Medical Manuscript
Attachment Style Dimensions Can Affect Prolonged Grief Risk in Caregivers of Terminally Ill Patients With Cancer
American Journal of Hospice & Palliative Medicine® 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114547945 ajhpm.sagepub.com
Carlo Lai, PhD1, Massimiliano Luciani, PhD2, Federico Galli, MSc3, Emanuela Morelli, MSc3, Roberta Cappelluti, MSc1, Italo Penco, MD3, Paola Aceto, MD, PhD4, and Luigi Lombardo, MD3
Abstract Objective: The aim of the present study was to evaluate the predictive role of attachment dimensions on the risk of prolonged grief. Sixty caregivers of 51 terminally ill patients with cancer who had been admitted in a hospice were selected. Methods: Caregivers were interviewed using Attachment Scale Questionnaire, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Prolonged Grief Disorder 12 (PG-12). Results: The consort caregivers showed higher PG-12 level compared to the sibling caregivers. Anxiety, depression, need for approval, and preoccupation with relationships levels were significantly correlated with PG-12 scores. Conclusion: Female gender, high levels of depression, and preoccupation with relationships significantly predicted higher levels of prolonged grief risk. Keywords attachment, prolonged grief disorder, palliative care, depression, anxiety, caregiver
Introduction Although grief is not a disease, bereavement has been associated with decrements in physical health and risk of mortality,1 particularly in the early months after loss.1 Furthermore, bereaved individuals reported diverse psychological reactions and mental disorders or complications, which may ensue in the grieving process. In order to explain how people process grief and loss, it has been hypothesized that bereavement involves 2 types of stressors, one related to the loss of the loved one and the other to the restoration or reorganization of life and of the mental representations without the loved one.2-4 The outcome of this process is related to the alternation in adaptive coping of confrontation–avoidance referred to loss and restoration stressors.2,3 Successive studies argued that loss stressors, such as death circumstances, were related to the negative feelings experienced during the early stages of bereavement, while restoration stressors, such as dating, were related to positive effect mainly lived later.5 In this framework, the attachment style and mental representations assume an important role in grief processing where the central outcome seems to be the meaning attribution to the loss of the loved one.6 Coherently, previous studies suggested a positive correlation between insecure attachment style and prolonged grief symptoms.7
A previous study8 showed that anticipatory grief (before loss) experimented by spouses of terminally ill patients was similar to conventional grief (after loss), in terms of its emotional, physical, and social dynamics.8,9 These findings suggest that there is a continuum between anticipatory and conventional grief and that both are characterized by similar levels of emotional distress, such as depression, anxiety, and preoccupation.8 Successive studies confirmed an association between prebereavement grief symptoms and prolonged grief symptoms after loss.10 Recent studies on grief assessment before loss in caregivers of vegetative and terminally ill patients go in the same directions.11-14
1
Dynamic and Clinical Psychology, Sapienza University, Rome, Italy Psychiatry and Psychology Institute, Catholic University of Sacred Heart, Rome, Italy 3 Fondazione Roma, Hospice-SLA-Alzheimer, Rome, Italy 4 Department of Anaesthesiology and Intensive Care, Catholic University of Sacred Heart, Rome, Italy 2
Corresponding Author: Carlo Lai, PhD, Dynamic and Clinical Psychology Department, Sapienza University, Via degli Apuli 1, Roma 00185, Italy. Email: [email protected]
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
2 Prolonged grief disorder is a psychopathological condition that has been recently described as the failure of the transition from acute to integrated grief within 6 to 12 months after the death of a loved one.15,16 It is a debilitating disorder characterized by sadness, insomnia, absence of hunger, inattention, distressing moods, turbulence, confusing thoughts, and feelings of aloneness and emptiness.17-25 Despite prolonged grief disorder has been associated with anxiety, posttraumatic stress disorder, and depression,26-29 it has recently been proposed as a specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5).30-36 The criteria set for prolonged grief disorder proposed in the DSM-530 has been chosen through an item response theory analyses that allowed to identify the most informative, unbiased prolonged grief disorder symptoms.37 Recent studies showed that prolonged grief risk is associated with female gender, lower ability to recognize emotions,15,38 and lower age of the patients who died.15,26 Moreover, some studies39,40 showed that prolonged grief disorder seems to be associated with the closeness and the intensity of the relationship with the loved one, as well as with the circumstances surrounding the bereavement, where an unexpected, sudden, violent, or premature loss of a close and intense relationship is highly likely to cause a prolonged grief disorder.40 Despite encouraging data,37,40,41 which suggest that prolonged grief risk is associated with the type of relationship between the caregiver and the patients, at the present time, there are many studies about the psychopathological comorbidity associated with prolonged grief disorder, but few of these have investigated the role of different attachment styles or dimensions on the prolonged grief risk.7 The aim of the present study was to investigate the association between prolonged grief risk and the dimensions characterizing the attachment styles, anxiety, and depression in a sample of caregivers of terminally ill patients with cancer. The hypothesis of the study stated that high levels of insecure attachment dimensions, anxiety, and depression are associated with a higher prolonged grief risk.
where the palliative care physician proposed a psychological interview with the caregiver during the next day. A psychologist, through the interview with the caregiver, performed a sociodemographic interview and a psychological assessment. At the end of the evaluation, the psychologist proposed to the caregiver to participate in the research protocol. After obtaining the informed consent, the caregiver underwent the psychological evaluation. The caregiver was interviewed face-to-face using a demographic schedule, the Prolonged Grief Disorder 12 (PG-12),34 the Hamilton Anxiety Rating Scale (HAM-A),42 the Hamilton Depression Rating Scale (HAM-D),43 and the Attachment Style Questionnaire (ASQ).44 The Italian version of PG-1245 evaluates the risk of prolonged grief disorder. It showed a good internal consistency (Cronbach a ¼ .88) and a monofactorial structure.45 The HAM-A42 (14 items) was used to rate the severity of the anxiety, while the HAM-D43 (21 items) measures the severity of depression. The Italian version of the ASQ (40 items)46 is a 40-item self-report measure of adult attachment. Items are rated on a 6-point Likert-type scale (1 ¼ totally disagree and 6 ¼ totally agree). The ASQ includes 5 subscales: confidence (eg, ‘‘I feel confident that other people will be there for me when I need them’’), discomfort with closeness (eg, ‘‘I worry about people getting too close’’), need for approval (eg, ‘‘It’s important to me that others like me’’), preoccupation with relationships (eg, ‘‘I worry a lot about my relationships’’), and relationships as secondary (eg, ‘‘Achieving things is more important than building relationships‘‘). High scores on the confidence subscale and low scores on the other 4 subscales represent secure attachment. Discomfort with closeness is representative of avoidant attachment. Relationships as secondary is representative of dismissing attachment. Need for approval and preoccupation with relationships are representative of preoccupied attachment or anxious attachment.44 A taxometric study47 suggested the use of the scores on dimensional scales rather than in discrete categorizations. Internal consistency coefficients of the 5 dimensions in both clinical and nonclinical samples was good (.64 < Cronbach a < .74).46
Method This study was conducted in an Italian center for palliative care (hospice). The study was approved by the hospice’s institutional review board and conformed to the provisions of the Declaration of Helsinki. The caregivers of terminally ill patients with cancer were included in the study during the period before patients’ death (mean of hospital stay: 21 days). During the medical assessment of the patient, the selfidentified caregiver was asked to participate in this study and to sign the informed consent. The inclusion criteria were family relationship with a patient with terminal cancer, living in the Lazio region, Italian speaking, ability to give informed consent, and aged at least 18 years. After arrival of the patient to the hospice with his or her caregiver, the patient underwent a medical examination
Statistical Analyses Correlation analyses (Pearson r and Point Biserial rpb when appropriate) were conducted in order to evaluate the relationship between PG-12 values and other demographic, clinical, and attachment variables. A mathematical linear regression model was carried out in order to evaluate the effect of possible psychological predictors on the risk of prolonged grief. Only the variables that were significantly correlated with PG-12 scores were included in the model. Mean + standard deviation was reported, and P < .05 was considered statistically significant. StatSoft Version 5.0 was used for statistical analysis. Based on the effects reported in previous researches,15,26 a priori power analysis (G*Power 3.1.3) performed for linear multiple regression (effect size f2 ¼ 0.176; power at 0.90; level of significance at 0.05; number
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
Lai et al
3
Table 1. Distribution of the Caregivers Sample for Civil Status of Relationship With the Patient (Consort, Sibling, and Son/Daughter), Sex (Males/Females), Age (Mean + Standard Deviation), and PG-12 Score (Mean + Standard Deviation). Consort (n: 21) Sex (males/females) Age, mean + st dev
Sibling (n: 5)
Son/daughter (n: 34)
3/18 2/3 67.2 + 10.2 68.6+7.2
Total (n: 60)
Fisher F
12/22 17/43 49.6 + 12.6 57.4 + 14.4 F2,
PG-12 score, mean + st dev 32.3 + 10.6 22.0 + 7.9 29.2 + 10.0 29.7 + 10.3
Post hoc
¼ 18.0; P < .0001 Son vs consort: P < .0001 Son vs sibling: P ¼ .001 F2, 57 ¼ 2.2; P ¼ .117 Consort vs sibling: P ¼ .044 57
Abbreviations: PG-12, Prolonged Grief Disorder 12; st dev, standard deviation.
Table 2. Correlation Analyses (Pearson r) Among Clinical and Attachment Variables.a Ham-Anxiety Ham-Depression Ham-Depression ASQ-confidence with closeness ASQ-discomfort with closeness ASQ-need for approval ASQ-preoccupation with relationships ASQ-relationships as secondary
.82 P < .0001 .12 P ¼ .348 .05 P ¼ .676 .32 P ¼ .013 .32 P ¼ .014 .16 P ¼ .210
.10 P ¼ .437 .03 P ¼ .815 .22 P ¼ .084 .24 P ¼ .060 .10 P ¼ .464
ASQ-confidence ASQ-discomfort ASQ-need for ASQ-preoccupation with closeness with closeness approval with relationships
.70 P < .0001 .22 P ¼ .094 .28 P ¼ .029 .55 P ¼ .0001
.18 P ¼ .159 .22 P ¼ .088 .50 P ¼ .0001
.45 P ¼ .0003 .24 P ¼ .064
.29 P ¼ .022
Abbreviation: ASQ, Attachment Style Questionnaire. a n ¼ 60. Boldface rerpresents P values < .05.
of predictors: 7) showed that a sample size with a minimum of 51 participants was needed.
Results Sixty caregivers of 51 patients (age: 75.50 + 11.7) were recruited in the present study between March 2012 and July 2012. The percentage of eligible caregivers who completed the assessment was at an acceptable level (96%); approximately 4% refused to participate. The reason for refusal of participants was the lack of time. As shown in Table 1, the caregivers (60: 17 males and 43 females) were sons or daughters (34: 12 males and 22 females), consorts (21: 3 males and 18 females), and siblings (5: 2 males and 3 females). Obviously, sons/daughters were significantly younger (49.6 + 12.6 years) compared to consorts (67.2 + 10.2; P ¼ .001) and siblings (68.6 + 7.2; P ¼ .001). The consorts showed higher PG-12 scores than siblings (32.3 + 10.6 vs 22.0 + 7.9; P ¼ .044). Table 2 shows an high positive correlation between Hamilton anxiety and Hamilton depression values (r: .82; P < .0001). Hamilton depression scores were not correlated with attachment variables, while Hamilton anxiety scores were positively correlated with ASQ-need for approval (r: .32; P ¼ .013) and ASQ-preoccupation with relationships (r: .32; P ¼ .014) values. The ASQ-confidence with closeness values were negatively correlated with ASQ-discomfort with
closeness (r: .70; P < .0001), ASQ-preoccupation with relationships (r: .28; P ¼ .029), and with ASQ-relationships as secondary (r: .55; P < .0001). The ASQ-relationships as secondary scores were positively correlated with ASQ-discomfort with closeness (r: .50; P < .0001) and ASQ-preoccupation with relationships (r: .29; P ¼ .022). The ASQ-need for approval values were positively correlated with ASQpreoccupation with relationships (r: .45; P ¼ .0003). Table 3 shows that PG-12 scores (n ¼ 60) were significantly and positively correlated with sex of the caregiver (rpb: .31; P ¼ .014), Hamilton Anxiety (r: .54; P < .0001), Hamilton Depression (r: .60; P < .0001), ASQ-need for approval (r: .26; P ¼ .049), and ASQ-preoccupation with relationships (r: .42; P ¼ .001). The variables that significantly (P < .05) correlated with PG-12 scores (sex, Hamilton depression, Hamilton anxiety, preoccupation with relationships, and need for approval) were inserted in a mathematical linear regression model as predictors of PG-12 levels. The model was significant (R ¼ .70; R2 ¼ .49; R2adg ¼ .44; F5, 54 ¼ 10.28; P < .0001). The PG-12 scores were significantly associated with sex, b: .23; B: 5.2; t(54): 2.1; P ¼ .039, Hamilton depression, b: .51; B: 0.62; t(54): 3.0; P ¼ .004, and preoccupation with relationships, b: .34; B: 0.42; t(54): 3.0; P ¼ .004, and not significantly associated with Hamilton anxiety, b: .08; B: .07; t(54): 0.41; P ¼ .686, and need for approval, b: .02; B: 0.02; t(54): 0.13; P ¼ .893.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
4 Table 3. Correlation Analyses (Pearson r and Point Biserial rpb When Appropriate) Between Prolonged Grief Risk (PG-12 Score) and Demographic, Clinical, and Attachment Variables.a
Sex of caregiver Age of caregiver Sex of patient Ham-Anxiety Ham-Depression ASQ-confidence with closeness ASQ-discomfort with closeness ASQ-need for approval ASQ-preoccupation with relationships ASQ-relationships as secondary
PG-12 score
P value
.31 .19 .15 .54 .60 .11 .06 .26 .42 .12
.014 .150 .248 .0001 .0001 .395 .655 .049 .0007 .352
Abbreviations: ASQ, Attachment Style Questionnaire; PG-12, Prolonged Grief Disorder 12. a n ¼ 60.
Discussion The main result of the present study is the finding that the dimension ‘‘preoccupation with relationships’’ of ASQ was a good predictor of prolonged grief risk. Moreover, this finding confirms those of previous studies in which female caregivers with higher levels of depression showed a higher probability of prolonged grief risk.15,26,48 Moreover, the caregiver consorts of the terminally ill patients with cancer showed a significantly higher risk of prolonged grief risk than the patients’ sons and daughters. These data confirm the findings of previous studies showing that prolonged grief risk was associated with a marital relationship with the loved one.40,49 Coherently with a previous study,45 the correlation analyses among attachment dimensions showed an high association among ‘‘confidence with closeness,’’ ‘‘discomfort with closeness,’’ and ‘‘relationships as secondary’’ (related to an avoidant attachment style) and between ‘‘need for approval’’ and ‘‘preoccupation with relationships’’ (related to a anxious attachment style). In the present study, interestingly only ‘‘preoccupation with relationship’’ was a good predictor among the 5 dimensions of ASQ. The prolonged grief risk was only associated with ‘‘preoccupation with relationships’’ and not with ‘‘confidence with relationships.’’ Considering that both dimensions have been previously associated with anxious attachment style,45 this finding suggests that it is not the anxious attachment style to be associated with prolonged grief risk but only the dimension ‘‘preoccupation with relationships.’’ A previous study7 hypothesized a crucial role for avoidant attachment style in prolonged grief risk. In the present study, the 3 dimensions associated with the avoidant attachment style (‘‘confidence with closeness,’’ ‘‘discomfort with closeness,’’ and ‘‘relationships as secondary’’) were not associated with the prolonged grief risk. The caregivers with an attachment style characterized by high preoccupation with relationship and depression presented a higher risk of experiencing a prolonged grief after the death of the loved one. This result is coherent with the studies that showed an association between
the anxious–preoccupied attachment style and depression levels.50 This finding contributes to focusing clinical attention on this relational dimension in caregivers of terminally ill patients with cancer. Moreover, it suggests to consider psychological treatments focused on the relationship with the loved one and oriented to increase the acceptance of the imminent loss and to decrease denial and self-blame13 in order to prevent the onset of prolonged grief.51,52 Despite the fact that attachment dimensions are commonly considered stable psychological dimensions, in the present study, it cannot be excluded that the bereavement experience could increase the ‘‘preoccupation with relationships.’’ There have been studies that have focused on the stability of attachment styles and their dimensions53; conversely, there have been very few studies on whether and how attachment styles could change during an individual’s lifetime. Bereavement experiences during life could have the potential to (reversibly or not) change a person’s attachment style. Future studies should be planned in order to test the possible changes in attachment style dimensions after bereavement. In addition to the restricted sample size that limits the generalizability of the results, a limitation of the present study was that, despite PG-1234 items are clinically coherent with the criteria set for persistent complex bereavement disorder (PCBD) proposed in the DSM-5,30 the dependent variable was the prolonged grief risk and not the onset of PCBD. A future longitudinal study could confirm the relationship between prolonged grief risk and the onset of the disorder. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370(9630):1960-1973. 2. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Stud. 1999;23(3): 197-224. 3. Stroebe M, Schut H. The dual process model of coping with bereavement: a decade on. Omega. 2010;61(4):273-289. 4. Stroebe M, Schut H, Boerner K. Continuing bonds in adaptation to bereavement: toward theoretical integration. Clin Psychol Rev. 2010;30(2):259-268. 5. Richardson VE. The dual process model of coping with bereavement: a decade later. Omega. 2010;61(4):269-271. 6. Davis CG, Wortman CB, Lehman DR, Silver RC. Searching for meaning in loss: are clinical assumptions correct. Death Stud. 2000;24(6):497-540. 7. Shear K, Monk T, Houck P, et al. An attachment-based model of complicated grief including the role of avoidance. Eur Arch Psychiatr Clin Neurosci. 2007;257(8):453-461.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
Lai et al
5
8. Gilliland G, Fleming S. A comparison of spousal anticipatory grief and conventional grief. Death Stud. 1998;22(6):541-569. 9. Rando TA. Anticipatory grief: the term is a misnomer but the phenomenon exists. J Palliat Care. 1988;4(1-2):70-73. 10. Ghesquiere A, Haidar YM, Shear MK. Risks for complicated grief in family caregivers. J Soc Work End Life Palliat Care. 2011;7(2-3):216-240. 11. Chiambretto P, Moroni L, Guarnerio C, Bertolotti G, Prigerson HG. Prolonged grief and depression in caregivers of patients in vegetative state. Brain Injury. 2010;24(4):581-588. 12. Guarnerio C, Prunas A, Della Fontana I, Chiambretto P. Prevalence and comorbidity of prolonged grief disorder in a sample of caregivers of patients in a vegetative state. Psychiatr Q. 2010; 83(1):65-73. 13. Elvira de la Morena MJ, Cruzado JA. Caregivers of patients with disorders of consciousness: coping and prolonged grief. Acta Neurol Scand. 2013;127(6):413-418. 14. Kiely DK, Prigerson HG, Mitchell SL. Health care proxy grief symptoms before the death of nursing home resident with advances dementia. Am J Geriatr Psychiatry. 2008;16(8):664-673. 15. Lombardo L, Morelli E, Luciani M, et al. Pre-loss demographic and psychological predictors of complicated grief among relatives of terminally III cancer patients. Psychother Psychosom. 2012; 81(4):256-258. 16. Kentish-Barnes N, Lemiale V, Chaize M, Pochard F, Azoulay E. Assessing burden in families of critical care patients. Crit Care. 2009;37(10 suppl):448-456. 17. Alkhunaizi RB, Levene RS. Overcoming grief: a self-help guide using cognitive behavioural techniques. J Palliat Med. 2012;15: 1284. 18. Boelen PA. Symptoms of prolonged grief, depression, and adult separation anxiety: distinctiveness and correlates. Psychiatry Res. 2013;207(1-2):68-72. 19. Claxton R, Reynolds CF. Complicated grief #254. J Palliat Med. 2012;15(7):829-830. 20. Leonardi M, Giovannetti AM, Pagani M, Raggi A, Sattin D. Burden and needs of 487 caregivers of patients in vegetative state and in minimally conscious state: results from a national study. Brain Inj. 2012;26(10):1201-1210. 21. O’Connos MF. Immunological and neuroimaging biomarkers of complicated grief. Dialogues Clin Neurosci. 2012;14(2):141-148. 22. Villar SR, Casado MS, Prigerson HG. Prolonged grief disorder in the next of Kin of adult patients who die during or after admission to intensive care. Chest. 2012;141(6):1635-1636. 23. Boerner K, Schulz R. Caregiving, bereavement and complicated grief. Bereave Care. 2009;28(3):10-13. 24. Marvardi M, Mattioli P, Spazzafumo L, et al; Study Group on Brain Aging; Italian Society of Gerontology and Geriatrics. The caregiver burden inventory in evaluating the burden of caregivers of elderly demented patients: results from a multicenter study. Aging Clin Exp Res. 2005;17(1):46-53. 25. Horowitz MJ, Siegel B, Holen A, Bonanno GA, Milbrath C, Stinson CH. Diagnostic criteria for complicated grief disorder. Am J Psychiatry.1997;154(7):904-910. 26. Lai C, Luciani M, Morelli E, et al. Predictive role of different dimensions of burden for risk of complicated grief in caregivers
27. 28. 29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39. 40.
41.
42. 43. 44.
of terminally ill patients. Am J Hosp Palliat Care. 2014;31(2): 189-193. doi:10.1177/1049909113490227. Bryant RA. Grief as a psychiatric disorder. Br J Psychiatry. 2012; 201(1):9-10. Simon NM. Is complicated grief a post-loss stress disorder? Depress Anxiety. 2012;29(7):541-544. Spuij M, Reitz E, Prinzie P, Stikkelbroek Y, De Ross C, Boelen PA. Distinctiveness of symptoms of prolonged grief, depression, and post-traumatic stress in bereaved children and adolescents. Eur Child Adolesc Psychiatry. 2012;21(12):673-679. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Barnes JB, Dickstein BD, Maguen S, Neria Y, Litz BT. The distinctiveness of prolonged grief and postraumatic stress disorder in adults bereaved by the attacks of Spetember 11th. J Affect Disord. 2012;136(3):366-369. Bevans MF, Sternberg EM. Caregiving burden, stress, health effects among family caregivers of adult cancer patients. JAMA. 2012;307(4):398-403. Golden AJ, Dalgleish T. Is prolonged grief distinct from bereavement-related posttraumatic stress? Psychiatry Res. 2010; 178(2):336-341. Prigerson HG, Vanderwerker LC, Maciejewski PK. Prolonged grief disorder: a case for inclusion in DSM-V. In: Stroebe M, Hansson R, Schut H, Stroebe W, eds. Handbook of Bereavement Research and Practice: 21st Century Perspectives. Washington, DC: American Psychological Association Press; 2008;8:165-186. Lombardo L, Lai C, Morelli E, Bellizzi F, Ciccolini M, Penco I. Rischio di lutto complicato in familiari di pazienti oncologici in fase terminale: uno studio di screening. Riv Ital Cure Palliat. 2007;4:28-34. Caserta MS, Lund DA, Wright SD. Exploring the Caregiver Burden Inventory (CBI): further evidence for a multidimensional view of burden. Int J Aging Hum Dev. 1996;43(1):21-34. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121. Taylor GJ, Bagby RM, Parker JDA. Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press; 1997. Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care. 2012;18(5):540-547. van Doorn C, Kasl SV, Beery LC, Prigerson HG. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis. 1998;186(9):566-573. Mancini AD, Bonanno GA. The persistence of attachment complicated grief, threat, and reaction times to the deceased’s name. J Affect Disord. 2012;139(3):256-263. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-55. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62. Feeney JA, Noller P, Hanrahan M. Assessing adult attachment. In: Sperling MB, Berman WH, eds. Attachment in Adults: Clinical
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
6
45.
46.
47.
48.
and Developmental Perspectives. New York: Guilford Press; 1994:128-152. Chiambretto P, Moroni L, Guarnerio C, Bertolotti G. Italian validation of the prolonged grief disorder questionnaire (PG-12). G Ital Med Lav Ergon. 2008;30(1 suppl A):A105-A110. Fossati A, Feeney JA, Donati D, et al. On the dimensionality of the attachment style questionnaire in Italian clinical and nonclinical participants. J Soc Pers Relat. 2003;20(1):55-79. Fraley RC, Waller NG. Adult attachment patterns: a test of the typological model. In: Simpson JA, Rholes WS, eds. Attachment Theory and Close Relationships. New York: Guilford Press; 1998:77-114. Tang ST, Chang W, Chen J, et al. Course and predictors of depressive symptoms among family caregivers of terminally ill cancer patients until their death. Psychooncology. 2013;22(6): 1312-1318. doi:10.1002/pon.3141.
49. Utz RB, Caserta M, Lund D. Grief, depressive symptoms, and physical health among recently bereaved spouses. Gerontologist. 2011;52(4):460-471. 50. Permuy B, Merino H, Fernandez-Rey J. Adult attachment styles and cognitive vulnerability to depression in a sample of undergraduate students: the mediational roles of sociotropy and autonomy. Int J Psychol. 2010;45(1):21-27. 51. Lichtenthal WG, Nilsson M, Breitbart W, Kacel E, Jones EC, Prigerson HG. Underutilization of mental health services among bereaved caregivers with prolonged grief disorder. Psychiatr Serv. 2011;62(10):1225-1229. 52. Workman S. Prolonged grief disorder: a problem for the past, the present, and the future. PLoS Med. 2009;6(8):e1000122. 53. Green BL, Furrer CJ, McAllister CL. Does attachment style influence social support or the other way around? A longitudinal study of early head start mothers. Attach Hum Dev. 2011;13(1):27-47.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
Attachment Style Dimensions Can Affect Prolonged Grief Risk in Caregivers of Terminally Ill Patients With Cancer
American Journal of Hospice & Palliative Medicine® 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114547945 ajhpm.sagepub.com
Carlo Lai, PhD1, Massimiliano Luciani, PhD2, Federico Galli, MSc3, Emanuela Morelli, MSc3, Roberta Cappelluti, MSc1, Italo Penco, MD3, Paola Aceto, MD, PhD4, and Luigi Lombardo, MD3
Abstract Objective: The aim of the present study was to evaluate the predictive role of attachment dimensions on the risk of prolonged grief. Sixty caregivers of 51 terminally ill patients with cancer who had been admitted in a hospice were selected. Methods: Caregivers were interviewed using Attachment Scale Questionnaire, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Prolonged Grief Disorder 12 (PG-12). Results: The consort caregivers showed higher PG-12 level compared to the sibling caregivers. Anxiety, depression, need for approval, and preoccupation with relationships levels were significantly correlated with PG-12 scores. Conclusion: Female gender, high levels of depression, and preoccupation with relationships significantly predicted higher levels of prolonged grief risk. Keywords attachment, prolonged grief disorder, palliative care, depression, anxiety, caregiver
Introduction Although grief is not a disease, bereavement has been associated with decrements in physical health and risk of mortality,1 particularly in the early months after loss.1 Furthermore, bereaved individuals reported diverse psychological reactions and mental disorders or complications, which may ensue in the grieving process. In order to explain how people process grief and loss, it has been hypothesized that bereavement involves 2 types of stressors, one related to the loss of the loved one and the other to the restoration or reorganization of life and of the mental representations without the loved one.2-4 The outcome of this process is related to the alternation in adaptive coping of confrontation–avoidance referred to loss and restoration stressors.2,3 Successive studies argued that loss stressors, such as death circumstances, were related to the negative feelings experienced during the early stages of bereavement, while restoration stressors, such as dating, were related to positive effect mainly lived later.5 In this framework, the attachment style and mental representations assume an important role in grief processing where the central outcome seems to be the meaning attribution to the loss of the loved one.6 Coherently, previous studies suggested a positive correlation between insecure attachment style and prolonged grief symptoms.7
A previous study8 showed that anticipatory grief (before loss) experimented by spouses of terminally ill patients was similar to conventional grief (after loss), in terms of its emotional, physical, and social dynamics.8,9 These findings suggest that there is a continuum between anticipatory and conventional grief and that both are characterized by similar levels of emotional distress, such as depression, anxiety, and preoccupation.8 Successive studies confirmed an association between prebereavement grief symptoms and prolonged grief symptoms after loss.10 Recent studies on grief assessment before loss in caregivers of vegetative and terminally ill patients go in the same directions.11-14
1
Dynamic and Clinical Psychology, Sapienza University, Rome, Italy Psychiatry and Psychology Institute, Catholic University of Sacred Heart, Rome, Italy 3 Fondazione Roma, Hospice-SLA-Alzheimer, Rome, Italy 4 Department of Anaesthesiology and Intensive Care, Catholic University of Sacred Heart, Rome, Italy 2
Corresponding Author: Carlo Lai, PhD, Dynamic and Clinical Psychology Department, Sapienza University, Via degli Apuli 1, Roma 00185, Italy. Email: [email protected]
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
2 Prolonged grief disorder is a psychopathological condition that has been recently described as the failure of the transition from acute to integrated grief within 6 to 12 months after the death of a loved one.15,16 It is a debilitating disorder characterized by sadness, insomnia, absence of hunger, inattention, distressing moods, turbulence, confusing thoughts, and feelings of aloneness and emptiness.17-25 Despite prolonged grief disorder has been associated with anxiety, posttraumatic stress disorder, and depression,26-29 it has recently been proposed as a specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5).30-36 The criteria set for prolonged grief disorder proposed in the DSM-530 has been chosen through an item response theory analyses that allowed to identify the most informative, unbiased prolonged grief disorder symptoms.37 Recent studies showed that prolonged grief risk is associated with female gender, lower ability to recognize emotions,15,38 and lower age of the patients who died.15,26 Moreover, some studies39,40 showed that prolonged grief disorder seems to be associated with the closeness and the intensity of the relationship with the loved one, as well as with the circumstances surrounding the bereavement, where an unexpected, sudden, violent, or premature loss of a close and intense relationship is highly likely to cause a prolonged grief disorder.40 Despite encouraging data,37,40,41 which suggest that prolonged grief risk is associated with the type of relationship between the caregiver and the patients, at the present time, there are many studies about the psychopathological comorbidity associated with prolonged grief disorder, but few of these have investigated the role of different attachment styles or dimensions on the prolonged grief risk.7 The aim of the present study was to investigate the association between prolonged grief risk and the dimensions characterizing the attachment styles, anxiety, and depression in a sample of caregivers of terminally ill patients with cancer. The hypothesis of the study stated that high levels of insecure attachment dimensions, anxiety, and depression are associated with a higher prolonged grief risk.
where the palliative care physician proposed a psychological interview with the caregiver during the next day. A psychologist, through the interview with the caregiver, performed a sociodemographic interview and a psychological assessment. At the end of the evaluation, the psychologist proposed to the caregiver to participate in the research protocol. After obtaining the informed consent, the caregiver underwent the psychological evaluation. The caregiver was interviewed face-to-face using a demographic schedule, the Prolonged Grief Disorder 12 (PG-12),34 the Hamilton Anxiety Rating Scale (HAM-A),42 the Hamilton Depression Rating Scale (HAM-D),43 and the Attachment Style Questionnaire (ASQ).44 The Italian version of PG-1245 evaluates the risk of prolonged grief disorder. It showed a good internal consistency (Cronbach a ¼ .88) and a monofactorial structure.45 The HAM-A42 (14 items) was used to rate the severity of the anxiety, while the HAM-D43 (21 items) measures the severity of depression. The Italian version of the ASQ (40 items)46 is a 40-item self-report measure of adult attachment. Items are rated on a 6-point Likert-type scale (1 ¼ totally disagree and 6 ¼ totally agree). The ASQ includes 5 subscales: confidence (eg, ‘‘I feel confident that other people will be there for me when I need them’’), discomfort with closeness (eg, ‘‘I worry about people getting too close’’), need for approval (eg, ‘‘It’s important to me that others like me’’), preoccupation with relationships (eg, ‘‘I worry a lot about my relationships’’), and relationships as secondary (eg, ‘‘Achieving things is more important than building relationships‘‘). High scores on the confidence subscale and low scores on the other 4 subscales represent secure attachment. Discomfort with closeness is representative of avoidant attachment. Relationships as secondary is representative of dismissing attachment. Need for approval and preoccupation with relationships are representative of preoccupied attachment or anxious attachment.44 A taxometric study47 suggested the use of the scores on dimensional scales rather than in discrete categorizations. Internal consistency coefficients of the 5 dimensions in both clinical and nonclinical samples was good (.64 < Cronbach a < .74).46
Method This study was conducted in an Italian center for palliative care (hospice). The study was approved by the hospice’s institutional review board and conformed to the provisions of the Declaration of Helsinki. The caregivers of terminally ill patients with cancer were included in the study during the period before patients’ death (mean of hospital stay: 21 days). During the medical assessment of the patient, the selfidentified caregiver was asked to participate in this study and to sign the informed consent. The inclusion criteria were family relationship with a patient with terminal cancer, living in the Lazio region, Italian speaking, ability to give informed consent, and aged at least 18 years. After arrival of the patient to the hospice with his or her caregiver, the patient underwent a medical examination
Statistical Analyses Correlation analyses (Pearson r and Point Biserial rpb when appropriate) were conducted in order to evaluate the relationship between PG-12 values and other demographic, clinical, and attachment variables. A mathematical linear regression model was carried out in order to evaluate the effect of possible psychological predictors on the risk of prolonged grief. Only the variables that were significantly correlated with PG-12 scores were included in the model. Mean + standard deviation was reported, and P < .05 was considered statistically significant. StatSoft Version 5.0 was used for statistical analysis. Based on the effects reported in previous researches,15,26 a priori power analysis (G*Power 3.1.3) performed for linear multiple regression (effect size f2 ¼ 0.176; power at 0.90; level of significance at 0.05; number
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
Lai et al
3
Table 1. Distribution of the Caregivers Sample for Civil Status of Relationship With the Patient (Consort, Sibling, and Son/Daughter), Sex (Males/Females), Age (Mean + Standard Deviation), and PG-12 Score (Mean + Standard Deviation). Consort (n: 21) Sex (males/females) Age, mean + st dev
Sibling (n: 5)
Son/daughter (n: 34)
3/18 2/3 67.2 + 10.2 68.6+7.2
Total (n: 60)
Fisher F
12/22 17/43 49.6 + 12.6 57.4 + 14.4 F2,
PG-12 score, mean + st dev 32.3 + 10.6 22.0 + 7.9 29.2 + 10.0 29.7 + 10.3
Post hoc
¼ 18.0; P < .0001 Son vs consort: P < .0001 Son vs sibling: P ¼ .001 F2, 57 ¼ 2.2; P ¼ .117 Consort vs sibling: P ¼ .044 57
Abbreviations: PG-12, Prolonged Grief Disorder 12; st dev, standard deviation.
Table 2. Correlation Analyses (Pearson r) Among Clinical and Attachment Variables.a Ham-Anxiety Ham-Depression Ham-Depression ASQ-confidence with closeness ASQ-discomfort with closeness ASQ-need for approval ASQ-preoccupation with relationships ASQ-relationships as secondary
.82 P < .0001 .12 P ¼ .348 .05 P ¼ .676 .32 P ¼ .013 .32 P ¼ .014 .16 P ¼ .210
.10 P ¼ .437 .03 P ¼ .815 .22 P ¼ .084 .24 P ¼ .060 .10 P ¼ .464
ASQ-confidence ASQ-discomfort ASQ-need for ASQ-preoccupation with closeness with closeness approval with relationships
.70 P < .0001 .22 P ¼ .094 .28 P ¼ .029 .55 P ¼ .0001
.18 P ¼ .159 .22 P ¼ .088 .50 P ¼ .0001
.45 P ¼ .0003 .24 P ¼ .064
.29 P ¼ .022
Abbreviation: ASQ, Attachment Style Questionnaire. a n ¼ 60. Boldface rerpresents P values < .05.
of predictors: 7) showed that a sample size with a minimum of 51 participants was needed.
Results Sixty caregivers of 51 patients (age: 75.50 + 11.7) were recruited in the present study between March 2012 and July 2012. The percentage of eligible caregivers who completed the assessment was at an acceptable level (96%); approximately 4% refused to participate. The reason for refusal of participants was the lack of time. As shown in Table 1, the caregivers (60: 17 males and 43 females) were sons or daughters (34: 12 males and 22 females), consorts (21: 3 males and 18 females), and siblings (5: 2 males and 3 females). Obviously, sons/daughters were significantly younger (49.6 + 12.6 years) compared to consorts (67.2 + 10.2; P ¼ .001) and siblings (68.6 + 7.2; P ¼ .001). The consorts showed higher PG-12 scores than siblings (32.3 + 10.6 vs 22.0 + 7.9; P ¼ .044). Table 2 shows an high positive correlation between Hamilton anxiety and Hamilton depression values (r: .82; P < .0001). Hamilton depression scores were not correlated with attachment variables, while Hamilton anxiety scores were positively correlated with ASQ-need for approval (r: .32; P ¼ .013) and ASQ-preoccupation with relationships (r: .32; P ¼ .014) values. The ASQ-confidence with closeness values were negatively correlated with ASQ-discomfort with
closeness (r: .70; P < .0001), ASQ-preoccupation with relationships (r: .28; P ¼ .029), and with ASQ-relationships as secondary (r: .55; P < .0001). The ASQ-relationships as secondary scores were positively correlated with ASQ-discomfort with closeness (r: .50; P < .0001) and ASQ-preoccupation with relationships (r: .29; P ¼ .022). The ASQ-need for approval values were positively correlated with ASQpreoccupation with relationships (r: .45; P ¼ .0003). Table 3 shows that PG-12 scores (n ¼ 60) were significantly and positively correlated with sex of the caregiver (rpb: .31; P ¼ .014), Hamilton Anxiety (r: .54; P < .0001), Hamilton Depression (r: .60; P < .0001), ASQ-need for approval (r: .26; P ¼ .049), and ASQ-preoccupation with relationships (r: .42; P ¼ .001). The variables that significantly (P < .05) correlated with PG-12 scores (sex, Hamilton depression, Hamilton anxiety, preoccupation with relationships, and need for approval) were inserted in a mathematical linear regression model as predictors of PG-12 levels. The model was significant (R ¼ .70; R2 ¼ .49; R2adg ¼ .44; F5, 54 ¼ 10.28; P < .0001). The PG-12 scores were significantly associated with sex, b: .23; B: 5.2; t(54): 2.1; P ¼ .039, Hamilton depression, b: .51; B: 0.62; t(54): 3.0; P ¼ .004, and preoccupation with relationships, b: .34; B: 0.42; t(54): 3.0; P ¼ .004, and not significantly associated with Hamilton anxiety, b: .08; B: .07; t(54): 0.41; P ¼ .686, and need for approval, b: .02; B: 0.02; t(54): 0.13; P ¼ .893.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
4 Table 3. Correlation Analyses (Pearson r and Point Biserial rpb When Appropriate) Between Prolonged Grief Risk (PG-12 Score) and Demographic, Clinical, and Attachment Variables.a
Sex of caregiver Age of caregiver Sex of patient Ham-Anxiety Ham-Depression ASQ-confidence with closeness ASQ-discomfort with closeness ASQ-need for approval ASQ-preoccupation with relationships ASQ-relationships as secondary
PG-12 score
P value
.31 .19 .15 .54 .60 .11 .06 .26 .42 .12
.014 .150 .248 .0001 .0001 .395 .655 .049 .0007 .352
Abbreviations: ASQ, Attachment Style Questionnaire; PG-12, Prolonged Grief Disorder 12. a n ¼ 60.
Discussion The main result of the present study is the finding that the dimension ‘‘preoccupation with relationships’’ of ASQ was a good predictor of prolonged grief risk. Moreover, this finding confirms those of previous studies in which female caregivers with higher levels of depression showed a higher probability of prolonged grief risk.15,26,48 Moreover, the caregiver consorts of the terminally ill patients with cancer showed a significantly higher risk of prolonged grief risk than the patients’ sons and daughters. These data confirm the findings of previous studies showing that prolonged grief risk was associated with a marital relationship with the loved one.40,49 Coherently with a previous study,45 the correlation analyses among attachment dimensions showed an high association among ‘‘confidence with closeness,’’ ‘‘discomfort with closeness,’’ and ‘‘relationships as secondary’’ (related to an avoidant attachment style) and between ‘‘need for approval’’ and ‘‘preoccupation with relationships’’ (related to a anxious attachment style). In the present study, interestingly only ‘‘preoccupation with relationship’’ was a good predictor among the 5 dimensions of ASQ. The prolonged grief risk was only associated with ‘‘preoccupation with relationships’’ and not with ‘‘confidence with relationships.’’ Considering that both dimensions have been previously associated with anxious attachment style,45 this finding suggests that it is not the anxious attachment style to be associated with prolonged grief risk but only the dimension ‘‘preoccupation with relationships.’’ A previous study7 hypothesized a crucial role for avoidant attachment style in prolonged grief risk. In the present study, the 3 dimensions associated with the avoidant attachment style (‘‘confidence with closeness,’’ ‘‘discomfort with closeness,’’ and ‘‘relationships as secondary’’) were not associated with the prolonged grief risk. The caregivers with an attachment style characterized by high preoccupation with relationship and depression presented a higher risk of experiencing a prolonged grief after the death of the loved one. This result is coherent with the studies that showed an association between
the anxious–preoccupied attachment style and depression levels.50 This finding contributes to focusing clinical attention on this relational dimension in caregivers of terminally ill patients with cancer. Moreover, it suggests to consider psychological treatments focused on the relationship with the loved one and oriented to increase the acceptance of the imminent loss and to decrease denial and self-blame13 in order to prevent the onset of prolonged grief.51,52 Despite the fact that attachment dimensions are commonly considered stable psychological dimensions, in the present study, it cannot be excluded that the bereavement experience could increase the ‘‘preoccupation with relationships.’’ There have been studies that have focused on the stability of attachment styles and their dimensions53; conversely, there have been very few studies on whether and how attachment styles could change during an individual’s lifetime. Bereavement experiences during life could have the potential to (reversibly or not) change a person’s attachment style. Future studies should be planned in order to test the possible changes in attachment style dimensions after bereavement. In addition to the restricted sample size that limits the generalizability of the results, a limitation of the present study was that, despite PG-1234 items are clinically coherent with the criteria set for persistent complex bereavement disorder (PCBD) proposed in the DSM-5,30 the dependent variable was the prolonged grief risk and not the onset of PCBD. A future longitudinal study could confirm the relationship between prolonged grief risk and the onset of the disorder. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370(9630):1960-1973. 2. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Stud. 1999;23(3): 197-224. 3. Stroebe M, Schut H. The dual process model of coping with bereavement: a decade on. Omega. 2010;61(4):273-289. 4. Stroebe M, Schut H, Boerner K. Continuing bonds in adaptation to bereavement: toward theoretical integration. Clin Psychol Rev. 2010;30(2):259-268. 5. Richardson VE. The dual process model of coping with bereavement: a decade later. Omega. 2010;61(4):269-271. 6. Davis CG, Wortman CB, Lehman DR, Silver RC. Searching for meaning in loss: are clinical assumptions correct. Death Stud. 2000;24(6):497-540. 7. Shear K, Monk T, Houck P, et al. An attachment-based model of complicated grief including the role of avoidance. Eur Arch Psychiatr Clin Neurosci. 2007;257(8):453-461.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
Lai et al
5
8. Gilliland G, Fleming S. A comparison of spousal anticipatory grief and conventional grief. Death Stud. 1998;22(6):541-569. 9. Rando TA. Anticipatory grief: the term is a misnomer but the phenomenon exists. J Palliat Care. 1988;4(1-2):70-73. 10. Ghesquiere A, Haidar YM, Shear MK. Risks for complicated grief in family caregivers. J Soc Work End Life Palliat Care. 2011;7(2-3):216-240. 11. Chiambretto P, Moroni L, Guarnerio C, Bertolotti G, Prigerson HG. Prolonged grief and depression in caregivers of patients in vegetative state. Brain Injury. 2010;24(4):581-588. 12. Guarnerio C, Prunas A, Della Fontana I, Chiambretto P. Prevalence and comorbidity of prolonged grief disorder in a sample of caregivers of patients in a vegetative state. Psychiatr Q. 2010; 83(1):65-73. 13. Elvira de la Morena MJ, Cruzado JA. Caregivers of patients with disorders of consciousness: coping and prolonged grief. Acta Neurol Scand. 2013;127(6):413-418. 14. Kiely DK, Prigerson HG, Mitchell SL. Health care proxy grief symptoms before the death of nursing home resident with advances dementia. Am J Geriatr Psychiatry. 2008;16(8):664-673. 15. Lombardo L, Morelli E, Luciani M, et al. Pre-loss demographic and psychological predictors of complicated grief among relatives of terminally III cancer patients. Psychother Psychosom. 2012; 81(4):256-258. 16. Kentish-Barnes N, Lemiale V, Chaize M, Pochard F, Azoulay E. Assessing burden in families of critical care patients. Crit Care. 2009;37(10 suppl):448-456. 17. Alkhunaizi RB, Levene RS. Overcoming grief: a self-help guide using cognitive behavioural techniques. J Palliat Med. 2012;15: 1284. 18. Boelen PA. Symptoms of prolonged grief, depression, and adult separation anxiety: distinctiveness and correlates. Psychiatry Res. 2013;207(1-2):68-72. 19. Claxton R, Reynolds CF. Complicated grief #254. J Palliat Med. 2012;15(7):829-830. 20. Leonardi M, Giovannetti AM, Pagani M, Raggi A, Sattin D. Burden and needs of 487 caregivers of patients in vegetative state and in minimally conscious state: results from a national study. Brain Inj. 2012;26(10):1201-1210. 21. O’Connos MF. Immunological and neuroimaging biomarkers of complicated grief. Dialogues Clin Neurosci. 2012;14(2):141-148. 22. Villar SR, Casado MS, Prigerson HG. Prolonged grief disorder in the next of Kin of adult patients who die during or after admission to intensive care. Chest. 2012;141(6):1635-1636. 23. Boerner K, Schulz R. Caregiving, bereavement and complicated grief. Bereave Care. 2009;28(3):10-13. 24. Marvardi M, Mattioli P, Spazzafumo L, et al; Study Group on Brain Aging; Italian Society of Gerontology and Geriatrics. The caregiver burden inventory in evaluating the burden of caregivers of elderly demented patients: results from a multicenter study. Aging Clin Exp Res. 2005;17(1):46-53. 25. Horowitz MJ, Siegel B, Holen A, Bonanno GA, Milbrath C, Stinson CH. Diagnostic criteria for complicated grief disorder. Am J Psychiatry.1997;154(7):904-910. 26. Lai C, Luciani M, Morelli E, et al. Predictive role of different dimensions of burden for risk of complicated grief in caregivers
27. 28. 29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39. 40.
41.
42. 43. 44.
of terminally ill patients. Am J Hosp Palliat Care. 2014;31(2): 189-193. doi:10.1177/1049909113490227. Bryant RA. Grief as a psychiatric disorder. Br J Psychiatry. 2012; 201(1):9-10. Simon NM. Is complicated grief a post-loss stress disorder? Depress Anxiety. 2012;29(7):541-544. Spuij M, Reitz E, Prinzie P, Stikkelbroek Y, De Ross C, Boelen PA. Distinctiveness of symptoms of prolonged grief, depression, and post-traumatic stress in bereaved children and adolescents. Eur Child Adolesc Psychiatry. 2012;21(12):673-679. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Barnes JB, Dickstein BD, Maguen S, Neria Y, Litz BT. The distinctiveness of prolonged grief and postraumatic stress disorder in adults bereaved by the attacks of Spetember 11th. J Affect Disord. 2012;136(3):366-369. Bevans MF, Sternberg EM. Caregiving burden, stress, health effects among family caregivers of adult cancer patients. JAMA. 2012;307(4):398-403. Golden AJ, Dalgleish T. Is prolonged grief distinct from bereavement-related posttraumatic stress? Psychiatry Res. 2010; 178(2):336-341. Prigerson HG, Vanderwerker LC, Maciejewski PK. Prolonged grief disorder: a case for inclusion in DSM-V. In: Stroebe M, Hansson R, Schut H, Stroebe W, eds. Handbook of Bereavement Research and Practice: 21st Century Perspectives. Washington, DC: American Psychological Association Press; 2008;8:165-186. Lombardo L, Lai C, Morelli E, Bellizzi F, Ciccolini M, Penco I. Rischio di lutto complicato in familiari di pazienti oncologici in fase terminale: uno studio di screening. Riv Ital Cure Palliat. 2007;4:28-34. Caserta MS, Lund DA, Wright SD. Exploring the Caregiver Burden Inventory (CBI): further evidence for a multidimensional view of burden. Int J Aging Hum Dev. 1996;43(1):21-34. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121. Taylor GJ, Bagby RM, Parker JDA. Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press; 1997. Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care. 2012;18(5):540-547. van Doorn C, Kasl SV, Beery LC, Prigerson HG. The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis. 1998;186(9):566-573. Mancini AD, Bonanno GA. The persistence of attachment complicated grief, threat, and reaction times to the deceased’s name. J Affect Disord. 2012;139(3):256-263. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-55. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62. Feeney JA, Noller P, Hanrahan M. Assessing adult attachment. In: Sperling MB, Berman WH, eds. Attachment in Adults: Clinical
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
American Journal of Hospice & Palliative Medicine®
6
45.
46.
47.
48.
and Developmental Perspectives. New York: Guilford Press; 1994:128-152. Chiambretto P, Moroni L, Guarnerio C, Bertolotti G. Italian validation of the prolonged grief disorder questionnaire (PG-12). G Ital Med Lav Ergon. 2008;30(1 suppl A):A105-A110. Fossati A, Feeney JA, Donati D, et al. On the dimensionality of the attachment style questionnaire in Italian clinical and nonclinical participants. J Soc Pers Relat. 2003;20(1):55-79. Fraley RC, Waller NG. Adult attachment patterns: a test of the typological model. In: Simpson JA, Rholes WS, eds. Attachment Theory and Close Relationships. New York: Guilford Press; 1998:77-114. Tang ST, Chang W, Chen J, et al. Course and predictors of depressive symptoms among family caregivers of terminally ill cancer patients until their death. Psychooncology. 2013;22(6): 1312-1318. doi:10.1002/pon.3141.
49. Utz RB, Caserta M, Lund D. Grief, depressive symptoms, and physical health among recently bereaved spouses. Gerontologist. 2011;52(4):460-471. 50. Permuy B, Merino H, Fernandez-Rey J. Adult attachment styles and cognitive vulnerability to depression in a sample of undergraduate students: the mediational roles of sociotropy and autonomy. Int J Psychol. 2010;45(1):21-27. 51. Lichtenthal WG, Nilsson M, Breitbart W, Kacel E, Jones EC, Prigerson HG. Underutilization of mental health services among bereaved caregivers with prolonged grief disorder. Psychiatr Serv. 2011;62(10):1225-1229. 52. Workman S. Prolonged grief disorder: a problem for the past, the present, and the future. PLoS Med. 2009;6(8):e1000122. 53. Green BL, Furrer CJ, McAllister CL. Does attachment style influence social support or the other way around? A longitudinal study of early head start mothers. Attach Hum Dev. 2011;13(1):27-47.
Downloaded from ajh.sagepub.com at WESTERN OREGON UNIVERSITY on May 27, 2015
