Risk Factors of Prolonged Grief Disorder

Abstract

Prolonged Grief Disorder (PGD) is characterized by extensive yearning, which includes a strong desire, for the deceased that occurs for at least 12 months. The aim of this study was to identify risk factors that contribute to PGD including the type of loss, relationship to the deceased, and coping. The sample included 190 bereaved adults (71 unexpected or violent loss and 119 natural loss) that experienced the loss of a loved one at least 12 months prior to completing the survey used in this study. There were non-significant results for type of loss, the presence of PGD, and coping. Findings showed that dysfunctional coping including self-blame explained the presence of PGD. Closeness to the deceased prior to the loss contributed to the presence of PGD. The findings highlight the risk factors for adults that experience a presence of PGD.

Keywords

prolonged grief type of death loss dysfunctional coping self-blame relationship with the deceased

Introduction

The psychological response to the loss of a loved one can develop into an extended grieving process that includes complex symptoms of grief, which are distinguished from pathological grief due to the mourning process. After years of contention regarding a formal diagnosis related to grief, Prolonged Grief Disorder (PGD) was formally introduced in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) (American Psychiatric Association [APA], 2022) to provide clinicians with a framework for understanding extensive and complicated grief. Risk factors can influence one’s experience of PGD including the nature of the death, how one copes with symptoms, and the qualities of the relationship to the deceased prior to the death.

Criterion A and B of PGD in the DSM-5-TR indicates that the death loss must have happened at least 12 months prior and separation distress that occurs nearly each day or more often than not for at least a month (APA, 2022). Separation distress refers to excessive yearning or longing for the deceased or fixations on thoughts or memories of the deceased (APA, 2022). Criterion C dictates that 3 of 8 of the following symptoms including struggles with identity, disbelief of death loss, avoidance, challenges with reintegrating into life, feeling emotional numb, and believing that life is meaninglessness, and intense loneliness occur almost each day or more often for at least a month (Prigerson et al., 2021). Boelen and Lenferink (2022) compared bereaved individuals at one- and two-years post-loss, suggested that 71% of bereaved individuals that met criteria for PGD at one year were likely to have PGD in the second year, which demonstrates the pervasiveness of the disorder.

Studies have suggested that unexpected or violent loss contributes to increased rates of PGD (Djelantik et al., 2020; Eisma & Tamminga, 2022), yet neither of these studies utilized assessment instruments that are psychometrically validated in accordance with the DSM-5-TR diagnostic criteria of PGD. A more recent study reported that there were not significant differences in acute PGD severity between those bereaved by natural, unnatural, and COVID-19 related loss (Lenferink & Boelen, 2023). Although Treml et al. (2022) reported non-significance between PGD severity and cause of death, it is noted that the perception of violence in death can influence PGD. The inconclusive findings in the literature regarding type of loss and PGD severity is worth further exploration.

Perceived closeness to or conflict with the deceased prior to death has influenced the severity and extensivity of PGD symptoms (Sekowski & Prigerson, 2021). Closeness to the deceased prior to the death is significantly associated with PGD (Harrison et al., 2021; Heeke et al., 2017; Sekowski & Prigerson, 2022). On the contrary, there is evidence that closeness and conflict are predictors of grief reactions (Bottomley et al., 2019). This may be explained in that closeness prior to death loss has also demonstrated an increased likelihood of contributing to challenging grieving processes whereas conflict prior to the death may lead to a lack of resolve and adverse grief reactions (Smigelsky et al., 2020). Thus, clarifying how the relationship to the deceased prior to death relates to the presence of PGD is necessary.

Unhelpful coping strategies such as avoidance and loss rumination contribute to PGD (Smith & Ehlers, 2021). Repetitive negative thought processes assist in avoiding the reality of loss and have contributed to the intensity of PGD symptoms (Wenn et al., 2019). One study suggested that caregivers diagnosed with PGD utilized problem-focused coping strategies such as active coping, instrumental support, planning, and the emotion-focused coping strategy of acceptance (de la Morena & Cruzado, 2013). However, dysfunctional coping strategies like denial (p = .003; η² = .98) and self-blame (p = .004, η² = .91) increased the severity of PGD in caregivers (de la Morena & Cruzado, 2013). Furthermore, Fisher et al. (2020) found that individuals bereaved by an unexpected or violent death used dysfunctional coping such as denial, behavioral disengagement, and self-blame, which resulted in negative bereavement outcomes and higher grief severity. Adaptive coping strategies including active coping can serve as protective risk factors in the development of PGD (Miller et al., 2020). Adaption to loss through acceptance could alleviate PGD (Prigerson et al., 2022). The type of death and the relationship to the deceased affect the coping strategies implemented post-loss (Buckley et al., 2015; Kokou-Kpolou et al., 2020); thus, further analysis of the interaction between these variables as they relate to PGD can assist clinicians in understanding the new diagnostic criteria and appropriate interventions.

To our knowledge, there is limited research that addresses the DSM-5-TR diagnostic criteria of PGD and risk factors such as coping, as defined by Carver’s (1997) model, and the relationship to the deceased prior to death. Furthermore, it is clear that there is a gap in the literature regarding the presence of PGD for those bereaved by unexpected or violent loss and natural loss. The purpose of this study was to examine how type of loss (i.e., unexpected or violent vs. natural) influenced the presence of PGD and coping. Secondly, this study sought to assess associations between the presence of PGD and the relationship with the deceased prior to the death loss. The following research questions were assessed for the present study: (1) Is there a difference between type of loss and the presence of PGD? (2) What differences exist between type of loss and coping strategies? (3) Do dysfunctional coping strategies influence the presence of PGD? (4) Does the relationship to the deceased prior to the loss impact the presence of PGD?

Method

Participants

Participants for this study (N = 190) consisted of adults who were between the ages of 19–64 that experienced the loss of a partner/spouse, parent, child, or other significant person at least 12 months prior to completing the survey and considered themselves to be grieving. Participants indicated an average age of 37.39 (SD = 12.91). The median age of the sample was 41; 67.4% of the participants reported an age of 41 or younger and 32.6% of the participants were over the age of 41. Majority of respondents (79.5%; n = 151) identified as cisgender women, most identified as heterosexual (84.2%; n = 160), and white (78.9%; n = 150). With regard to mental health disorders, 30% (n = 57) of participants indicated a mental disorder diagnosis. Frequency statistics of participant demographic information is located in Table 1. Of the participants, 37.3% reported experiencing unexpected or violent loss (n = 71) and 62.6% reported bereavement by natural loss (n = 119). With regard to the relationship to the deceased, majority of the participants reported the loss of a parent (33.7%) or a spouse/partner (16.8%). Of the sample, 72 participants (71 female and 1 transgender male) with a mean age of 39.06 (SD = 13.37) met diagnostic criteria for PGD. 118 participants (80 female and 38 male) with a mean age of 36.38 (SD = 12.59) did not meet diagnostic criteria for PGD. Participant information regarding the type of loss based on the presence of PGD is depicted in Table 2.

Table 1.

Frequency Statistics of Participant Demographic Information.

Category	n	%
Gender
Cisgender men	38	20
Cisgender women	151	79.5
Transgender man	1	0.5
Race
Black or African American	16	8.4
White	150	78.9
Asian	9	4.7
Hispanic or Latino	9	4.7
Native American	5	2.6
Other	1	0.5
Age
<41	128	67.4
>41	62	32.6
Relationship status
Single	37	19.5
Partnered	30	15.8
Married	91	47.9
Widowed	19	10
Divorced	11	5.8
Separated	2	1.1
Geographic location
Southern United States	105	55.3
Midwestern United States	31	16.3
Northeastern United States	24	12.6
Western United States	28	14.7
No response	2	1.1

Table 2.

Loss Characteristics Based on the Presence of PGD.

	Presence of PGD		No presence of PGD
	n = 72		n = 118
Characteristic	n	%	n	%
Given at least one day’s notice prior to loss
No	52	72.2	19	16.1
Yes	20	27.8	99	83.9
Relationship to the deceased
Spouse/Partner	13	18.1	19	16.1
Parent	29	40.3	35	29.7
Child	12	16.7	17	14.4
Sibling	2	2.8	12	10.2
Grandparent	8	11.1	3	2.5
Aunt/Uncle	2	2.8	4	3.4
Close friend	4	5.6	24	20.3
Other	2	2.8	3	2.5
Type of death
Homicide	2	2.8	2	1.7
Suicide	4	5.6	20	16.9
Accident	4	5.6	27	22.9
Natural disaster	1	1.4	7	5.8
Terrorism	1	1.4	2	1.7
Warfare	1	1.4	2	1.7
Natural causes	22	30.6	30	25.4
Chronic illness	31	43.1	25	21.2
COVID-19	1	1.4	3	2.5
Other	5	6.9	0	0

Note. Presence of PGD = participants that scored ≥30 on the PG-13-R, No Presence of PGD = participants that scored ≤ 29 on the PG-13-R.

The sample included two loss groups:

1. Participants bereaved by natural loss, comprising of 71 participants (51 females, 19 males, and 1 transgender male). Mean age was 37.41 (SD = 13.25).

2. Participants bereaved by unexpected or violent loss, comprising of 119 participants (100 females and 19 males). Mean age was 37.39 (SD = 12.75).

Procedure

Following IRB approval, participants were recruited through various clinical practices, grief-related groups, mental health listservs, and social media channels. All participants agreed to an informed consent prior to starting the survey. For the purpose of this study, participants were prompted to respond if they were given at least one day’s notice that the loss was going to occur. This study excluded individuals that were currently receiving inpatient services or residential treatment since these individuals are engaged in ongoing therapeutic processes that could influence results. Individuals that indicated having a diagnosis of a substance use disorder were excluded from the study since this would implicate findings on dysfunctional coping. Single episodes of loss were considered for this study to depict transparency of PGD severity. Participants that directly witnessed a violent death were excluded due to symptoms of PTSD influencing coping strategies. No identifying information of participants was collected.

The survey was administered using Qualtrics software. The survey consisted of five parts, which included a demographics survey, and three inventories; the Prolonged Grief Disorder-13-Revised (PG-13-R) (Prigerson et al., 2021), the Brief COPE inventory (Carver, 1997), and the Quality of Relationships Inventory-Bereavement Version (QRI-B) (Bottomley & Neimeyer, 2018), with a total of 70 items that included multiple choice and slider questions.

Instruments

Participant Demographic Survey

Participants were prompted to report demographic characteristics including age, gender, race, relationship status, and geographic location.

The PG-13-R evaluates the presence of prolonged grief based on the diagnostic criteria from the DSM-5-TR. The inventory contains two gatekeeper items that prompt responders to report if they have experienced a death loss and the number of months since the death loss. Responses for 10 symptom items are recorded on a 5-point Likert scale that ranges from “not at all” to “several times a day”, yielding a total score ranging from 10 to 50 (Prigerson et al., 2021). The responses of the 10 symptom items are summed to indicate a total score. A total score of 30 or greater suggests that the responder meets the criteria of PGD based on the DSM-5-TR. indicates the level of severity. The reliability of the scale in this study was α = .89.

The Brief COPE Inventory assesses for problem-focused, emotion-focused, and dysfunctional coping strategies by having participants rate their coping experiences on a 28-item instrument with 14 subscales that indicate scores for the three coping strategies with responses ranging from “I haven’t been doing this at all” to “I’ve been doing this a lot” on a 4-point Likert scale, resulting in a range from 2 to 8 (Carver, 1997). To determine the composite subscale scores of the coping strategies, the participant scores for problem-focused items (i.e., active coping, planning, and instrumental support), emotion-focused items (i.e., acceptance, emotional support, humor, positive re-framing, and religion), and dysfunctional items (i.e., denial, self-distraction, substance abuse, behavioral disengagement, self-blame, and venting) of the Brief COPE Inventory were categorized and summed. Subscales were created by summing the two items per coping strategy. In this study, the Cronbach’s alphas for the subscales ranged from .55 to .77.

The QRI-B instrument contains 13 items that measure two subscales (i.e., closeness or conflict) to assess the pre-death mourner-decedent relationship through a 4-point Likert scale wherein responses range from “not at all” to “very much” and scores are organized and summed for a total score to represent each subscale (Bottomley & Neimeyer, 2018). The QRI-B closeness scale assesses the support and intimacy of the relationship prior to death. The conflict scale recognizes the frequency and degree of interpersonal friction in the relationship prior to death. In this study, the closeness subscale α = .92 and the conflict subscale α = .83.

Data Analytic Strategy

Preliminary analyses of the data included an examination of assumptions. Specifically, assumptions of regression including the dependent variable (i.e., presence of PGD) is binary and ordinal, observations are independent of one another, and there was little to no multicollinearity between independent variables (i.e., coping, relationship to the deceased). Frequency statistics were performed on demographic information and loss characteristics. Descriptive statistics were conducted to calculate the means, standard deviations, and Cronbach’s alphas of the study variables. Pearson correlations were performed to explore the associations between the study variables. Independent samples t test and logistic regression were performed for this study. A p-value of .01 was used for significance in order to reduce the threat of Type I error. Analyses were conducted in SPSS version 29.

Results

Preliminary analysis demonstrated positive associations between PGD scores and dysfunctional coping strategies including denial (r = .49; p = .000), self-distraction (r = .43; p = .000), self-blame (r = .57; p = .000), substance abuse (r = .17; p = .000), behavioral disengagement (r = .34; p = .000), and venting (r = .26; p = .000). Additionally, there were positive relationships between closeness to the deceased prior to death and PGD scores (r = .33; p = .000). Pearson r correlations are shown in Table 3. The subscale means, standards deviations, and Cronbach’s alpha are reported for the inventories in Table 4.

Table 3.

Pearson’s r Correlation Matrix of PGD Scores.

Variable	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21
1.Age	-
2.PGD score	0.08	-
3.PFC	−0.1	.21^**	-
4.AC	−0.05	.24^**	.78^**	-
5.Plan	0.03	.37^**	.79^**	.53^**	-
6.IS	−0.13	.26^**	.77^**	.47^**	.58^**	-
7.EFC	−0.11	.20^**	.65^**	.50^**	.45^**	.59^**	-
8.Accept	0.08	−.24^**	.23^**	.28^**	0.09	0.08	.46^**	-
9.ES	−0.04	0.11	.61^**	.46^**	.44^**	.64^**	.72^**	.29^**	-
10.Humor	−.32^**	0.02	.23^**	0.13	.14^*	.23^**	.40^**	−0.04	.25^**	-
11.PR	−.16^*	−.23^**	.66^**	.38^**	.28^**	.29^**	.44^**	.36^**	.30^**	.20^**	-
12.Relig	0.09	−0.07	.20^**	.16^*	0.13	0.12	.47^**	.24^**	.16^*	−0.08	.35^**	-
13.DC	−.14^*	.53^**	.32^**	.22^**	.39^**	.34^**	.28^**	−.27^**	.20^**	.26^**	0.01	−0.11	-
14.Denial	−0.08	.49^**	.17^*	0.08	.28^**	.27^**	.15^*	−.39^**	0.1	0.14	−0.09	−0.01	.72^**	-
15.SD	−0.05	.43^**	.43^**	.47^**	.39^**	.33^**	.31^**	.17^*	.30^**	0.04	0.11	−0.05	.50^**	0.14	-
16.SA	−0.11	.17^*	0.14	−0.01	.21^**	.18^**	.18^*	−.21^**	.14^*	.29^**	0.02	−0.1	.74^**	.41^**	0.08	-
17.BD	−0.13	.34^**	0.06	−0.02	.14^*	0.12	0.09	−.38^**	−0.06	.31^**	−0.05	−0.12	.70^**	.48^**	0	.47^**	-
18.SB	−0.1	.57^**	.29^**	.23^**	.32^**	.37^**	.46^**	−.15^*	.19^**	.17^*	−0.02	−0.08	.53^**	.39^**	.31^**	.33^**	.38^**	-
9.Vent	−0.11	.26^**	.41^**	.31^**	.31^**	.47^**	.61^**	0.07	.46^**	.15^*	.15^*	0	.38^**	.28^**	.21^**	.27^**	.24^**	.38^**	-
20.Conflict	−0.07	0.08	.24^**	0.14	.23^**	.29^**	.27^**	−0.07	.19^**	.30^**	0.08	0.03	.28^**	.20^**	0.11	.20^**	.26^**	.26^**	.19^**	-
21.Closeness	.30^**	.33^**	0.01	0.07	0.02	−0.04	0.12	.24^**	0.09	−.17^*	−0.02	.14^*	−0.01	−0.05	.26^**	−0.12	−0.13	0.05	−0.07	−.26^**	-

Note. **p < .01. PFC = Problem-Focused Coping; AC = Active Coping; Plan. = Planning; IS = Instrumental Support; EFC = Emotion-Focused Coping; Accept = Acceptance; ES = Emotional Support; PR = Positive Re-framing; Relig. = Religion; DC = Dysfunctional Coping; SD = Self Distraction; SA = Substance Abuse; BD = Behavioral Disengagement; SB = Self Blame; Vent. = Venting.

Table 4.

Means, Standard Deviations, and Cronbach’s Alphas of Scales.

Scale	M	SD	α
PG-13-R	2.69	8.74	.89
Brief COPE inventory
Problem focused subscale	17.51	4.79	.76
Active coping	4.75	1.52	.72
Planning	4.21	1.61	.72
Instrumental support	4.32	1.58	.71
Emotion focused subscale	27	5.3	.55
Acceptance	5.86	1.72	.77
Emotional support	4.75	1.6	.72
Humor	3.09	1.48	.75
Positive reframing	4.22	1.66	.74
Religion	4.83	2.14	.77
Dysfunctional subscale	14.91	4.25	.71
Denial	3.34	1.41	.75
Self-distraction	5.08	1.77	.74
Substance abuse	3.17	1.71	.75
Behavioral disengagement	3.29	1.49	.76
Self-blame	4.09	1.78	.74
Venting	4.35	1.49	.73
QRI-B inventory
Closeness subscale	24.53	6.49	.92
Conflict subscale	9.43	3.66	.83

Note. Includes all participants. PG-13-R = Prolonged Grief Disorder-13-Revised; QRI-B = Quality of Relationship Inventory – Bereavement Version.

The independent samples t test did not indicate a statistically significant difference between the unexpected or violent loss group (M = 27.29, SD = 9.00) and natural loss group (M = 26.22, SD = 8.15) for the presence of PGD; t (188) = .820, p = .413. There was not a difference in the presence of PGD between those bereaved by unexpected or violent loss and natural loss.

A second independent samples t test did not indicate a statistically significant difference between the unexpected or violent loss group (M = 17.30, SD = 5.04) and the natural loss group (M = 17.85, SD = 4.35) with problem-focused coping; t (188) = −.773, p = .440. The independent samples t test did not indicate a statistically significant difference between the unexpected or violent loss group (M = 26.58, SD = 5.67) and the natural loss group (M = 27.69, SD = 4.57) for the emotion-focused coping composite subscale; t (188) = −1.388, p = .167. The independent samples t test for the dysfunctional coping subscale did not indicate a statistically significant difference between the unexpected or violent loss group (M = 14.78, SD = 4.32) and the natural loss group (M = 15.14, SD = 4.14); t (188) = −.563, p = .574. However, there was a statistically significant difference between the unexpected or violent loss group (M = 4.16, SD = 1.44) and the natural loss group (M = 4.67, SD = 1.50) with regard to venting; t (188) = −2.26, p = .025 with a small effect size (eta squared = .026). This suggested that the natural loss group endorsed venting more frequently than the unexpected or violent loss group.

Participants were grouped based on their total score on the PG-13-R. Group 1 included participants with a total score of 29 or below, which indicated no presence of PGD (n = 118). Group 2 was composed of participant total scores of 30 and above, which suggested the presence of PGD based on DSM-5-TR criteria (n = 72). A logistic regression was conducted to assess the impact of coping strategies on the likelihood that participants would report the presence of PGD. The model contained three independent variables (emotion-focused, problem-focused, and dysfunctional coping strategies). The full model contained all predictors and was statistically significant X² (3, N = 191) = 24.06, p < .001. The model as a whole explained 11.9% (Cox and Snell R square) and 16.2% (Nagelkerke R square) of variance in the presence of PGD, and correctly identified 66.3% of cases. The strongest predictor of reporting the presence of PGD was dysfunctional coping with an odds ratio of 1.19. This suggested that participants that experienced the presence of PGD were more likely to report dysfunctional coping strategies, while controlling for all other factors in the model. Results of the regression are shown in Table 5.

Table 5.

Summary of Logistic Regression for Coping Strategies and Presence of PGD.

Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	95.0% C.I.
Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	Lower	Upper
Dysfunctional*	0.177	0.042	17.704	1	<.001	1.194	1.099	1.296
Emotion-focused	0.027	0.041	0.442	1	0.506	1.027	0.949	1.113
Problem-focused	−0.008	0.044	0.035	1	0.851	0.992	0.91	1.081

Note. *Results significant at the .01 level.

Another logistic regression was performed to assess the impact of a number of factors on the likelihood that participants would report the presence of PGD. The model contained six independent variables (venting, denial, substance abuse, behavioral disengagement, self-distraction, and self-blame). The full model contained all predictors and was statistically significant X² (6, N = 191) = 64.74, p < .001, indicating that the model was able to distinguish between participants who had the presence of PGD and those that did not. The model as a whole explained 28.9% (Cox and Snell R square) and 39.3% (Nagelkerke R square) of variance in the presence of PGD, and correctly classified 77.4% of cases. The strongest predictor of reporting the presence of PGD was self-blame that had an odds ratio of 1.71. This indicated that participants who had the presence of PGD were almost twice as likely to use self-blame as a coping strategy, controlling for all other factors in the model. Results for this logistic regression are depicted in Table 6.

Table 6.

Summary of Logistic Regression for Dysfunctional Coping Strategies and Presence of PGD.

Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	95.0% C.I.
Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	Lower	Upper
Venting	−0.09	0.139	0.425	1	0.51	0.914	0.696	1.199
Denial	0.436	0.157	7.757	1	0.005	1.547	1.138	2.102
Substance abuse	−0.302	0.127	5.665	1	0.017	0.74	0.577	0.948
Behavioral disengagement	0.157	0.149	1.103	1	0.294	1.169	0.873	1.566
Self-distraction	0.349	0.118	8.737	1	0.003	1.418	1.125	1.788
Self-blame*	0.535	0.13	16.924	1	<.001	1.708	1.323	2.204

Note. *Results significant at the .01 level.

Logistic regression was conducted to assess the impact of two factors on the likelihood that participants would report the presence of PGD. The model contained two independent variables (closeness and conflict). The full model contained both predictors and was statistically significant X² (2, N = 191) = 22.34, p < .001, indicating that the model was able to distinguish between participants who had the presence of PGD and those that did not. The model as a whole explained 11.1% (Cox and Snell R square) and 15.1% (Nagelkerke R square) of variance in the presence of PGD, and correctly classified 64.2% of cases. The strongest predictor of reporting the presence of PGD was closeness, which had an odds ratio of 2.74. This suggested that participants who had the presence of PGD were almost three times as likely to report closeness to the deceased prior to death, while controlling for all other factors. The results for this logistic regression are shown in Table 7.

Table 7.

Summary of Logistic Regression for Relationship to the Deceased and Presence of PGD.

Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	95.0% C.I.
Predictor	B	S.E.	Wald X ²	df	p	Odds Ratio	Lower	Upper
Closeness*	1.008	0.241	17.5	1	<.001	2.741	1.709	4.396
Conflict	0.594	0.239	6.155	1	0.013	1.811	1.133	2.896

Note. *Results significant at the .01 level.

Discussion

The aim of this study was to examine how type of loss (i.e., unexpected or violent vs. natural) influenced the presence of PGD and coping. Secondly, this study sought to determine associations between the presence of PGD and the relationship with the deceased prior to the death loss. A goal of the study was to identify how risk factors contribute to the presence of PGD. Contradicting previously literature findings that unexpected or violent loss increases PGD severity (Buckley et al., 2015; Doering et al., 2022), there were not any differences in the presence of PGD between those bereaved by natural loss versus unexpected or violent loss. Yet, Sekowski and Prigerson (2022) noted that there was a weak association between unexpected loss and PGD severity. The lack of difference between these groups should be considered by clinicians when assessing for PGD.

Results of this study suggested that participants who had a presence of PGD endorsed higher scores of dysfunctional coping strategies including self-blame, which aligns with previous literature (Fisher et al., 2020; Wenn et al., 2019). Self-blame as described in loss rumination has demonstrated to be a contributor of PGD (Smith & Ehlers, 2021). These findings may be further explained by the perception of dysfunctional coping strategies require less effort as compared to emotion-focused or problem-focused coping. For example, Wenn et al. (2019) noted that the use of dysfunctional coping strategies may be related to the mental load of using coping strategies related to emotional processing, wherein bereaved individuals report exhaustion. Perpetuating symptoms of PGD via thought processes can develop into a feedback loop or cycle, which influences the coping strategies utilized by bereaved individuals (Smith & Ehlers, 2021). Furthermore, Prigerson et al. (2022) suggested that self-blame impedes the early grieving process, which may contribute to the development of PGD. It is recommended that clinicians assist clients with replacing dysfunctional coping with problem-focused coping strategies, which is perceived as the most beneficial coping strategy for those with PGD (de la Morena & Cruzado, 2013). Bereaved individuals can use the information in this study by re-evaluating the effectiveness of their coping skills, which may encourage them to pursue clinical treatment. Future studies should consider the influence of COVID-19 on coping strategies since individuals have been limited in coping due to previous quarantine guidelines (Fisher et al., 2022) and the lack of closure.

In this study, closeness to the deceased prior to the loss explained the presence of PGD, which has also been demonstrated in the work by Harrison et al. (2021) and Heeke et al. (2017). Stronger attachments to the deceased have added to the complexity of prolonged grieving processes (Djelantik et al., 2017; Sekowski & Prigerson, 2022). On the contrary, both closeness and conflict have contributed to grief severity (Bottomley et al., 2019; Smigelsky et al., 2020). These results offer further evidence to prior literature that closeness prior to the death loss has a strong relationship with PGD; however, conflicting findings across studies highlights the need for further research.

With regard to this study, generalizability is of concern. Although participants indicated varying locations around the United States, the majority of participants were located in the southern United States. Moreover, the majority of the participants of the sample identified as white and or cisgender women, demonstrating a lack of racial and gender diversity within the study. Due to the non-probability sampling method, there may be an overrepresentation of individuals that have sought support, which excludes those that have coped on their own; however, specific groups such as those bereaved by multiple losses or directly witnessed the death were excluded to limit bias. Future studies to incorporate samples with greater diversity, substance abuse disorder, and multiple losses or directly witnessing the death. This study relied on self-report measures, which can pose a concern with regard to construct validity. The utilization of survey as the method of data collection can also threaten internal validity as participants are responsible for their own interpretation of items. Nevertheless, the instrumentation selected for the study demonstrated adequate reliability and validity, resulting in the reduction of variable error. Thirdly, a limitation of this study was the lack of differentiation between unexpected and violent loss. Some of the participants in this study who reported a natural loss selected that the death was unexpected. It is specifically recommended that prospective studies focus on either unexpected or violent losses rather than including these terms together as this would provide further clarification with regard to the extensivity of grief experienced by bereaved individuals.

The findings of this study emphasize the importance of understanding the level of closeness or conflict to the deceased prior to the death loss and encourage the need for continued research on prolonged grief can provide normalization and validation for bereaved individuals. Closeness and dysfunctional coping offered explanation for the presence of PGD experienced by bereaved adults. Overall, the findings of this study demonstrate the importance of understanding PGD as a diagnosis in the DSM-5-TR along with the multiple factors that limit an individual’s ability to process grief.

Footnotes

Acknowledgements

We are grateful for each of the participants that contributed to this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial funding was provided by the Department of Special Education, Rehabilitation, and Counseling in the College of Education at Auburn University. Financial funding supported the raffle offered to participants as incentive for completing the survey in the study.

Ethical Statement

ORCID iD

Emma Quadlander-Goff

Data Availability Statement

Participants in this study did not consent to have their data shared publicly. Due to the sensitive nature of the topic of the study, supporting data is not available.*

Author Biographies

Dr Emma Quadlander-Goff is an Assistant Professor and Assessment Coordinator in the Department of Counseling, Rehabilitation, and Interpreter Training in the College of Education at Troy University. Dr. Quadlander-Goff received her Ph.D. in Counselor Education from Auburn University in 2023 and her M.S. in Clinical Mental Health Counseling from Troy University in 2019. She is a Licensed Professional Counselor (Alabama) and a Nationally Certified Counselor. Her research is focused on bereavement, unexpected loss, prolonged grief disorder, comorbid diagnoses, and ADHD. Her publications have been featured in The Professional Counselor and the Journal of Pharmacology Biochemistry and Behavior.

Dr Jill Meyer is a Professor and Director of Counselor Education in the Department of Special Education, Rehabilitation, and Counseling at Auburn University (AU). She has received a number of Rehabilitation Services Administration (RSA) grants, including an Innovative Grant funding the Vocational Evaluation Forensic Certification program at AU. Her research examines the process of coping, adaptation, and identity, as these constructs relate to the psychosocial experiences of individuals with chronic illness and disability. She is also interested in emerging adulthood, psychological well-being, and perceived disability of, and adaptation to acquired chronic conditions, in addition to forensic rehabilitation. Her publications have appeared in the Journal of Counseling Psychology and Rehabilitation Psychology. Her courses include Research Design, Research Practicum, Research Methods in Rehabilitation, and Medical, Psychosocial, and Vocational Aspects of Disability. Dr. Meyer received her MS in Rehabilitation Counseling from the University of Illinois, and her PhD in Counseling Education and Supervision from the University of Missouri – St. Louis.

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