Loss and psychotrauma
Week 1: Psychotherapy for Prolonged and Traumatic Grief: A Guide for Mental
Health Professionals.
Most people recover emotionally after the death of a loved one, but a minority develop
persistent and disabling grief.
Core of grief: separation distress (emotional, cognitive, behavioral)
1. Emotional: yearning, longing, despair, emptiness, loneliness.
2. Cognitive: disbelief, ‘unrealness’, hearing/seeing the lost person.
3. Behavioral: visiting meaningful places, maintaining belongings, searching
behavior.
When grief becomes a disorder: persists over time (months/years) and impairs
functioning.
Diagnostic criteria
DSM 5 Prolonged Grief Disorder (PSG):
- Loss ≥ 12 months ago.
- ≥ 1 separation distress symptom (yearning/preoccupation).
- ≥ 3 of 8 additional symptoms (identity disruption, disbelief, avoidance, emotional
pain, diOiculty moving on, numbness, meaninglessness, loneliness).
ICD-11:
- Loss ≥ 6 months ago.
- Yearning / preoccupation plus intense emotional pain (sadness, guilt, anger,
denial etc.).
Both require that symptoms exceed cultural norms and cause significant impairment.
DiOerential diagnostic considerations
PGD shares features with PTSD and depression, but they are distinct disorders.
All involve diOiculties regulating emotions and coping eOectively.
Emotional focus:
- PGD -> separation distress.
- PTSD -> anxiety, hypervigilance.
- Depression -> dysphoria, loss of pleasure.
Memory focus:
- PGD -> memories of the deceased/loss.
- PTSD -> intrusive, traumatic memories.
- Depression -> general negative self-referential memories.
Behavioral focus:
- PGD -> approach (proximity-seeking) + avoidance (of reminders).
- PTSD -> avoidance of threat cues.
- Depression -> inactivity, withdrawal.
Underlying mechanisms:
- PGD -> chronic activation of attachment system.
- PTSD -> chronic activation of fear network.
- Depression -> disturbed mood and motivation.
Research confirms PGD as distinct (also neural evidence).
PGD predicts future impairment even when PTSD and depression are controlled for.
PGD requires specific grief-focused therapy; PTSD/depression therapies often fail.
,Around 50% of PGD patients also meet criteria for PTSD and/or depression -> concept of
‘traumatic grief’.
Loss can also trigger other disorders: depression, panic disorder, mania, substance use,
PTSD.
Sudden loss is both the most common and most psychologically impactful life event.
Challenges for Bereavement research and care
Defining normal vs. disordered grief:
- Debate over criteria (symptom count, duration).
- DSM-5 vs. ICD-11 diOer (12 vs. 6 months).
- Some worry PGD pathologizes normal grief, but evidence shows not all grief is
healthy.
- Misconceptions may discourage people from seeking help.
Risk factors:
1. Female gender.
2. Unexpected loss.
3. Lack of social support.
4. Pre-existing mental vulnerability.
5. Rigid negative cognitions.
6. Avoidant coping.
Still unclear:
- Early vs. late onset PGD.
- Pre- vs. post loss influences.
- Interactions between risk factors.
- Role of protective factors (resilience, support).
Need to balance overtreatment and undertreatment:
- Therapy not useful for mild grief -> may disrupt natural recovery.
o But delaying care for severe grief can worsen chronicity.
Clinical stages of PGD
General staging template (psychiatry):
- Stage 0: at-risk; minimal / no symptoms.
- Stage 1: mild, non-specific or prodromal symptoms; low impairment.
- Stage 2: full syndrome. Episode; moderate-severe distress/disability.
- Stage 3: persistent / relapsing course; incomplete remission.
- Stage 4: chronic, unremitting disorder; severe impairment.
Applied to grief (nascent PGD staging):
Stage 0 (bereaved + risk):
- Normal, transient grief signs; risk factors present; protective factors may buOer.
Stage 1 (subclinical / acute distress):
- Non-specific depression / anxiety signs + intensified separation and / or
traumatic distress.
- Distressing and harder to control, but below diagnostic threshold.
Stage 2 (PGD diagnosis):
, - Diagnostic threshold met for PGD (± traumatic distress, depression, other
symptoms)
- Time anchor: only after 6 months post-loss; severe symptoms before 6 months =
stage 1.
- Impact: moderate-severe distress; impairment in multiple domains.
Stage 3 (persistent / relapsing PGD):
- Ongoing PGD with severe distress, functional disability, frequent comorbidity.
- Patterns: incomplete remission; recurrence after partial recovery; or multiple
recurrences with persistent impairment.
- Clinical note: often stable high symptom levels rather than fluctuations.
- Time anchor: only after 12 months post-loss
Stage 4 (entrenched, unremitting PGD):
- PGD + comorbid disorders; severe distress (e.g., uninterrupted pain) and global
disability (e.g., suicidality, impaired self-care).
Profiling hypothesized stages of PGD
Clinical characteristics (descriptive):
- Separation distress at all stages; becomes more frequent, prolonged, pervasive
at advanced stages.
- Avoidance is normal unless unbalanced by confrontation or paired with intense
fear / withdrawal.
- Proximity-seeking normal unless it blocks acknowledgment of irreversibility /
future planning.
- Progression markers: rising distress, disability, social / occupational dysfunction,
comorbidity, poor treatment response and time since loss (≥6m for Stage 2;
≥12m often for Stage 3).
- Red flags: bizarre / obscure reactions (e.g., persistent denial, impaired reality
testing).
Relatively static risk factors (predictive):
- Sociodemographic: female gender, older age, lower education / SES.
- Pre-loss: prior mental / physical problems, neuroticism, attachment insecurity /
anxiety.
- Loss characteristics: very close / dependent relationship, sudden, violent /
unnatural death.
- Aftermath / context: SES decline, legal proceedings, negative social support,
stigma.
Relatively static protective factors:
- Male gender, younger age, higher education / SES, good pre-loss mental /
physical health, secure attachments, strong social support, foreseeable losses
with preparatory opportunities.
Modifiable biopsychosocial mechanisms (targets):
- Neurobiological (emerging): reward-system hyperactivity, reduced serotonergic
activity, altered cortisol (treatment implications not yet clear).
- Psychological:
o Over-dominant loss orientation vs. insuOicient restoration orientation.
o Rigid negative appraisals, depressive/anxious avoidance, unhelpful
coping.
, o Merged identity with the deceased; poor integration of the loss into self /
relationship models.
o DiOiculty constructing adaptive meaning.
- Progression hypothesis: as stages advance -> appraisals become more negative /
rigid, avoidance broadens across life domains.
More risk + fewer protections -> greater chance of stage progression.
Some factors (loss of only child, violent death) may carry greater weight than others.
External static factors interact with internal dynamic factors; the. latter likely drive the
grief process more strongly.
Stepped bereavement care (stage-matched interventions)
Principles:
1. Least intensive early, more intensive later.
2. Target modifiable mechanisms relevant to that stage.
3. Evaluate both symptom relief and prevention of progression.
Stage 0:
- Informal support (friends, family).
- Public health: grief literacy campaigns; diversified resources.
- Tailoring: self-help/online resources for higher-resource individuals; watchful
waiting by GP + peer groups for more vulnerable individuals.
Stage 1 (Subclinical/acute, high risk):
- Preventive care window.
- Options: trained-facilitator peer groups (e.g., suicide loss, late-life spousal loss),
self-guided or guided iCBT for subsyndromal PGD; transdiagnostic preventive
programs for diOuse symptoms.
Stage 2 (Diagnosed PGD):
- Evidence-based treatments by trained clinicians: Prolonged Grief Treatment
(PGT); CBT (individual or group); internet-based CBT.
- Context-fit: group/systemic approaches when social context is fragile.
- Tailored CBT protocols exist for traumatic loss subgroups (homicide, suicide,
road accidents) and specific populations (children, older adults, refugees).
Stage 3 (Persistent/relapsing PGD):
- Continue PGD-focused therapy (adequate dose/duration).
- Augmentation as indicated: pharmacotherapy (for severe comorbid
depression/anxiety), systemic/family interventions, social work/rehabilitation
support.
- For relapsing courses: maintenance treatment (relapse monitoring, routines that
stabilize functioning).
Stage 4 (Entrenched PGD with major disability):
- Highly specialized, patient-centered multimodal care.
- Map severe symptoms, maintaining conditions, social resources; combine
maintenance pharmacotherapy, rehabilitation (connectedness, hope, identity,
meaning, empowerment), and multimodal packages.
- Primary aims: functioning, social participation, and halting further deterioration.
Week 1: Psychotherapy for Prolonged and Traumatic Grief: A Guide for Mental
Health Professionals.
Most people recover emotionally after the death of a loved one, but a minority develop
persistent and disabling grief.
Core of grief: separation distress (emotional, cognitive, behavioral)
1. Emotional: yearning, longing, despair, emptiness, loneliness.
2. Cognitive: disbelief, ‘unrealness’, hearing/seeing the lost person.
3. Behavioral: visiting meaningful places, maintaining belongings, searching
behavior.
When grief becomes a disorder: persists over time (months/years) and impairs
functioning.
Diagnostic criteria
DSM 5 Prolonged Grief Disorder (PSG):
- Loss ≥ 12 months ago.
- ≥ 1 separation distress symptom (yearning/preoccupation).
- ≥ 3 of 8 additional symptoms (identity disruption, disbelief, avoidance, emotional
pain, diOiculty moving on, numbness, meaninglessness, loneliness).
ICD-11:
- Loss ≥ 6 months ago.
- Yearning / preoccupation plus intense emotional pain (sadness, guilt, anger,
denial etc.).
Both require that symptoms exceed cultural norms and cause significant impairment.
DiOerential diagnostic considerations
PGD shares features with PTSD and depression, but they are distinct disorders.
All involve diOiculties regulating emotions and coping eOectively.
Emotional focus:
- PGD -> separation distress.
- PTSD -> anxiety, hypervigilance.
- Depression -> dysphoria, loss of pleasure.
Memory focus:
- PGD -> memories of the deceased/loss.
- PTSD -> intrusive, traumatic memories.
- Depression -> general negative self-referential memories.
Behavioral focus:
- PGD -> approach (proximity-seeking) + avoidance (of reminders).
- PTSD -> avoidance of threat cues.
- Depression -> inactivity, withdrawal.
Underlying mechanisms:
- PGD -> chronic activation of attachment system.
- PTSD -> chronic activation of fear network.
- Depression -> disturbed mood and motivation.
Research confirms PGD as distinct (also neural evidence).
PGD predicts future impairment even when PTSD and depression are controlled for.
PGD requires specific grief-focused therapy; PTSD/depression therapies often fail.
,Around 50% of PGD patients also meet criteria for PTSD and/or depression -> concept of
‘traumatic grief’.
Loss can also trigger other disorders: depression, panic disorder, mania, substance use,
PTSD.
Sudden loss is both the most common and most psychologically impactful life event.
Challenges for Bereavement research and care
Defining normal vs. disordered grief:
- Debate over criteria (symptom count, duration).
- DSM-5 vs. ICD-11 diOer (12 vs. 6 months).
- Some worry PGD pathologizes normal grief, but evidence shows not all grief is
healthy.
- Misconceptions may discourage people from seeking help.
Risk factors:
1. Female gender.
2. Unexpected loss.
3. Lack of social support.
4. Pre-existing mental vulnerability.
5. Rigid negative cognitions.
6. Avoidant coping.
Still unclear:
- Early vs. late onset PGD.
- Pre- vs. post loss influences.
- Interactions between risk factors.
- Role of protective factors (resilience, support).
Need to balance overtreatment and undertreatment:
- Therapy not useful for mild grief -> may disrupt natural recovery.
o But delaying care for severe grief can worsen chronicity.
Clinical stages of PGD
General staging template (psychiatry):
- Stage 0: at-risk; minimal / no symptoms.
- Stage 1: mild, non-specific or prodromal symptoms; low impairment.
- Stage 2: full syndrome. Episode; moderate-severe distress/disability.
- Stage 3: persistent / relapsing course; incomplete remission.
- Stage 4: chronic, unremitting disorder; severe impairment.
Applied to grief (nascent PGD staging):
Stage 0 (bereaved + risk):
- Normal, transient grief signs; risk factors present; protective factors may buOer.
Stage 1 (subclinical / acute distress):
- Non-specific depression / anxiety signs + intensified separation and / or
traumatic distress.
- Distressing and harder to control, but below diagnostic threshold.
Stage 2 (PGD diagnosis):
, - Diagnostic threshold met for PGD (± traumatic distress, depression, other
symptoms)
- Time anchor: only after 6 months post-loss; severe symptoms before 6 months =
stage 1.
- Impact: moderate-severe distress; impairment in multiple domains.
Stage 3 (persistent / relapsing PGD):
- Ongoing PGD with severe distress, functional disability, frequent comorbidity.
- Patterns: incomplete remission; recurrence after partial recovery; or multiple
recurrences with persistent impairment.
- Clinical note: often stable high symptom levels rather than fluctuations.
- Time anchor: only after 12 months post-loss
Stage 4 (entrenched, unremitting PGD):
- PGD + comorbid disorders; severe distress (e.g., uninterrupted pain) and global
disability (e.g., suicidality, impaired self-care).
Profiling hypothesized stages of PGD
Clinical characteristics (descriptive):
- Separation distress at all stages; becomes more frequent, prolonged, pervasive
at advanced stages.
- Avoidance is normal unless unbalanced by confrontation or paired with intense
fear / withdrawal.
- Proximity-seeking normal unless it blocks acknowledgment of irreversibility /
future planning.
- Progression markers: rising distress, disability, social / occupational dysfunction,
comorbidity, poor treatment response and time since loss (≥6m for Stage 2;
≥12m often for Stage 3).
- Red flags: bizarre / obscure reactions (e.g., persistent denial, impaired reality
testing).
Relatively static risk factors (predictive):
- Sociodemographic: female gender, older age, lower education / SES.
- Pre-loss: prior mental / physical problems, neuroticism, attachment insecurity /
anxiety.
- Loss characteristics: very close / dependent relationship, sudden, violent /
unnatural death.
- Aftermath / context: SES decline, legal proceedings, negative social support,
stigma.
Relatively static protective factors:
- Male gender, younger age, higher education / SES, good pre-loss mental /
physical health, secure attachments, strong social support, foreseeable losses
with preparatory opportunities.
Modifiable biopsychosocial mechanisms (targets):
- Neurobiological (emerging): reward-system hyperactivity, reduced serotonergic
activity, altered cortisol (treatment implications not yet clear).
- Psychological:
o Over-dominant loss orientation vs. insuOicient restoration orientation.
o Rigid negative appraisals, depressive/anxious avoidance, unhelpful
coping.
, o Merged identity with the deceased; poor integration of the loss into self /
relationship models.
o DiOiculty constructing adaptive meaning.
- Progression hypothesis: as stages advance -> appraisals become more negative /
rigid, avoidance broadens across life domains.
More risk + fewer protections -> greater chance of stage progression.
Some factors (loss of only child, violent death) may carry greater weight than others.
External static factors interact with internal dynamic factors; the. latter likely drive the
grief process more strongly.
Stepped bereavement care (stage-matched interventions)
Principles:
1. Least intensive early, more intensive later.
2. Target modifiable mechanisms relevant to that stage.
3. Evaluate both symptom relief and prevention of progression.
Stage 0:
- Informal support (friends, family).
- Public health: grief literacy campaigns; diversified resources.
- Tailoring: self-help/online resources for higher-resource individuals; watchful
waiting by GP + peer groups for more vulnerable individuals.
Stage 1 (Subclinical/acute, high risk):
- Preventive care window.
- Options: trained-facilitator peer groups (e.g., suicide loss, late-life spousal loss),
self-guided or guided iCBT for subsyndromal PGD; transdiagnostic preventive
programs for diOuse symptoms.
Stage 2 (Diagnosed PGD):
- Evidence-based treatments by trained clinicians: Prolonged Grief Treatment
(PGT); CBT (individual or group); internet-based CBT.
- Context-fit: group/systemic approaches when social context is fragile.
- Tailored CBT protocols exist for traumatic loss subgroups (homicide, suicide,
road accidents) and specific populations (children, older adults, refugees).
Stage 3 (Persistent/relapsing PGD):
- Continue PGD-focused therapy (adequate dose/duration).
- Augmentation as indicated: pharmacotherapy (for severe comorbid
depression/anxiety), systemic/family interventions, social work/rehabilitation
support.
- For relapsing courses: maintenance treatment (relapse monitoring, routines that
stabilize functioning).
Stage 4 (Entrenched PGD with major disability):
- Highly specialized, patient-centered multimodal care.
- Map severe symptoms, maintaining conditions, social resources; combine
maintenance pharmacotherapy, rehabilitation (connectedness, hope, identity,
meaning, empowerment), and multimodal packages.
- Primary aims: functioning, social participation, and halting further deterioration.
