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Background: Prolonged grief disorder (PGD) has been included in the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders 5 Text Revision (DSM-5-TR). Loss-related avoidance behavior perpetuates grief and effective interventions for prolonged grief symptoms target such avoidance behavior. Yet, behaviors characterized by approach of loss-related cues (i.e. rumination, yearning, proximity seeking) are also implicated in prolonged grief reactions. Objective: To solve this paradox, we will test the Approach Avoidance Processing Hypothesis, which holds that loss-related approach and avoidance behaviors co-occur in PGD, using latent class analyses (LCA). Methods: Two-hundred eighty-eight bereaved adults (92% female) completed questionnaires assessing loss-related approach behaviors (rumination, yearning, proximity seeking), loss-related avoidance behaviors (anxious avoidance, experiential avoidance) and ICD-11 and DSM-5-TR prolonged grief symptoms. Results: LCA demonstrated the best fit for a three-class solution comprising a low approach/low avoidance class (n = 98, 34%), a high approach/low avoidance class (n = 79, 27%), and a high approach/high avoidance class (n = 111, 39%). The latter class showed significantly higher prolonged grief symptom levels and higher odds of probable PGD compared to the other classes. Conclusions: Co-occurrence of loss-related approach and avoidance appears characteristic to prolonged grief reactions. Distinguishing bereaved people with these behavioral patterns from those solely experiencing loss-related approach behaviors may improve the efficacy of PGD therapies.

Background: Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results. Objective: In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes. Methods: Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted. Results: For PTSD, a seven factor, so-called ‘Hybrid’ model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD). Conclusions: This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.