Is prolonged grief distinct from bereavement-related posttraumatic stress? Ann-Marie J. Golden ⁎, Tim Dalgleish Emotion Research Group, Medical Research Council Cognition and Brain Sciences Unit, Cambridge, England, United Kingdom abstract article info Article history: Received 23 October 2008 Received in revised form 28 April 2009 Accepted 27 August 2009 Keywords: Prolonged grief disorder Complicated grief Depression Anxiety Principal component analysis (PCA) PTSD Prolonged grief disorder (PGD) (previously called complicated grief (CG)) is proposed as a distinct post loss syndrome, with its own core symptoms. A key issue concerning the diagnostic validity of PGD is whether it can reliably be distinguished from related psychiatric outcomes following bereavement. This study therefore sought to determine whether the core symptoms of PGD could be distinguished from those of bereavement-related anxiety, depression and posttraumatic stress disorder (PTSD). Data were derived from a community sample of 223 bereaved adults in Croatia. PGD symptomatology was measured using the Revised Inventory of Complicated Grief. Depression and anxiety symptoms were measured using the Beck Depression and Anxiety Inventories, respectively. The intrusion and avoidance symptoms of PTSD were assessed using the Revised Impact of Event Scale. The distinctiveness of the five symptom clusters was examined using principal component analysis (PCA). Symptoms of prolonged grief, depression, anxiety, PTSD-intrusion, and PTSD-avoidance clustered together into five distinct factors. These results support the phenomenological distinctiveness of prolonged grief symptoms, from those of bereavement-related anxiety, depression and, for the first time, PTSD. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Following the loss of a significant other, a period of acute distress is common. However, a notable minority of individuals so bereaved develop clinically disabling grief symptoms. At present, the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not recognise such grief reactions as a separate disorder but lists bereavement as a “V” code condition that “may be a focus of clinical attention” (DSM-IV-The Current Version (TR)). However, there is a growing consensus that pathological grief reactions — variously called “complicated grief” (Boelen and van den Bout, 2008; Boelen, et al., 2007; Boelen et al., 2006; Prigerson, et al., 1995a; Prigerson, et al., 1996a), “complicated grief disorder” (Horowitz, et al., 2003), “Traumatic Grief” (Boelen and van den Bout, 2002; Boelen et al., 2003; Prigerson et al., 1997a,b; Prigerson, et al., 1999a,b) or, most recently, “prolonged grief disorder (PGD)” (Boelen and Prigerson, 2007; Goldsmith, et al., 2008; Prigerson et al., 2007) merit inclusion in the DSM as a distinct mental disorder that induces clinically significant distress associated with substantive disability. The current consensus criteria for PGD are presented in the Appendix. One of several key criteria for establishing the validity of a putative psychiatric diagnosis is the distinctiveness of the clinical phenomenology (see Robins and Guze, 1970, for a fuller discussion). Distinctiveness is important because one wants to know that the disorder in question is not simply a different but overlapping expression of another condition. In the case of PGD, efforts to demonstrate distinctiveness have focussed on delineating its core symptoms from those of anxiety, and depression surrounding the bereavement (Boelen and van den Bout, 2005; Boelen et al., 2003; Ogrodniczuk, et al., 2003; Prigerson et al., 1995a,b; Prigerson, et al., 1996a). The most persuasive empirical data in support of the distinctiveness of PGD phenomenology come from a series of innovative factor analytic (FA) studies on bereaved samples revealing that the core symptoms of PGD load on separate factors to the symptoms of anxiety and depression related to the bereavement using principal component analysis (PCA) and principal axis factoring (Boelen et al., 2003; Chen et al., 1999; Prigerson, et al., 1995a; Prigerson, et al., 1996a); using exploratory factor analysis (EFA) (Ogrodniczuk et al., 2003; Prigerson et al., 1995b) and using confirmatory factor analysis (CFA) (Boelen and van den Bout, 2005; Prigerson et al., 1996b). For example, in the prototypical study (Prigerson, et al., 1995a) on elderly, bereaved spouses who completed various measures of pathological grief and depression symptomatology, PCA revealed a two-factor solution including a prolonged grief factor that constituted symptoms of yearning, searching, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death and lack of acceptance of the death. Critically, this grief factor was distinct from a bereavement-depression symptom factor (e.g., apathy, depressed mood). This work was extended to include an examination of bereavement-related anxiety symptoms revealing sepa- rable factors reflecting prolonged grief, anxiety and depression symp- toms, associated with the bereavement, in bereaved elders (Prigerson, et al., 1996a) and a Dutch community sample (Boelen et al., 2003), and using both exploratory (Boelen et al., 2003) and confirmatory factor analysis (Boelen and van den Bout, 2005). Taken together, these studies provide compelling evidence that, despite overlap in the symptom criteria of PGD and anxiety and Psychiatry Research 178 (2010) 336–341 ⁎ Corresponding author. MRC Cognition and Brain Sciences Unit, 15 Chaucer Road, Cambridge CB2 7EF, UK. Tel. +44 1223 355 294x682; fax: +44 1223 359 062. E-mail address: ann-marie.golden@mrc-cbu.cam.ac.uk (A.-M.J. Golden). 0165-1781/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2009.08.021 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres