Summary Loss & Psychotrauma
WEEK 1
Lecture
Paul Boelen – Loss and Psychotrauma: introduction
Prolonged and traumatic grief: Symptoms, staging and stepped care – Boelen H1
Most people that are confronted with the death of a loved one, quickly recover and find
emotional balance again. However, in some people, this doesn’t happen and the death activates pre-
existing symptoms of mental disorders or the grief response gradually develops into disabling grief.
Therefore prolonged grief disorder has been included in the DSM V and ICD-11.
Prolonged grief disorder (PGD) is characterized by separation distress, which has
behavioural, emotional and cognitive elements. Separation distress is a normal response but it can lead
to PGD if it persists for a long time and cause dysfunction. The criteria of PGD in the DSM: loss for
more than 12 months ago and at least one of two separation distress symptoms and three of eight
additional symptoms. The grief reaction is not conform social norms.
Differential diagnosis:
PGD can be very similar to depression and PTSD. All three disorders are characterized by
emotion regulation difficulties, negative beliefs and thinking patterns and ineffective coping
behaviours.
PGD PTSD Depression
Central Separation distress Anxiety and Dysphoria and reduced
hypervigilance positive affect
Memories Reliving of memories Intrusive flashbacks Broader negative self-
about the deceased and associated with the referential memories
around the death of the loss
deceased
Behaviours Both approach (of the Avoidance of cues that Withdrawal and
loved one) and can trigger the anxiety inactivity
avoidance (of cues that
the separation is
permanent) behaviours
It’s a chronic… Activation of the Activation of the fear Disturbance in mood
attachment system network and approach
motivation
Research has shown that PGD, PTSD and depression are three distinct phenomena. PGD
symptoms do not reduce enough when treatment is only focused on PTSD and depression. However,
comorbidity is very common.
The prevalence of PGD is unclear and also differences between cultures are unclear. The
unexpected death of a loved one is not only a precursor for PGD, PTSD and depression but also for
many other mental health problems.
Challenges for bereavement and research care
The distinction between normal and pathological grief is still not very clear and there are
differences between the ICD-11 and the DSM-V. Predictors of pervasive grief are gender (female),
characteristics of the loss (unexpectedness) and additional stress in the aftermath and there are certain
,individual characteristics (like vulnerability before the death or rigid negative thinking). But there is
limited research about protective factors and many risk factors still have to be explored.
If people experience normal grief, it is important to not put them in healthcare because this
interferes with the normal grief reaction. However, for those with pervasive grief, waiting with
treatment may lead to more chronic conditions. There are some interventions to prevent PGD but is
unclear if they are really effective. Treatment for PGD has to be ameliorated because not everyone
recovers (enough).
Clinical staging, profiling and stepped care
A clinical staging approach distinguishes stages in temporal development of a disorder and
integrates the knowledge we already have. It can be combined with profiling (= connecting stages in
the course of a disorder with clinical characteristics and risk and protective factors to distinguish
people in different stages and to predict disorder improvement, progression and extension).
Clinicians have already made a general staging model with five stages. In the table below the
stages are described for PGD . Many people in bereavement experience the subclinical symptoms of
PGD. Few people progress to stage 2, but if they do this can only happen 6 months after the death.
Stage 3 is persistent PGD and in this stage the symptoms are stable and don’t fluctuate as much as in
stage 2. In stage 4, former treatment hasn’t worked yet and the PGD symptoms are still very severe.
, Profiling states several factors that characterise the different stages of the model. Clinical
characteristics include the nature, duration, intensity and frequency of symptoms as well as the
disability and distress caused by these symptoms. The clinical characteristics of symptoms differ
between the stages and are descriptive of the grief severity. Social functioning is critical in assessing
the disability. The time since death and the nature of the grief reactions are also important in
determining in which stage the individual exists.
Predictive factors of grief can be static risk and protective factors. These factors include
socio-demographic variables (being elderly or a woman), pre loss vulnerabilities (mental health
problems, neuroticism), characteristics of the loss (losing a closer attachment figure, death from
violent causes) and circumstances in the loss’ aftermath (economic problems, legal procedures or
stigmatization).
There is not much known about neurobiological mechanisms. Grief theories stated that the
perseverance of loss is associated with too much loss-oriented coping, rigid negative appraisals,
depressive and anxious avoidance strategies and other ineffective coping strategies. The bereaved ones
have a merged identity with the deceased, inadequate integration of the loss in ones self-concept and
relationship model and an inability to attribute adaptive meanings to the loss. There is a mismatch in
internal understanding of self and the loss and the external reality in combination with maladaptive
appraisals and coping.
Stepped bereavement care
Interventions in early stages are less invasive than in later stages. In the table above, the different
interventions are mentioned. At stage 1, preventive care can be applied to reduce distress and to
prevent someone from progressing to stage 2. This doesn’t have to be done by a clinical psychologist
but has to be done by clinicians. At stage 2, the diagnostic threshold for PGD is passed and
psychotherapy is needed. At stage 3, the clinical picture is more complex and the treatment of stage 2
has not worked sufficiently. Additional interventions are needed. In stage 4 highly specialized care is
needed.
Conclusion and discussion
It’s important to do more research about PGD and the clinical staging approach offers an important
framework to understand grief. It yet has to be studied how risk and protective factors interact and
what factors determine the movement from one stage to the next and which variables determine
extremely severe grief. There are also many variables that have not been discovered or studied yet.
Also, a better understanding of neurobiological mechanisms would maybe lead to pharmacological
treatments. The clinical staging model has a disorder specific approach but given the many
comorbidities and the important trans diagnostical factors, the clinical staging model will later turn out
to be a trans diagnostic model in which loss is an etiological factor. The clinical staging model doesn’t
distinguish between healthy and unhealthy grief and offers low threshold interventions which can
prevent PGD. Identifying strong risk factors aims to help those earlier than the one year mark for
PGD.
Workshop
Lyanne Reitsma – Narrative exposure therapy
Narrative exposure therapy = a treatment for people who have survived traumatic events and
continue to suffer from these past experiences. During NET, individuals create a coherent
autobiographical narrative of their most significant life events. It is used for people with complex and
prolonged trauma and it makes internal triggers lose control over the individual
Requirements of NET: 1) the therapy is applicable to various traumatic groups 2) NET has been
evaluated in ecologically valid settings and works fast 3) NET is simple and robust 4) NET
acknowledges the fact that complex trauma inevitable involves the abuse of human rights.
WEEK 1
Lecture
Paul Boelen – Loss and Psychotrauma: introduction
Prolonged and traumatic grief: Symptoms, staging and stepped care – Boelen H1
Most people that are confronted with the death of a loved one, quickly recover and find
emotional balance again. However, in some people, this doesn’t happen and the death activates pre-
existing symptoms of mental disorders or the grief response gradually develops into disabling grief.
Therefore prolonged grief disorder has been included in the DSM V and ICD-11.
Prolonged grief disorder (PGD) is characterized by separation distress, which has
behavioural, emotional and cognitive elements. Separation distress is a normal response but it can lead
to PGD if it persists for a long time and cause dysfunction. The criteria of PGD in the DSM: loss for
more than 12 months ago and at least one of two separation distress symptoms and three of eight
additional symptoms. The grief reaction is not conform social norms.
Differential diagnosis:
PGD can be very similar to depression and PTSD. All three disorders are characterized by
emotion regulation difficulties, negative beliefs and thinking patterns and ineffective coping
behaviours.
PGD PTSD Depression
Central Separation distress Anxiety and Dysphoria and reduced
hypervigilance positive affect
Memories Reliving of memories Intrusive flashbacks Broader negative self-
about the deceased and associated with the referential memories
around the death of the loss
deceased
Behaviours Both approach (of the Avoidance of cues that Withdrawal and
loved one) and can trigger the anxiety inactivity
avoidance (of cues that
the separation is
permanent) behaviours
It’s a chronic… Activation of the Activation of the fear Disturbance in mood
attachment system network and approach
motivation
Research has shown that PGD, PTSD and depression are three distinct phenomena. PGD
symptoms do not reduce enough when treatment is only focused on PTSD and depression. However,
comorbidity is very common.
The prevalence of PGD is unclear and also differences between cultures are unclear. The
unexpected death of a loved one is not only a precursor for PGD, PTSD and depression but also for
many other mental health problems.
Challenges for bereavement and research care
The distinction between normal and pathological grief is still not very clear and there are
differences between the ICD-11 and the DSM-V. Predictors of pervasive grief are gender (female),
characteristics of the loss (unexpectedness) and additional stress in the aftermath and there are certain
,individual characteristics (like vulnerability before the death or rigid negative thinking). But there is
limited research about protective factors and many risk factors still have to be explored.
If people experience normal grief, it is important to not put them in healthcare because this
interferes with the normal grief reaction. However, for those with pervasive grief, waiting with
treatment may lead to more chronic conditions. There are some interventions to prevent PGD but is
unclear if they are really effective. Treatment for PGD has to be ameliorated because not everyone
recovers (enough).
Clinical staging, profiling and stepped care
A clinical staging approach distinguishes stages in temporal development of a disorder and
integrates the knowledge we already have. It can be combined with profiling (= connecting stages in
the course of a disorder with clinical characteristics and risk and protective factors to distinguish
people in different stages and to predict disorder improvement, progression and extension).
Clinicians have already made a general staging model with five stages. In the table below the
stages are described for PGD . Many people in bereavement experience the subclinical symptoms of
PGD. Few people progress to stage 2, but if they do this can only happen 6 months after the death.
Stage 3 is persistent PGD and in this stage the symptoms are stable and don’t fluctuate as much as in
stage 2. In stage 4, former treatment hasn’t worked yet and the PGD symptoms are still very severe.
, Profiling states several factors that characterise the different stages of the model. Clinical
characteristics include the nature, duration, intensity and frequency of symptoms as well as the
disability and distress caused by these symptoms. The clinical characteristics of symptoms differ
between the stages and are descriptive of the grief severity. Social functioning is critical in assessing
the disability. The time since death and the nature of the grief reactions are also important in
determining in which stage the individual exists.
Predictive factors of grief can be static risk and protective factors. These factors include
socio-demographic variables (being elderly or a woman), pre loss vulnerabilities (mental health
problems, neuroticism), characteristics of the loss (losing a closer attachment figure, death from
violent causes) and circumstances in the loss’ aftermath (economic problems, legal procedures or
stigmatization).
There is not much known about neurobiological mechanisms. Grief theories stated that the
perseverance of loss is associated with too much loss-oriented coping, rigid negative appraisals,
depressive and anxious avoidance strategies and other ineffective coping strategies. The bereaved ones
have a merged identity with the deceased, inadequate integration of the loss in ones self-concept and
relationship model and an inability to attribute adaptive meanings to the loss. There is a mismatch in
internal understanding of self and the loss and the external reality in combination with maladaptive
appraisals and coping.
Stepped bereavement care
Interventions in early stages are less invasive than in later stages. In the table above, the different
interventions are mentioned. At stage 1, preventive care can be applied to reduce distress and to
prevent someone from progressing to stage 2. This doesn’t have to be done by a clinical psychologist
but has to be done by clinicians. At stage 2, the diagnostic threshold for PGD is passed and
psychotherapy is needed. At stage 3, the clinical picture is more complex and the treatment of stage 2
has not worked sufficiently. Additional interventions are needed. In stage 4 highly specialized care is
needed.
Conclusion and discussion
It’s important to do more research about PGD and the clinical staging approach offers an important
framework to understand grief. It yet has to be studied how risk and protective factors interact and
what factors determine the movement from one stage to the next and which variables determine
extremely severe grief. There are also many variables that have not been discovered or studied yet.
Also, a better understanding of neurobiological mechanisms would maybe lead to pharmacological
treatments. The clinical staging model has a disorder specific approach but given the many
comorbidities and the important trans diagnostical factors, the clinical staging model will later turn out
to be a trans diagnostic model in which loss is an etiological factor. The clinical staging model doesn’t
distinguish between healthy and unhealthy grief and offers low threshold interventions which can
prevent PGD. Identifying strong risk factors aims to help those earlier than the one year mark for
PGD.
Workshop
Lyanne Reitsma – Narrative exposure therapy
Narrative exposure therapy = a treatment for people who have survived traumatic events and
continue to suffer from these past experiences. During NET, individuals create a coherent
autobiographical narrative of their most significant life events. It is used for people with complex and
prolonged trauma and it makes internal triggers lose control over the individual
Requirements of NET: 1) the therapy is applicable to various traumatic groups 2) NET has been
evaluated in ecologically valid settings and works fast 3) NET is simple and robust 4) NET
acknowledges the fact that complex trauma inevitable involves the abuse of human rights.
