Rumination and Avoidance as Predictors of Prolonged Grief, Depression, and Posttraumatic Stress in Female Widowed Survivors of War Nexhmedin Morina, PhD Abstract: This study examined independent contributions of rumination and experiential avoidance in predicting symptoms of psychological distress among female widowed survivors of war. A decade after the war in Kosovo, 100 widowed survivors of war completed measures of rumination, experien- tial avoidance, depression, posttraumatic stress, and prolonged grief. Results showed that both rumination and experiential avoidance significantly predicted the symptom severity of prolonged grief, depression, and posttraumatic stress. Furthermore, rumination accounted for additional variance above and beyond experiential avoidance and vice versa. Finally, the interaction of rumination and experiential avoidance did not provide significant explanatory power over and above the individual main effects. These findings suggest that rumina- tion and experiential avoidance may be significant factors in understanding and treating psychological distress following exposure to potentially traumatic events and loss due to violence. Key Words: Rumination, avoidance, depression, posttraumatic stress disorder, grief. (J Nerv Ment Dis 2011;199: 921Y927) A n accumulating body of research demonstrates that a subset of bereaved individuals experiences enduring psychological distress after loss of a significant other (Prigerson et al., 2009; Stroebe et al., 2007b). Among the most common psychological symptoms are grief- specific symptoms (also labeled as complicated grief or prolonged grief), major depressive disorder (MDD), and anxiety (Stroebe et al., 2007b). Research indicates that the symptoms of prolonged grief per se constitute a clinically significant syndrome that shows distinctive phenomenology from MDD and anxiety disorders (Prigerson et al., 1995a, 2009). Symptoms of prolonged grief include yearning, emo- tional numbness, feeling stunned or that life is meaningless, mistrust, avoidance of the reality of the loss, or difficulty in moving on with life. Furthermore, these symptoms must persist for at least 6 months after the loss and be associated with functional impairment (Prigerson et al., 2009). Research has demonstrated incremental validity of pro- longed grief (Bonanno et al., 2007). Finally, recent research supports the psychometric validity of the criteria for prolonged grief disorder (PGD), which was proposed to be included in DSM-V and ICD-11 (Prigerson et al., 2009). Given the potential long-term course of pathological distress following the loss of significant others (Byrne and Raphael, 1997; Chen et al., 1999; Morina et al., 2010c), it is important to better identify psychological factors associated with the maintenance of grief-related pathological distress. The aim of this study was to ex- amine the contributions of rumination and experiential avoidance in predicting symptoms of prolonged grief, depression, and posttrau- matic stress among widowed survivors of war. Both rumination and experiential avoidance are considered transdiagnostic processes that might explain the development and maintenance of mental disorders (Ehring et al., 2008b; Hayes et al., 1996). Experiential avoidance has been defined as the tendency to negatively evaluate unwanted emo- tions, thoughts, and bodily sensations and the attempt to alter the form of these events and the situations where they might occur (Hayes et al., 1996). Although experiential avoidance might result in short-term relief from distress, several studies indicate that attempts to alter emo- tions, thoughts, or bodily sensations may contribute to the mainte- nance of anxiety and mood disorders (Hayes et al., 2004; Wenzlaff and Eisenberg 2001) or even an increased anxiety and cognitive reactivity (Wegner, 1994). Support for the detrimental effect of experiential avoidance also comes from experimental studies indicating that attempts to control aversive emotions increase anxiety compared with attempts to accept emotions (Campbell-Sills et al., 2006; Wegner, 1994). Several models suggest that healthy emotional processing after exposure to traumatic events requires some sort of exposure to aversive reminders of traumatic events and their associated emotions (Ehlers and Clark, 2000; Foa and Kozak, 1986). Attempts to avoid or alter negative emotions, thoughts, or bodily sensations might interfere with potential disconfirming evidence of danger and diminish the individual’s ability to focus on healthy experiences (Hayes et al., 2006). Research has demonstrated that experiential avoidance is associated with psychological distress following different forms of traumatic events (Kashdan et al., 2009; Marx and Sloan, 2005; Morina et al., 2008; Tull et al., 2004). A recent study also indicated that experiential avoidance was associated with concurrent and prospective symptoms of pro- longed grief (Boelen, 2010). Rumination has been most extensively examined in relation to depression. Within the framework of the response style theory of depression (Nolen-Hoeksema, 1991), rumination has been defined as repetitive and passive thinking about negative emotions and the possible causes and consequences of symptoms of distress. Research has provided evidence that a ruminative response style is associated with the onset and maintenance of depression (Lyubomirsky and Nolen-Hoeksema, 1995; Nolen-Hoeksema, 2000; Nolen-Hoeksema et al., 1993; Watkins et al., 2000). Within the framework of behavioral activation conceptualiza- tion of depression, rumination is suggested to lead to an avoidance of active engagement with aversive environments that might be re- sponsible for the maintenance of depression (Martell et al., 2001). According to this framework, ruminative thinking is associated with inactivity and social withdrawal and functions to enable the individual to avoid dealing with difficult situations and associated distress. Preliminary studies support the association between rumination and behavioral avoidance (Cribb et al., 2006; Moulds et al., 2007). In a review of the response style theory, Nolen-Hoeksema et al. (2008) argue that in addition to disengaging people from aversive environ- ment, rumination intensifies hopelessness and thereby justifies inac- tivity. Furthermore, there is evidence that rumination plays a social signaling function in the sense that people with a ruminative style of coping with distress think more about their emotional reactions to stressful or traumatic events and thereby seek out others with whom to share feelings and thoughts. Nolen-Hoeksema and Davis (1999) ORIGINAL ARTICLE The Journal of Nervous and Mental Disease & Volume 199, Number 12, December 2011 www.jonmd.com 921 University of Amsterdam, Amsterdam, the Netherlands. Send reprint requests to Nexhmedin Morina, PhD, University of Amsterdam, Department of Clinical Psychology, Roetersstraat 15, 1018 WB Amsterdam, the Netherlands. E-mail: n.morina@uva.nl. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0022-3018/11/19912Y0921 DOI: 10.1097/NMD.0b013e3182392aae Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.