Memories, appraisals, and coping strategies in prolonged grief disorder
Keywords: Cognitive psychology
trauma
Grief
Bereavement
memory

Prolonged grief disorder (PGD) is a clinical classification of severe and enduring grief that can develop following the death of a loved one. PGD holds conceptual similarities to posttraumatic stress disorder (PTSD), another psychological disorder that arises following a stressful event. Memories, appraisals, and coping strategies are the targets for treatment in PTSD (Ehlers & Clark, 2000), but it is still unclear how these cognitive predictors relate to grief severity after loss. This thesis presents six studies, designed to investigate four research questions. 1) Are the cognitive factors relevant in the treatment of PTSD (e.g. memories, appraisals, and coping strategies) important in PGD? 2) Are there cognitive concepts missing from the literature that are relevant to PGD? 3) Are the cognitive factors associated with bereavement-related mental health problems such as PGD, PTSD and depression? 4) Do the cognitive factors predict grief severity over time?
Study 1 showed that self-report items measuring appraisals and coping strategies, developed from the literature and in collaboration with experienced therapists, significantly differentiated between bereaved individuals with and without PGD. Study 2 identified further cognitive concepts not previously discussed in the literature such as loss-related memory characteristics, social disconnection beliefs beliefs and grief resilience beliefs as being relevant to the experience of PGD. New questionnaires were developed from participants’ testimonies to reflect these concepts. Study 3 investigated the factoral and psychometric validity of the questionnaires developed in Studies 1 and 2. All questionnaires demonstrated acceptable to excellent reliability and validity. Study 4 showed bereaved individuals suffering from PGD, PTSD, and PGD+PTSD scored higher than non-clinical bereaved individuals on all new questionnaires measuring cognitive factors. Study 5 tested whether the influence of negative appraisals and loss-related memory characteristics on bereavement-related mental health problems (PGD, PTSD and depression) is mediated by maladaptive coping strategies in a sample of newly bereaved (&LT; 6 months post loss) and those bereaved longer (&GT; 6 months post loss). Results showed significant mediation for PGD, PTSD and depression in the newly bereaved sample. In those bereaved longer, the mediating effect of coping strategies was found to be comparatively weaker for PGD and no mediation was found for depression. For PTSD, the results across samples were comparable. Study 6 identified four latent classes of grief trajectory in the first 12-18 months of loss: high grief stable (HGS), high grief low adaptation (HGLA), high grief high adaptation (HGHA), and low grief (LG). Individually all of the cognitive predictors were elevated in the high grief classes compared to the low grief class. When all predictors were analysed together with loss characteristics and pre-loss individuals differences, loss-related memory characteristics were elevated in the high grief classes compared with the LG class. Negative appraisals were elevated in the HGLA and the HGS class compared to the HGHA class. A multi-group structural equation model demonstrated that the HGHA class were the only class for whom greater loss-related memory characteristics did not predict more maladaptive coping strategies, perhaps explaining adaptation in the presence of high grief. In sum, the studies supported the influence of cognitive predictors on grief severity concomitantly and over time. These results have implications for understanding grief symptoms and have clinical relevance for the treatment of bereavement-related mental health problems.