptive grief is essentially similar to “normative” grief reactions shortly following the death, with the exception that the clinical course of maladaptive grief has an unusually prolonged duration and is linked to significant functional impairment (Boelen & Prigerson, 2012; Lannen,Wolfe, Prigerson, Onelov, & Kreicbergs, 2008; Prigerson et al., 2009).

Efforts to rigorously address the question of whether PCBD manifests in similar versus dissimilar ways across developmental periods should also give careful consideration to the particular tests used; the specific populations, settings, and applications with and for which the measures were originally developed; and the theoretical, methodological, and psychometric “imprint” that these features may carry forward into all subsequent test applications. For example, the majority of existing empirical studies focusing on maladaptive grief reactions in adults have used the Inventory of Complicated Grief (ICG; Prigerson et al., 1995), limitations of which include (as noted by Shear et al., 2011, p. 107) restricted construct span, a history of being administered to primarily “older (average age 62) Caucasian (95%) widows (84%)”, and the presumption of unidimensionality in the underlying grief construct the ICG purports to measure.

Of particular relevance to examining developmentally linked differences in the manifestation of grief, the ICG has been adapted for use with bereaved children via item wording modifications to enhance comprehension, accompanied by pilot testing with eight children bereaved by parental suicide (see ICG-RC; Melhem et al., 2007, p. 495). Although reporting apparent evidence of multidimensionality via factor analysis in their study sample, the authors’ test scoring algorithm adheres closely to that used with adults (Prigerson et al., 2009) in that all items are summed to create a total score and interpreted as “complicated grief” (Melhem et al., 2007) or (most recently) “prolonged grief reactions” (Melhem et al., 2013).

Melhem et al. have asserted that findings of studies of childhood complicated grief (CG) using the ICG-RC are “consistent with” (2007, p. 497) or “convergent with” (2011, p. 917) findings in bereaved adults, including similar prevalence rates, clinical correlates, and relations with measures of functional impairment (Prigerson et al., 1995; 2009). While noting some differences between CG in youth versus adults (e.g., less frequent endorsement of certain symptoms as measured by the ICG-R), Melhem et al. (2007, p. 497) also state that childhood CG, is “an extension of CG as defined in adults, and as such, is similar to the adult consensus criteria of CG developed by a panel of bereavement experts” convened in the 1990’s (i.e., Prigerson et al., 1999).

Such striking similarities between adult and child studies may possibly reflect true similarities in the structure and manifestations of grief across different age groups. At present, however, it cannot be ruled out that such similarities across age groups may instead arise from methodological artifact (i.e., common use of a test originally developed with older adults, common algorithms for test scoring and interpretation predicated on the assumption of unidimensionality) that may obscure important developmentally-linked differences in the ways in which different age groups grieve (Nader & Layne, 2009; Pynoos, Steinberg, & Wraith, 1995). 

It also cannot be ruled out that pursuing an alternative strategy of commencing with a developmentally-informed theory of grief and creating an original test item pool for use with bereaved children and adolescents (rather than pursuing the “downward” developmental modification of an already-complete adult measure by altering the wordings of selected items) would have produced a markedly different test and clinical picture of childhood grief. The child and adolescent grief field is now being provided with an unprecedented opportunity to systematically compare and evaluate the fruits, performance, and relative psychometric merits of such contrasting “developmental point of origin” (i.e., original test construction, Layne, Kaplow, & Pynoos, 2013; versus adult test downward adaptation, Melhem et al., 2013) strategies in relation to the assessment of bereaved youth.

Having previously underscored the crucial role of guiding theory in initial test construction and validation, we further propose that theory should be just as important in guiding, describing, explaining, and justifying the adaptation of tests as it is in test construction. For example, is it theoretically plausible to presume that grief reactions among older adults bereaved by the death of a spouse of 50 years will manifest in ways that very closely resemble those of bereaved children who are not only 60 to 70 years younger (and thus at very different developmental stages and members of very different sociohistorical cohorts), but also have different relationships to the deceased (e.g., death of a parent, sibling, or close friend) and are often bereaved under very different circumstances (e.g., murder, suicide, warfare)? Although grief reactions many indeed share some fairly universal elements (e.g., separation distress) across different age or cultural groups, other elements may be specific to particular groups (e.g., developmentally-linked manifestations, culturally idiosyncratic idioms, circumstance-related distress).

To progress in its understanding and capacity to meet the needs of diverse bereaved groups, the grief field must rigorously search for both potentially common (i.e., universal) as well potentially specific (i.e., group-dependent) aspects of grief, treating both elements as open empirical questions, and incorporate such knowledge in its theory, measurement tools, interventions, and the implications thereof for public policy. We thus urge healthy skepticism with regard to the presumption of the universality of grief across age and other groups, especially when unaccompanied by justifying theory and sound empirical evidence. We also encourage test users to avoid treating grief-related theories, constructs, construct domains, terms, and measures as functionally interchangeable. As previously discussed (Kaplow et al., 2012; Nader & Layne, 2009), rigorous study designs that utilize developmentally appropriate measures of grief carry the greatest promise for identifying and clarifying potential developmentally-linked differences in the etiology, manifestations, intensity, clinical course, and sequelae of maladaptive grief and specific PCBD criteria across different age groups.

4. Is PCBD more likely to occur under certain death-related circumstances?

The PCBD diagnosis allows for a Traumatic Bereavement Specifier, which is to be endorsed if the death is judged to (a) have occurred under traumatic circumstances (defined as either homicide or suicide only), and (b) produce persistent distressing thoughts or feelings related to traumatic features of the death (e.g., the deceased person’s degree of suffering, malicious intent), often in response to loss reminders (see Layne et al., 2006) (American Psychiatric Association, 2012). The choice to include the Traumatic Bereavement Specifier as an integral part of PCBD draws upon the traumatic grief or circumstance-related distress literature. The roots of this perspective trace back to such pioneering work as psychoanalytic studies conducted with surviving relatives of victims of the 1942 Cocoanut Grove Fire (Adler, 1943; Lindemann, 1944), as well as more recent theoretical and empirical work regarding ways in which the circumstances of the death, and the interplay between trauma and grief, can influence the nature and course of adjustment following bereavement (Pynoos, 1992; see also Kaplow et al., 2012, 2013; Layne et al., 2001, 2008).

This perspective is also informed in part by Cohen et al.’s (2002; Mannarino & Cohen, 2011) conception of “childhood traumatic grief”, which the authors define as the interference of classic posttraumatic stress symptoms in adaptive grief tasks in bereaved children. It is especially notable that the DSM-5 Posttraumatic Stress Disorder (PTSD) diagnosis now includes a statement indicating that traumatic experiences involving violent death may result in a significant interaction between problematic bereavement reactions and PTSD (American Psychiatric Association, 2012). This is the first time the DSM has overtly acknowledged the interplay of trauma and loss and the difficulties inherent in contending with these often simultaneous yet theoretically distinct processes (e.g., coping with both trauma and loss reminders; see Kaplow, Saxe, Putnam, Pynoos, & Lieberman, 2006; Layne et al., 2006; Pynoos, 1992).

Although the PCBD Traumatic Bereavement Specifier is currently limited in DSM-5 to a narrow range of only two types of (typically unexpected) death-related circumstances (homicide and suicide), preliminary empirical evidence suggests that youth in particular may also experience circumstance-related distress in response to anticipated death. For example, traumatogenic or pathogenic elements such as exposure to graphic medical procedures, the progressive deterioration and helplessness of the dying person, and family members’ distress in the context of prolonged wasting illness, appear to be associated with levels of post-death maladaptive grief and posttraumatic stress that are equivalent to or higher than distress levels reported by youth bereaved by sudden natural deaths (Kaplow, Howell, & Layne, in press; McClatchey & Vonk, 2005; Saldinger, Cain, & Porterfield, 2003).

The inclusion of the Traumatic Bereavement Specifier in PCBD invites much-needed scientific scrutiny concerning the relative contributions of different causes of death (e.g., accidental deaths, anticipated deaths due to illness, military-related deaths, suicide, homicide, etc.) and facets of the circumstances of death (e.g., predictability, duration/suddenness, violence, malicious intent, human negligence) to maladaptive grief and, by implication, regarding which types of death-related circumstances may carry the highest risk for severe persisting distress and functional impairment. We thus advocate that investigations into which causal risk factors constitute the most potent etiologic agents, how different factors may intersect (Layne, Beck, Rimmasch, Southwick, Moreno, & Hobfoll, 2009), causally relate (Layne, Steinberg, & Steinberg, in press), and differentially relate to different dimensions of grief (Layne et al., 2010), treat these issues as open empirical questions.

Conclusions

Addressing the above questions in ways that rigorously “grow” the empirical and theoretical literature will require the use of developmentally sensitive, meticulously constructed or adapted, and carefully validated measures of PCBD criteria that adhere to best practice test development/adaptation/validation procedures (Layne et al., 2012). The implications that such assessment-driven questions carry for clinical practice and informed public policy cannot be overstated.

For example, if PCBD manifests differently in child versus adolescent versus adult populations, then each population may call for not only distinctly different and developmentally validated assessment tools, but also meaningfully distinct and developmentally informed interventions. Similarly, if the domains of PCBD differ not only in their particular manifestations, but also with respect to their causal risk factors or consequences (e.g., suicidal ideation, risk-taking behaviors), then they may point to subgroups that carry different risk profiles (Layne et al., 2010) and call for meaningfully distinct interventions. Such interventions will require properly designed assessment tools to selectively match specific grief domains (e.g., separation distress, circumstance-related distress, etc.) with key treatment components (see Kaplow et al., 2013; Saltzman et al., 2013).

In summary, we advocate that PCBD be given its just due—as an amalgamation of diverse criteria, drawn from multiple perspectives and schools of thought—whose essential features across developmental periods (including its dimensionality) are treated as open empirical questions. The costs of prematurely closing this debate may be serious and long lasting, if indeed different dimensions of grief exist and arise from different etiologic risk factors (and may thus produce different subgroups of bereaved individuals with different risk profiles) or differentially respond to different treatment components (and thus call for different types of interventions). Although it does not carry all of the advantages of commencing with a broad-spectrum test item pool (Layne et al., 2012), the diverse range of criteria and schools of thought reflected in PCBD criteria increase the construct span of the item set. Thus, PCBD may carry a greater likelihood of capturing “specific” features of grief linked to development, gender, culture, race/ethnicity, or circumstances of the death, and enhancing content validity, than constructs and associated measures from which it was derived.

With respect to implications for intervention and public policy, “one size fits all” approaches to treating maladaptive grief predicated upon assumptions of unidimensionality and/or universality—if and when those assumptions are incorrect—may be less efficient, less effective, less relevant, or indeed contraindicated for some youth depending on their specific profiles of grief reactions and life circumstances. Meaningful distinctions between adult versus child and adolescent PCBD profiles—should they emerge as the field responds to the call to action accompanying PCBD—may also be inconsistent with the downward “adaptation of successful adult treatment approaches” proposed by Melhem et al. (2011, p. 918) as a logical implication of the authors’ conclusion that bereaved children grieve in ways that closely parallel bereaved adults.

A recent study of the contributing role of the circumstances of the death to the prediction of child versus caregiver adjustment, for example, found evidence that specific circumstances of the death were differentially related to child versus adult grief-related outcomes (see Kaplow, Howell, & Layne, in press)—suggesting that age may act as an influential moderator of post-loss adjustment. We thus propose that questions concerning the relative utility of where theory-building, test construction, and intervention development efforts should commence as initial starting points (e.g., late vs. middle vs. young adulthood; adolescence; childhood) should also be treated as open empirical questions that are only now beginning to be systematically explored. Such efforts will help to promote the accurate identification of bereaved youth at high risk for developing (or maintaining) symptoms of PCBD and the effective tailoring of intervention components to address their potentially age-specific needs (Nader & Layne, 2009).

It is important to recognize that childhood bereavement alone is unlikely to lead to clinically significant psychiatric symptoms or “maladaptive grief” (e.g., Dowdney, 2000; Kaplow, Saunders, Angold, & Costello, 2010) and that many bereaved youth may never be in need of psychosocial intervention. It is also noteworthy that, unlike other diagnostic constructs (e.g., depression), there are generally adaptive aspects of grief that are typically the norm in most groups. Thus, developing clear theoretical and empirical distinctions between adaptive versus maladaptive grief is essential to reduce the risk of overpathologizing normal grief reactions, as well as underdiagnosing “actual positive” cases of youth struggling with maladaptive grief (Kaplow et al., 2013; Layne et al., 2011).

We propose that the intensive study of PCBD criteria domains will ultimately furnish clinicians with the tools and knowledge needed to accurately detect the significant minority of youth who do require expert assistance following the loss. We hope that the inclusion of PCBD in the DSM-5 will serve its intended purpose, not only as an invitation for further research, but as a “call to action” to promote the construction/adaptation of developmentally informed measures, scientifically rigorous studies, and the synergistic development of effective interventions for those bereaved youth in greatest need.

About the Authors

Julie Kaplow, PhD, ABPP,  is a licensed clinical psychologist, Assistant Professor, and Director of the Trauma and Grief Center for Youth in the Department of Psychiatry at the University of Michigan. She is also Director of the UM Clinical Child Psychology Postdoctoral Training Program. Dr. Kaplow’s professional interests have focused on adaptive and maladaptive grief reactions in bereaved youth as well as the interplay between childhood trauma and grief. Findings from these research studies are now being used to inform theory-building, test development, assessment, and intervention efforts targeting bereaved youth and families, including those in underserved communities.

Christopher Layne, PhD, is a Research Psychologist in the UCLA Department of Psychiatry and Biobehavioral Sciences and Director of Education in Evidence Based Practice at the UCLA/Duke University National Center for Child Traumatic Stress. His professional interests include evidence-based assessment and practice; professional education; and the conceptualization, measurement, and treatment of traumatized and bereaved youth. Dr. Layne has over 15 years of experience in constructing and empirically evaluating tests designed to assess grief reactions.

Robert Pynoos, MD, MPH, is Professor of Psychiatry and Biobehavioral Sciences, Director of Outpatient Trauma Psychiatry, and Co-Director of the UCLA/Duke University National Center for Child Traumatic Stress at UCLA. Dr. Pynoos was a member of the DSM-5 sub-work group that formulated the criteria for PCBD. He is an internationally known expert in childhood traumatic stress and grief and has written extensively on the developmental consequences of childhood trauma and loss, including efforts to elevate the standards of mental health care for child victims and witnesses.

Author Disclosure

Drs. Layne, Kaplow, and Pynoos are co-developers of the PCBD Checklist, the Multidimensional Grief Reactions Scale, and Trauma and Grief Component Therapy. Drs. Layne and Kaplow are also co-authors of the Bereavement Risk and Resilience Index, a measure of empirically derived risk, vulnerability, and protective factors surrounding the circumstances of the death.

References

Adler, A. (1943). Neuropsychiatric complications in victims of Boston’s Cocoanut Grove disaster. Journal of the American Medical Association, 123, 1098-1101.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Boelen, P. A., & Prigerson, H. G. (2012). Commentary on the inclusion of persistent complex bereavement-related disorder in DSM-5. Death Studies, 36, 771-794.

Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: A confirmatory factor analysis study. American Journal of Psychiatry, 162, 2175-2177.

 

Brown, E. J., Amaya-Jackson, L., Cohen, J., Handel, S., Thiel De Bocanegra, H., Zatta, E.,…Mannarino, A. (2008). Childhood traumatic grief: A multi-site empirical examination of the construct and its correlates. Death Studies, 32, 899-923.

 

Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: An exploration of the construct in children bereaved on September 11. Journal of Clinical Child and Adolescent Psychology, 34, 248-259.

Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley, C. (2002). Childhood traumatic grief: Concepts and controversies. Trauma,Violence, & Abuse, 3, 307-327.

Dowdney, L. (2000). Annotation: Childhood bereavement following parental death. Journal of Child Psychology and Psychiatry, 41, 819-830.

Horowitz, M.J., Bonanno, G. A., & Holen, A. (1993). Pathological grief: Diagnosis and explanation. Psychosomatic Medicine, 55, 260-273.

Kaplow, J.B., Howell, K.H., & Layne, C.M. (In press). Do circumstances of the death matter? Identifying socioenvironmental risks for grief-related psychopathology in bereaved youth. Journal of Traumatic Stress.

Kaplow, J.B., Layne, C.M., Pynoos, R.S., Cohen, J., & Lieberman, A. (2012). DSM-V diagnostic criteria for bereavement-related disorders in children and adolescents: Developmental considerations. Psychiatry, 75(3), 242-265.

Kaplow, J.B., Layne, C.M., Saltzman, W.R., Cozza, S.J., & Pynoos, R.S. (2013). Using Multidimensional Grief Theory to explore effects of deployment, reintegration, and death on military youth and families. Clinical Child and Family Psychology Review, 16, 322-340.

Kaplow, J. B., Saunders, J., Angold, A., & Costello, E. J. (2010). Psychiatric symptoms in bereaved versus nonbereaved youth and young adults: A longitudinal epidemiological study. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1145-1154.

Kaplow, J. B., Saxe, G., Putnam, F., Pynoos, R., & Lieberman, A. (2006). The long-term consequences of early childhood trauma: A case study and discussion. Psychiatry, 69, 362-375.

Lannen, P., Wolfe, J., Prigerson, H., Onelov, E., & Kreicbergs, U. (2008). Unresolved grief in a national sample of bereaved parents: Impaired mental and physical health 4 to 9 years later. Journal of Clinical Oncology, 26, 5870-5876.

Layne, C. M., Beck, C. J., Rimmasch, H., Southwick, J. S., Moreno, M. A. & Hobfoll, S. E. (2009). Promoting “resilient” posttraumatic adjustment in childhood and beyond: “Unpacking” life events, adjustment trajectories, resources, and interventions. In D. Brom, R. Pat-Horenczyk, & J. Ford (eds). Treating traumatized children: Risk, resilience, and recovery (pp. 13-47). New York: Routledge.

Layne, C.M., Kaplow, J.B., & Pynoos, R.S. (2012, November). Using developmentally-informed theory and evidence-based assessment to guide intervention with bereaved youth and families. In CM Layne (Chair), Integrating Developmentally-Informed Theory, Evidence-Based Assessment, and Evidence-Based Treatment of Childhood Maladaptive Grief. Symposium presented at the Annual Meeting of the International Society for Traumatic Stress Studies, Los Angeles, CA.

Layne, C.M., Kaplow, J.B., & Pynoos, R.S. (2013). Persistent Complex Bereavement Disorder (PCBD) Checklist – Youth Version 1.0. and Test Administration Manual. University of California, Los Angeles.

Layne, C. M., Olsen, J. A., Baker, A. Legerski, J. P., Isakson, B., Pašalić, A., Pynoos, R. S. (2010). Unpacking trauma exposure risk factors and differential pathways of influence: Predicting post-war mental distress in Bosnian adolescents. Child Development, 81, 1053-1076.

Layne, C.M., Olsen, J.A., Kaplow, J.B., Shapiro, D., & Pynoos, R.S. (2011, November). Do traumatic circumstances of the death matter? Predicting the longitudinal course of grief in adolescents. In C. M. Layne (Chair), Developmental Perspectives on Proposed DSM-V Bereavement Criteria: Three Longitudinal Studies of Bereaved Children and Adolescents. Symposium presented at the 27th Annual Meeting of the International Society for Traumatic Stress Studies, Baltimore, MD.

Layne, C. M., Saltzman, W. R., Poppleton, L., Burlingame, G. M., Pašali, A., Durkavovi, E., Pynoos, R. S. (2008). Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1048-1062.

Layne, C. M., Saltzman, W. R., Savjak, N., Popovic, T., Music, M., Djapo, N., Pynoos, R. S. (2001). Trauma/grief-focused group psychotherapy: School-based postwar intervention with traumatized Bosnian adolescents. Group Dynamics, 5, 277-290.

Layne, C. M., Savjak, N., Saltzman, W. R., & Pynoos, R. S. (2001). Extended Grief Inventory. Unpublished psychological test. University of California, Los Angeles.

Layne, C.M., Steinberg, J.R., & Steinberg, A.M. (in press). Causal reasoning skills training for mental health practitioners: Promoting sound clinical judgment in evidence-based practice. Training and Education in Professional Psychology.

Layne, C.M., Strand, V., Popescu, M., Kaplow, J.B., Abramovitz, R., Stuber, M., Amaya-Jackson, L., Ross, L., & Pynoos, R.S. (In press). Using the Core Curriculum on Childhood Trauma to strengthen clinical knowledge in evidence-based practitioners. Journal of Clinical Child and Adolescent Psychology.

Layne, C.M., Warren, J.S., Saltzman, W.R., Fulton, J., Savjak, N., Popovic, T., Pynoos, R.S. (2006). Contextual influences on post-traumatic adjustment: Retraumatization and the roles of distressing reminders, secondary adversities, and revictimization. In Schein, L.A., Spitz, H.I., Burlingame, G.M., & Muskin, P.R., (Eds.), Psychological effects of catastrophic disasters: Group approaches to treatment. New York: Haworth.

Layne, C. M., Warren, J., Watson, P., & Shalev, A. (2007). Risk, vulnerability, resistance, and resilience: Towards an integrative model of posttraumatic adaptation. In M. J., Friedman, T. M., Kean, & P. A. Resick (Eds.), PTSD: Science & practice-A comprehensive handbook. New York: Guilford.

Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101,141-148.
Mannarino, A. P., & Cohen, J. A. (2011). Traumatic loss in children and adolescents. Journal of Child and Adolescent Trauma, 4, 22-33.

McClatchey, R. S., & Vonk, M. E. (2005). An exploratory study of post-traumatic stress disorder symptoms among bereaved children. Omega Journal of Death and Dying, 51, 285-300.

Melhem, N.M., Moritz, G., Walker, M., Shear, M.K., Brent, D. (2007). Phenomenology and correlates of complicated grief in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 493-499.

Melhem, N. M., Porta, G., Shamseddeen, W.,Walker Payne, M., & Brent, D. A. (2011). Grief in children and adolescents bereaved by sudden parental death. Archives of General Psychiatry, 68, 911-919.

Melhem, N. M., Porta, G., Walker Payne, M., & Brent, D. (2013). Identifying prolonged grief reactions in children: Dimensional and diagnostic approaches. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 599-607.

Nader, K. O., & Layne, C. M. (2009). Maladaptive grieving in children and adolescents: Discovering developmentally linked differences in the manifestation of grief. Stress Points, 23, 12-15.

Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., Anderson, B., Zubenko, G. S., Kupfer, D. J. (1995). Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22-30.

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8).

Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds III, C. F., Maciejewski, P. K., Davidson,
J. R., Zisook, S. (1999). Consensus criteria for traumatic grief. A preliminary empirical test. British Journal of Psychiatry, 174, 67-73.

Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care, 11, 2-10.

Pynoos, R. S., Steinberg, A. M., & Wraith, R. (1995). A developmental model of childhood traumatic stress. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Vol.2. Risk, disorder, and adaptation (pp. 72-95). New York: Wiley.

Saldinger, A., Cain, A., & Porterfield, K. (2003). Managing traumatic stress in children anticipating parental death. Psychiatry: Interpersonal and Biological Processes, 66, 168-181.

Saltzman, W., Layne, C.M., Kaplow, J.B., Olafson, E., Boat, B., & Pynoos, R. (2013). Trauma and Grief Component Therapy for Adolescents. University of California, Los Angeles.

Shear, M. K., Monk, T., Houck, P., Melhem, N., Frank, E., Reynolds, C., Sillowash, R. (2007). An attachment-based model of complicated grief including the role of avoidance. European Archives of Psychiatry and Clinical Neuroscience, 257, 453-461.

Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., ... Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM‐5. Depression and Anxiety, 28, 103-117.

Simon, N. M., Shear, K. M., Thompson, E. H., Zalta, A. K., Perlman, C., Reynolds, C. F., Silowash, R. (2007). The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Comprehensive Psychiatry, 48, 395-399.

Strauss, M.E., & Smith, G.T. (2009). Construct validity: Advances in theory and methodology. Annual Review of Clinical Psychology, 5, 1-25.

Wakefield, J. C. (2012). Should prolonged grief be reclassified as a mental disorder in DSM-5? Reconsidering the empirical and conceptual arguments for complicated grief disorder. The Journal of Nervous and Mental Disease, 6, 499-511.