New research provides evidence that persistent post-traumatic stress disorder symptoms increase the risk of complicated grief reactions among survivors of trauma. The longitudinal study, published in the journal Psychological Trauma: Theory, Research, Practice, and Policy, examined survivors of the 2011 terrorist attack on Utøya island.
“While the dual burden of direct traumatization and traumatic loss is characteristic of terrorist attacks, I knew that few researchers to date have explored the combined psychological consequences of trauma and loss. As such, I was interested in exploring the longitudinal association between symptoms of complicated grief and posttraumatic stress disorder (PTSD) among the survivors from the Utøya Island massacre,” said study author Kristin Alve Glad, clinical psychologist and researcher at the Norwegian Centre for Violence and Traumatic Stress Studies.
“In this terrorist attack, while in mortal danger themselves, many youth and young adults witnessed the violent death of close friends when a man, dressed as a police officer, came to the small island where their annual political summer camp was being hosted and began shooting those he came across. There were 564 people on the island, and the shooting lasted for approximately 90 minutes. In total, 69 people were killed in the Utøya attack; most of whom were youths or young adults.”
The researchers invited all 490 survivors of the massacre to participate in the three-wave study of complicated grief reactions and PTSD symptoms. The final sample consisted of 275 survivors who had lost a family member, partner, and/or close friend in the terrorist attack. The participants completed face-to-face interviews with experienced health care personnel 4-5 months, 14-15 months and 30-32 months after the attack.
“We know that grief is a normal response to the loss of someone close. However, while most people experience that their bereavement-related distress diminishes over time, traumatic loss (e.g., death by a terrorist attack) can lead to severe, intense and persistent psychological reactions, such as symptoms of PTSD and complicated grief,” Glad explained.
“The key distinctive feature of PTSD is fear. The hallmark of complicated grief is persistent intense yearning and sadness, usually accompanied by insistent thoughts or images of the deceased. Many will also experience a sense of disbelief or an inability to accept the painful reality of the person’s death.”
Glad and her colleagues found that survivors who reported higher levels of complicated grief also reported higher levels of PTSD symptomatology across all three waves. They had expected to find that levels of complicated grief would predict subsequent PTSD symptomatology. Instead, however, the researchers found that symptoms of PTSD predicted complicated grief reactions.
“We investigated the potential directional effects between PTSD and complicated grief at three different time-points among the young bereaved survivors of the 22nd of July terrorist attack on Utøya island,” Glad told PsyPost. “We found that PTSD symptoms predicted complicated grief reactions at a subsequent time-point, but not vice versa. This suggests that targeting PTSD symptoms in therapy may hinder later development of complicated grief.”
The researchers used a statistical model known as a random intercept cross-lagged panel, which allowed them to separate stable between-person differences from within-person fluctuations. But the study, like all research, includes some caveats.
“The study has some limitations which ought to be considered when interpreting the results,” Glad explained. “First, although many of our participants suffered several losses on Utøya island, we do not know exactly how many losses each survivor experienced. As such, we were unable to explore whether the number of losses affected PTSD and complicated grief severity.”
“Second, because there was approximately one year between each measurement, it is possible that earlier and/or more short-term associations exist between the constructs which could not be captured in the present design. Furthermore, the Utøya island massacre was a national trauma, and the Norwegian society openly supported and grieved with the bereaved. This aspect of the event may limit the generalizability of the findings.”
But the findings are mostly in line with previous cross-sectional research, which has found a positive association between complicated grief and PTSD symptomatology. Importantly, the new study provides insight into the directionality of this relationship.
“Knowledge about the temporal relationship between complicated grief reactions and symptoms of PTSD may have important implications for clinicians working with bereaved trauma survivors,” Glad noted. “For example, it can help refine clinicians’ ability to develop effective treatment strategies and formulate good treatment plans (e.g., deciding which symptoms to target first). Our findings suggest that persistent PTSD symptoms adversely impact long-term processing of loss and increase risk of complicated grief reactions among survivors of trauma, but more research is needed.”
The study, “The Longitudinal Association Between Symptoms of Posttraumatic Stress and Complicated Grief: A Random Intercepts Cross-Lag Analysis“, was authored by Kristin A. Glad, Synne Stensland, Nikolai O. Czajkowski, Paul A. Boelen, and Grete Dyb.