The loss of a fellow service member: Complicated grief in post‐9/11 service members and veterans with combat‐related posttraumatic stress disorder

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Bereavement is a highly distressing and disruptive experience. It is associated with the onset of a range of mental health conditions, including major depressive disorder (MDD) and posttraumatic stress disorder (PTSD; Keyes et al., 2014). In addition, approximately 7% of bereaved individuals will experience complicated grief (CG), a syndrome associated with adverse psychosocial outcomes, including increased risk for suicide (Kersting, Brahler, Glaesmer, & Wagner, 2011; Marques et al., 2013; Simon et al., 2011; Tal et al., 2016). Complicated grief (also referred to as prolonged grief disorder or traumatic grief) was recently proposed as a disorder needing further study within the newly formed trauma and stressor related conditions category of DSM‐5 under the name persistent complex bereavement disorder (PCBD). (American Psychiatric Association, 2013). Unlike acute grief, a variable but time‐limited response to loss, CG is a persistent, intense and impairing condition diagnosed when distressing and disabling grief has persisted at least 6 months following the loss.
Core symptoms of CG include intense yearning or longing for the deceased, sorrow or emotional pain, and preoccupation with thoughts about the death or the deceased (Simon et al., 2011). Additional symptoms include difficulty accepting the death, avoidance of reminders of the deceased or of the permanence of the loss, difficulty planning for the future, role and identity confusion, feeling that life is unbearable without the deceased, and a wish to die to join the deceased (Mauro et al., 2016; Simon et al., 2011). Although CG shares many similar symptoms with other stress‐related disorders, such as PTSD and MDD, it also includes symptoms that are not observed in PTSD or MDD, and CG can occur independently of these conditions (Bonanno et al., 2007; Simon, 2012). For instance, fear is a central component of PTSD, but is not characteristic of CG, whereas yearning and attachment‐related concerns are characteristic of CG but not PTSD (Simon, 2012). Nonetheless, due to the partial overlap of symptoms and etiological factors, CG frequently co‐occurs with psychiatric disorders such as PTSD, MDD, and a range of other anxiety disorders. Additionally, comorbidity between CG and these disorders is associated with significantly greater grief severity as well as greater work and social impairment (Marques et al., 2013; Simon et al., 2007).
Service members and veterans are at especially high risk for exposure to potentially traumatic events, including sudden and violent combat losses, suggesting bereavement‐related distress may be prevalent (Wisco et al., 2014). In a representative sample of 3,157 United States veterans of all eras, 87% reported exposure to at least one potentially traumatic event, and sudden death of a loved one was the most frequently endorsed of those events (Wisco et al., 2014). One study of Vietnam veterans seeking treatment for PTSD reported that the loss of fellow service members (FSM) in combat was associated with increased grief, but not with PTSD or depression (Pivar & Field, 2004). Notably, the authors concluded that grief following the loss of a FSM was similar in severity to the level of grief following spousal losses (Pivar & Field, 2004). In another study of Vietnam veterans, combat‐related losses were uniquely associated with impairment, yet not related to the severity of PTSD, suggesting more attention to grief after combat losses is needed in all veterans (Currier & Holland, 2012). To date, a small number of studies have examined grief in post‐9/11 service members and veterans. In one study of active duty service members, 75% reported having lost a FSM and 21% reported having difficulty coping with the death of someone close (Toblin et al., 2012).
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