Verslag_Bacheloronderzoek

Bachelorthesis
The organisation and content of loss-related
memories in complicated grief:
two correlational studies
Dimfke de Bok & Merel van Daalen
University of Utrecht
June 2009
Abstract
Complicated grief (CG) may be partly the result of insufficient integration of the loss into the
autobiographical memory. This notion shows great resemblance with cognitive theories of
posttraumatic stress disorder (PTSD), which propose that PTSD is the result of disorganised
trauma memories that have a more emotional and sensory content. Two correlational studies
examined if this notion about PTSD also holds for the development of CG. In the first study
(N=60) the relationship between the disorganisation of loss memories and CG was examined
using questionnaires, while the second study (N=17) examined the relationship of the
disorganisation, emotional and sensory content of the loss memories and CG using information
about loss-related memories obtained from spoken narratives about the loss. The first study
indicated some support for the hypothesis that disorganised memories may result in symptoms
of CG, whereas the second study failed to support this notion.

Bachelorthesis:
The organisation and content of loss-related memories in complicated grief: two correlational studies
Keywords: Complicated grief; Posttraumatic stress disorder; Narratives; Disorganised memories;
Emotional content; Sensory content
Introduction
Everyone has to deal with the death of a loved one at some point in life. Whereas most people
recover from this loss without any complications, some fail to recover and develop symptoms of
complicated grief (CG) (Boelen, van den Hout & van den Bout, 2006). It is essential to
recognise these symptoms because they are associated with mental and physical dysfunction
that can persist for years and even decades if left untreated (Lichtenthal, Cruess & Prigerson,
2004). They can also pose risk for persistent impairments in social and occupational functioning
(Chen, Bierhals, Prigerson, Kasl, Mazure & Jacobs, 1999; Prigerson, Bierhals, Kasl, Reynolds
III, Shear & Day, 1997; Silverman, Jacobs, Kasl, Shear, Maciejewski & Noaghiul, 2000). CG is
indicated when an individual, following the death of a loved one presents a range of symptoms
that have caused significant impairment in day-to-day functioning for six months or more
(Golden, Dalgleish & Mackintosh, 2007). Symptoms can be subdivided in two clusters,
separation distress and traumatic distress. Symptoms of separation distress include yearning,
searching, preoccupation with memories of the lost person, and loneliness. Symptoms of
traumatic distress include avoiding reminders of the loss, feelings of purposelessness about the
future, feeling stunned by the loss, difficulties acknowledging the death and anger over the loss
(Boelen et al., 2006).
A conceptualization of CG is given by Boelen et al. (2006). They provide a framework
for the hypothesis about mechanisms that underlie CG and they propose that three core
processes are crucial in the development and maintenance of CG. These processes are (a)
insufficient integration of the loss into the autobiographical memory, (b) negative global beliefs
and misinterpretations of grief reactions and (c) anxious and depressive avoidance strategies.
The key assumption within this conceptualization is that the three processes themselves are
assumed to be responsible for the occurrence of symptoms of CG, whereas it is the interaction
among the processes that causes these symptoms to become marked and persistent and to move
from being normal to being indicative of a disturbance. The present studies will focus on the
first process of the model. The conceptualization of Boelen et al. (2006) proposes that one of the
main problems in CG is that information about the loss is poorly elaborated and insufficiently
integrated with other autobiographical memory. This means that the loss does not get integrated
with other information about the self and the relationship with the deceased. As a result the
separation continues to be experienced as an event that is very distinct, consequential and
emotional.
The above mentioned theory of CG shows great similarities with cognitive theories of
posttraumatic stress disorder (PTSD). These theories propose that the overwhelming nature of
Dimfke de Bok & Merel van Daalen, June 2009 2

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traumatic experiences prevents individuals from fully processing the trauma into the
autobiographical memory (Halligan, Clark & Ehlers, 2002). To some extent, this poor
processing of the trauma is caused by peritraumatic dissociation, the experience of alterations in
perception of time, place and person during a traumatic event, which reflects a sense of
unreality, such as, depersonalisation and derealisation (Van der Kolk & Fisler, 1995; Zoelner,
Alvarez-Conrad & Foa, 2002). Peritraumatic dissociation may result in a predominance of data-
driven processing during the trauma (i.e. processing sensory impressions and perceptual
characteristics rather than the meaning of the event) as opposed to conceptual processing (i.e.
processing the meaning of the event, processing it in an organised way and placing it into
context) (Ehlers & Clark, 2000, Halligan, et al., 2002; Halligan, Michael, Clark & Ehlers,
2003). As a consequence of the data-driven processing, the trauma memory is poorly elaborated
and inadequately integrated into its context, time, place, previous information and other
autobiographical memories (Ehlers & Clark, 2000; Halligan, et al., 2002, 2003). This manifests
itself in disorganized and fragmented autobiographical memories of the traumatic event (Foa &
Kozak, 1986; Foa & Riggs, 1993; Zoelner et al., 2002). As a result the intentional recall of the
traumatic event is fragmented and poorly organised, details are missing and there is a difficulty
to recall the exact temporal order of events (Amir, Stafford, Fresman & Foa, 1998; Foa, Molnar
& Cashman, 1995; Jones, Harvey & Brewin, 2007; van der Kolk & Fisler, 1995). Additionally,
the memories have a more sensory and emotional content because the trauma is initially
encoded as sensory and emotional impressions that are not transformed into a meaningful
concept (Brewin, Dalgleish & Joseph, 1996; Ehlers & Clark, 2000; Hellawell & Brewin, 2004;
Jones et al., 2007; van der Kolk & Fissler, 1995).
This way of encoding traumatic information seems to lead to problems in intentionally
recalling the trauma on the one hand and the occurrence of intrusive memories on the other
hand (Halligan et al., 2003). Ehlers and Clark (2000) drew on current theories of
autobiographical memory to explain why this happens. Storage of autobiographical events is
thought to occur through associations with thematically and temporally related experiences
within the autobiographical memory. To the extent that elaboration increases the number of
such associations, it facilitates the intentional retrieval of memories through higher order search
strategies and simultaneously inhibits direct, lower level retrieval through matching sensory
cues (Conway & Pleydell-Pearce, 2000). Thus, if trauma memories are poorly elaborated within
the autobiographical memory base, these higher order strategies will not take shape and lower
level retrieval will not be inhibited. In addition to impairing intentional retrieval, this will render
memories more vulnerable to be triggered by matching sensory cues, thereby increasing the
frequency of intrusive symptoms (Halligan et al., 2003).

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So, although PTSD and CG seem to be two different disorders, people with PTSD
experience fear and anxiety that something terrible is going to happen, whereas people who
suffer from CG experience yearning and longing for the deceased (Lichtenthal et al., 2004), they
seem to share an underlying mechanism, namely a poor integration of the traumatic experience
or the death of a loved one into autobiographical memory. Both the experience of a trauma or
the loss of a loved one are difficult life events which are overwhelming, and for that reason
seem to prevent some individuals from fully processing them into the autobiographical memory.
This may explain a resemblance in the way that people respond to traumas and losses. This
leads to the presumption that people with symptoms of CG, like people with symptoms of
PTSD, have more fragmented and disorganised memories of the days surrounding the death of a
loved one than people without symptoms of CG. Especially, a violent loss (e.g. due to an
accident, suicide or homicide) as opposed to a non-violent loss (e.g. death after long sickness),
which has a more distinct and traumatic character may cause the development of disorganized
and fragmented memories and thus of CG (Boelen, et al., 2006; Bower & Sivers, 1998; Kaltman
& Bonnano, 2001).
The overall purpose of the current studies is to examine if the cognitive theory of PTSD
also holds for the development of CG. The first aim of this study is to examine if a poor
elaboration of the loss into the autobiographical memory results in more fragmented and
disorganized memories of the loss (Boelen, et al., 2006). The second aim is to examine if this
poor elaboration also results in a more sensory and emotional content of the loss related
memories. The first hypothesis is that the more severe symptoms of CG people have, the more
fragmented and disorganized their loss memories will be, even when controlling for time since
loss. The second hypothesis is that the loss memories of people with more severe symptoms of
CG have a more sensory and emotional content, than the memories of people with less severe
symptoms of CG, when time since loss is controlled for (Amir et al., 1998; Brewin et al., 1996;
Ehlers & Clark, 2000; Foa et al., 1995; Halligan, et al., 2002, 2003; Hellawell et al., 2004; Jones
et al., 2007; van der Kolk & Fisler, 1995). Time since loss is controlled for to eliminate the
possible effect of natural recovery from the loss over time.
The third aim of this study is to investigate if the above mentioned relationship will still
exist when symptoms of PTSD and major depressive disorder (MDD) are controlled for.
Although previous research has pointed out that PTSD and MDD are distinct disorders from CG
(Lichtenthal, et al., 2004), it should be ruled out that a possible co-occurrence of symptoms of
these disorders have an influence on the fragmentation and disorganisation of the
autobiographical memory. The third hypothesis is that the relationship between CG and
fragmentation and disorganisation of the loss memories will still exist, when besides time since
loss, symptoms of PTSD and MDD are controlled for.

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The last aim of this study is to investigate the possible mediating role of fragmented and
disorganized loss memories in the development of CG. Because of the assumption that CG and
PTSD share an underlying cause, namely poor integration of the trauma or the loss into
autobiographical memory, it may be that peritraumatic dissociation, in the same way as in the
development of PTSD, plays a role in the development of CG (Van der Kolk & Fisler, 1995;
Zoelner, Alvarez-Conrad & Foa, 2000). The first mediation-analysis will examine if there is a
relationship between peritraumatic dissociation during the death of a loved one and CG and if
this relationship is mediated by the fragmentation and disorganisation of the loss memories. The
fourth hypothesis is that the relationship between peritraumatic dissociation and CG is mediated
by fragmented and disorganised autobiographical memories, when time since loss is controlled
for.
The fifth and last analysis of this study will investigate if there is a relationship between
the nature of a loss and CG, and if this relationship is mediated by the fragmentation and
disorganisation of the loss memories. The reasoning is that violent losses (e.g. death due to an
accident, suicide or homicide) are more distinct and traumatic than nonviolent ones (e.g. death
after long sickness) and are therefore more difficult to incorporate into existing autobiographical
knowledge (Boelen et al., 2006; Bower & Sivers, 1998). That is why it is proposed that people
who experience a violent loss are more prone to develop CG than people who experience a non-
violent loss. The fifth hypothesis is that this relationship is mediated by the fragmented and
disorganised loss memories, when time since loss is controlled for.
Study 1
Method
Design
Study 1 examined four of the above stated hypothesis by using several questionnaires. The
hypothesis that people with more severe symptoms of CG will have memories with more
emotional and sensory content about the day their loved one died was not taken into account in
this study.
Participants
Data were available from 84 mourners, who all declared that they were willing to participate in
this research. These bereaved individuals were recruited via grief counsellors, therapists and
other caretakers. Eventually, 60 mourners who lost a loved one at some point in life completed
all the questionnaires. Table 1 shows the characteristics of this sample, indicating that most

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participants were female, the mean age was 42.9, most participants lost a parent or a partner,
which on average happened 37.8 months ago, and that most losses were due to non-violent
causes.
Table 1. Background characteristics of the sample (N=60)
Age (in years) (M [SD]) 42.9 (11.1)
Sex (n [%])
Female
Male
54
6
(90)
(10)
Times since loss (in months) (M [SD]) 37.8 (64.0)
Kinship to the deceased (n [%])
Partner 21 (35.0)
Child 6 (10.0)
Brother/sister 4 (6.7)
Father/Mother 27 (45.0)
Other 2 (3.3)
Cause of death (n [%])
Non-violent 52 (86.7)
Violent 8 (13.3)
Measures
Demographic survey
The demographic survey inquired about age, gender, education, relationship with the deceased,
time since the death, cause of death and the age of the deceased.
Complicated grief
A 13-item version of the Dutch version (RVL) of the Inventory of Complicated Grief-revised
(ICG-r) developed by Prigerson, Kasl and Jacobs (1997) was used to measure symptoms of CG.
This questionnaire measured both normal and possible problematic grief symptoms (Boelen, de
Keijser & van den Bout, 2001). Participants had to rate the frequency of a particular symptom in
the last month on a four-point scale, from 0 (never) to 4 (always). The total score is the sum of
the item response score of all items.
Disorganisation of memories
The fragmentation and disorganization of the loss memories were measured with the Trauma
Memory Questionnaire (TMQ). This questionnaire asked the participants to rate their trauma
memories and had two subscales, a disorganization subscale and an intrusion subscale. This
research has focused on the disorganization subscale which consists of five items. These five
items assess deficits in intentional recall, that is, the extend to which memory for the trauma is
disorganised or incomplete (e.g. ‘I cannot get what happened during the assault straight in my
mind’) (Halligan et al., 2003).
Posttraumatic stress

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PTSD was measured by the PTSD Symptom Scale (PSS, Foa, Riggs, Dancu, & Rothbaum,
1993; Dutch version by Engelhard, Arntz, & van den Hout, in press, in Boelen, van den Hout &
van den Bout, 2008). The PSS comprises 17 items corresponding to the experience of the 17
symptoms of re-experiencing, avoidance and arousal, outlined in DSM-IV. Each item requires
participants to rate the frequency of a particular symptom in the last month, and is scored on a
four-point scale, from 0 (not at all) to 3 (five or more times per week, almost always) so that the
total score ranges from 0 to 51.
Depression
MDD was measured with the depression subscale of The Hospital Anxiety and Depression
Scale (HADS) (Zigmond & Snaith, 1983). The HADS is a 14-item self-report questionnaire with
a depression subscale and an anxiety subscale, both composed of seven items. Each item was
scored from 0 to 3, with higher scores indicating greater anxiety or depression. Furthermore, the
HADS may be used as a measure of severity of symptoms of state-anxiety and depression from
normal (0-7), mild (8-10), moderate (11-14), to severe (15-21) (Horsch, McManus, Kennedy &
Edge, 2007). The HADS is reported to have good reliability (Quintana, Padierna, Esteban,
Arostequi, Bilbao & Ruiz, 2003).
Peritraumatic dissociation
Peritraumatic dissociation was measured with the State Dissociation Questionnaire (SDQ)
developed by Murray, Ehlers & Mayou (2002). The SDQ is a nine-item scale measuring
peritraumatic dissociative experiences, such as derealization, depersonalization, detachment,
altered time sense and emotional numbing (Halligan et al., 2002). The SDQ is developed in a
series of studies with trauma survivors and student volunteers and shows good reliability and
validity (Halligan et al., 2002).
Procedure
After the participants declared that they were willing to participate in this research, they
received a questionnaire at home which they had to complete and return to the researchers. This
questionnaire consisted of a demographic survey, inquiring about gender, age, educational level,
relationship with the deceased, time since the loss and the cause of death, a short version of the
RVL, the TMQ, the PSS, the HADS and the SDQ.
Data Analysis with SPSS

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Firstly, correlations of the predictor variables and CG were established to explore the data.
Secondly, research questions one and three were answered using regression analyses. Thirdly,
research questions four and five, which are mediation analyses, were carried out following the
four steps of Baron and Kenny (1986), using correlation and regression analyses. Lastly, for
establishing the effect of a violent versus non-violent loss on CG in research question 5 a t-test
was used.
Results
First, the correlations of the predictor variables (time since loss, disorganisation of memories,
PTSD, MDD and peritraumatic dissociation) and CG were examined. As shown in table 2 the
predictor variables time since loss, PTSD, MDD and peritraumatic dissociation were
significantly correlated with CG.
Table 2. Correlations for predictor variables with CG
Predictor variable Complicated grief
Time since loss (in months) -.367**
Disorganisation of the memories .253
Posttraumatic stress .715***
Depression .722***
Peritraumatic dissociation .330*
* p < .05, ** p < .01, *** p < .001
The first aim of this study was to examine if a poor elaboration of the loss memories
into the autobiographical memory results in more fragmented and disorganized loss memories,
whereby controlling for the effect of the time since loss. Using linear multiple regression
analysis with the enter method, a significant model emerged (F (2,57) = 10.468, p < .001). This
model explained 26.9% of the variance (Adjusted R² = .269). Table 3 gives information for the
predictor variables of the model. Time since death and disorganisation of the memories are
both significant predictors of CG.
Table 3. The unstandardised and standardised regression coefficients and the standard error for time
since death and the disorganisation of memories
Predictor variable B SE B ß
Time since death (in months) - .077*** .019 -.470
Disorganisation of memories .744** .230 .381
* p < .05, ** p < .01, *** p < .001
As noted earlier, the second hypothesis was not examined in this first study. Next, we
examined if the relationship between disorganisation of the loss memories and CG still existed
when, besides time since death, PTSD and MDD were controlled for. Using multiple regression
analysis with the enter method, a significant model emerged (F (4,55) = 21.231, p = .000). This

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model explained 60.7% of the variance (Adjusted R² = .670). Table 3 gives information for the
predictor variables of the model. Time since death and disorganisation of memories are not
significant predictors of CG in this model, whereas PTSD and MDD predict a large and
significant proportion of the variance of CG.
Table 4. The unstandardised and standardised regression coefficient and the standard error for time
since death, the disorganisation of memories, posttraumatic stress and depression
Time since death (in months) -.027 .016 -.165
Disorganisation of memories .316 .183 .162
Posttraumatic stress .372* .151 .345
Depression .691* .272 .358
* p < .05, ** p < .01, *** p < .001
The fourth aim of this study was to investigate the possible mediating role of
fragmented and disorganized memories in the relationship between peritraumatic dissociation
and CG. This mediation analysis was carried out following the four steps of Baron and Kenny
(1986). The first step needs to demonstrate that there is a relationship between the predictor
variable (peritraumatic dissociation) and the dependent variable (CG). Correlation analysis
showed that there was indeed a significant positive relationship between peritraumatic
dissociation and CG (r = .330, N = 60, p = .010). In the second step it needs tot be confirmed
that there is a relationship between the predictor variable (peritraumatic dissociation) and the
mediator variable (disorganisation of memories). Correlation analysis showed that there was a
significant positive relationship between peritraumatic dissociation and the disorganisation of
the loss memories (r = .485, N = 60, p = .000). The next and third step needs to establish that
there is a significant relationship between the mediator variable (disorganisation of memories)
and the dependent variable (CG) while controlling for the predictor variable (peritraumatic
dissociation). Using multiple linear regression analysis with the enter method, a significant
model emerged (F (3,56) = 8.170, p = .000), which explained 30.4% of the variance (Adjusted
R² = .304). Table 4 gives further information for the predictor variables, which indicates that
there was still a significant relationship between the mediator variable (disorganisation of
memories) and the dependent variable (CG) when the predictor variable (peritraumatic
dissociation) was controlled for. The last step is to demonstrate that the relationship of the
independent variable (peritraumatic dissociation) and the dependent variable (CG) does not
exist anymore. This relationship was not significant anymore.
Table 5. The unstandardised and standardised regression coefficients, the standard error for time since
death, the disorganisation of memories and peritraumatic dissociation

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Time since death -.073*** .019 -.449
Disorganisation of memories .526* .260 .269
Peritraumatic dissociation .253 .149 .218
* p < .05, ** p < .01, *** p < .001
The fifth and last aim of this study was to examine if there is a relationship between the
violent versus the non-violent nature of a loss and CG, and if this relationship was mediated by
the fragmentation and disorganisation of the loss memories. The first step was to establish a
relationship between the predictor variable (violent versus non-violent nature loss) and the
dependent variable (CG). An independent t-tests showed that there was no significant difference
in CG severity between violent and non-violent losses (t = .142, df = 58, p = .888). This means
that further mediation analysis cannot be done. The following table gives the means and
standard deviations of the CG scores for violent and non-violent losses.
Table 6. Mean and standard deviation of CG scores for violent versus non-violent loss group
Predictor variable Mean Standard deviation
Non-violent loss 36,94 10,08
Violent loss 36,38 13,28
Discussion
The results of 60 mourners in study 1 did not show a direct relationship between the
disorganisation of loss memories and CG. However, when time since loss was controlled for
there appeared a significant relationship. This finding is in line with the first hypothesis of the
study, namely that the more severe symptoms of CG people have, the more fragmented and
disorganized their loss memories will be, when controlling for time since loss. It seems logical
that the time since loss plays a crucial role in this relationship, because it varied from one month
to almost 30 years in this sample, which may have resolved in differences in natural recovery
from the loss. This result seems to partly support the conceptualization of CG by Boelen et al.
(2006) and in addition, that the cognitive theories of PTSD may in part apply to the
development of CG (Ehlers & Clark, 2000; Foa et al., 1995; Halligan, et al., 2002, 2003;
Hellawell et al., 2004; Jones et al., 2007). This supports the notion that, when a loss is not well
integrated with other information about the self and the relationship with the deceased in the
autobiographical memory, the loss will continually be experienced as an event that is very
distinct, consequential and emotional, which may in turn result in symptoms of CG (Boelen, et
al., 2006).
As has been mentioned, the second hypothesis was not addressed in the first study. The
third hypothesis, that the relationship between fragmentation and disorganisation of the loss

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memories and CG will still exist when, besides time since loss, PTSD and MDD are controlled
for, could not be supported with the results of this study. This is probably a consequence of the
strong relationship between PTSD, MDD and CG, whereby MDD and PTSD are strong
predictors of CG. So, if there is any effect of disorganisation and fragmentation of the loss
memories on CG, this will most likely fade away through the effects of PTSD and MDD on CG.
The fourth hypothesis, that the relationship between peritraumatic dissociation is
mediated by disorganised and fragmented loss memories could be supported when time since
loss was controlled for. This is in line with the cognitive theory of PTSD, that peritraumatic
dissociation may result in a predominance of data-driven processing during the trauma (Ehlers
& Clark, 2000, Halligan, et al., 2002; Halligan, Michael, Clark & Ehlers, 2003), whereby the
trauma event is poorly elaborated and inadequately integrated into its context, time, place,
previous information and other autobiographical memories (Ehlers & Clark, 2000; Halligan, et
al., 2002; Halligan et al., 2003). In conclusion, this part of the cognitive theories of PTSD may
also apply to the development of CG. The last hypothesis, that the relationship between the
violent versus non-violent nature of a loss and CG is mediated by the disorganisation of the loss
memories could not be supported. This is possibly due to the fact that only eight out of the sixty
participants suffered a violent loss, whereby it is almost impossible to find an effect by this
variable on CG.
Study 1 has some methodological shortcomings. First of all, disorganisation of the loss
memories was measured with only five items of the trauma memory questionnaire (TMQ).
Measuring a construct by only five items does not seem to be very valid. Future research should
measure disorganisation with a more valid questionnaire. Additionally, measuring
disorganisation of loss memories with a questionnaire is a subjective method and for that reason
not very reliable either. In study 2, disorganisation of the loss memories will be measured with
more objective measures. Another weakness of study 1 is that the sample did not exist of
mourners diagnosed with CG. In future research, a clinical sample can be used so that a stronger
and more direct relationship between disorganisation of loss memories and CG may be found.
Additionally, a clinical sample may also include more mourners that have encountered a violent
loss, so it can be decided if a violent loss as apposed to a non-violent loss, results in more severe
symptoms of CG. In future research, more mourners that had encountered a violent loss could
be recruited and selected.
Study 2
Method

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Design
Study 2 examined all of the above stated hypotheses by using questionnaires and narratives
about the day a loved one died, obtained by a telephone interview. The disorganisation and
fragmentation of these narratives were analysed with a narrative coding system.
Participants
Table 7 shows the characteristics of the sample, indicating that most participants were female,
the mean age was 29.2 years, most participants lost a child or a parent, which on average
happened 18.1 months ago and that the losses were mostly due to non-violent causes.
Table 7. Background characteristics of the sample (N=17)
Age (in years) (M [SD]) 29.2 (12.1)
Sex (n [%])
Female
Male
15
2
(88.2)
(11.8)
Times since loss (in months) (M [SD]) 18.1 (10.6)
Kinship to the deceased (n [%])
Partner 1 (5.9)
Child 6 (35.3)
Brother/sister 0 (0)
Father/Mother 4 (35.3)
Other 4 (25.5)
Cause of death (n [%])
Non-violent 11 (64.7)
Violent 6 (35.3)
Most of the participants were recruited through advertisements on campus of the University of
Utrecht. In total 47 students reacted, although only 12 of these students were applicable because
their losses were significant and rather recent. A loss was significant when someone died at a
rather young age (e.g. death of a friend or parent of a student) or went against the family cycle
(death of a child). Time since loss had to be a least 6 months with a maximum of 3 years to be
recent. The relationship to the deceased included parents, children, partners and good friends.
Participants who lost a grandparent were excluded in this study. Eventually, 11 mourners
completed all the questionnaires and the telephone interview. The other six participants were
recruited via grief counsellors, therapists and other caretakers.
Measures
Demographic survey
The demographic survey inquired about age, gender, education, relationship with the deceased,
time since the death, cause of death and the age of the deceased.

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Complicated grief
The Dutch version of the Inventory of Complicated Grief-revised (ICG-r) developed by
Prigerson, Kasl and Jacobs (1997) was used to measure symptoms of CG. The Dutch version is
called ‘Rouw Vragenlijst (RVL)’ and consists of 32 items that measure both normal and possible
problematic grief symptoms (Boelen et al., 2001). Participants had to rate the frequency of a
particular symptom in the last month on a four-point scale from 0 (never) to 4 (always). The
total score is the sum of the item response score of all items. The internal consistency and the
stability of the RVL are adequate and the concurrent and construct validity are also adequate
(Boelen et al., 2001).
Posttraumatic stress
PTSD was measured by the PTSD Symptom Scale (PSS, Foa et al., 1993; Dutch version by
Engelhard et al., in press). The PSS comprises 17 items corresponding to the experience of the
17 symptoms, of re-experiencing, avoidance and arousal, outlined in DSM-IV. Each item
requires participants to rate the frequency of a particular symptom in the last month, and is
scored on a four-point scale, from 0 (not at all) to 3 (five or more times per week, almost
always) so that the total score ranges from 0 to 51.
Depression
MDD was measured by the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock,
& Erbaugh, 1961; Dutch version by Bouman, Luteijn, Albersnagel, & van der Ploeg, 1985). The
BDI is inventory measuring depressed mood and vegetative symptoms of depression, by 21 sets
of four statements representing depressive symptoms, from which the respondent has to choose
the most applicable.
Peritraumatic dissociation
The Peritraumatic Dissociative Experiences Questionnaire (PDEQ) was used to measure
peritraumatic dissociation (PDEQ, Marmar, Weiss & Metzler, 1997). The PDEQ is a ten-item
questionnaire that assesses dissociative experiences that occurred during the traumatic event and
immediately afterwards. In the present study, the loss of a loved one was the designated
stressful life-event. Participants had to rate on a Likert scale (1= not true at all, 2= slightly true,
3= somewhat true, 4= very true, 5= extremely true) the degree to which they experienced
depersonalisation, derealisation, amnesia, out of body experiences, body image and an altered
time perception (Birmes, Brunet, Benoit, Defer, Hatton, Sztulman, Schmitt, 2004). The PDEQ
is scored as the mean item response of all items. The PDEQ has very good psychometric
properties (Marmar et al., 1997).

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Narrative memory
Narratives were used to capture autobiographical memories of the moments surrounding the
death. Phone conversations were made in order to collect narrative memory accounts of the day
that the loved one died. Participants were given the following instruction based on Foa et al.,
1995 and Jones et al., 2007: ‘In a moment I will ask you to describe your memories of the day
that your loved one died. Therefore, I would like you to think about that day as clearly as
possible. It is important that you do not give an exact and factual description of that day, but
rather tell me all your thoughts and memories that come to mind. Of course, it is okay when
there are certain things that you do not want to share and of course you do not have to tell these
things.’ When the participants started to ask questions they were told that they could say
anything that came to mind, as long as it was about the day that their loved one died. When
there was a silence lasting longer than 15 seconds, the interviewer encouraged the participants
by asking if they had any more thoughts or memories of that day.
Narrative Coding System - Fragmented and Disorganised Memories
Narratives were audiotaped and sequently transcribed verbatim. The written narratives were
divided into utterance units, which can be defined as clauses that include only one thought, idea
or action (Foa et al., 1995; Harvey and Bryant, 1999; Jones et al., 2007). The Pearson’s r
correlation was used to determine the interrater reliability for dividing the narratives into
utterances. This interrater reliability was very good (r = .91). Subsequently, these utterances
were coded according to the narrative coding system of Jones et al. (2007) which contains four
constructs that measure fragmentation and disorganisation of the narratives, and thereby of the
memories, namely repetition, non-consecutive chunks, confusion and a global measure of
coherence (Foa et al., 1995; Jones et al., 2007; Halligan et al., 2003, Harvey & Bryant, 1999).
The interrater reliability, using Pearson’s r correlations, of the disorganisation measures, namely
repetition (r = .87), non-consecutive chunks (r = .88), confusion (r = .83) and global coherence
(r = .96) were all excellent.
The first and according to Foa et al. (1995) most direct measure of fragmentation and
disorganisation is repetition. Repetition was coded for when an utterance unit, or a large portion
of it was repeated within the space of five utterances, for example ‘I was very aware of
everything that happened. It was not like I was not really there, but I was very aware of
everything. I was very aware of everything that happened’ (Halligan et al., 2003; Harvey &
Bryant, 1999; Jones et al., 2007). Second, non-consecutive chunks were coded for when
utterance units were out of order, or incongruous with each other, for example ‘I could not
really understand what happened. I went to her room where all her clothes. I talked a lot that

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day’ (Halligan et al., 2003; Harvey & Bryant, 1999; Jones et al., 2007). Third, confusion was
coded for when a participant was uncertain about his or her memory of events, for example ‘I
am not sure, I cannot remember much of that day’ (Halligan et al., 2003; Harvey & Bryant,
1999; Jones et al., 2007). Finally, a global coherence rating was given to each narrative as a
whole, ranging from 1 (extremely coherent) to 5 (extremely incoherent). This measure presents
to what extent the narrative as a whole has a logical temporal sequence and presents a complete
and structured story with a beginning and an end (Halligan et al., 2003; Harvey & Bryant, 1999;
Jones et al., 2007). Every utterance was coded as ‘present’ or ‘absent’ for one of the three
constructs and every narrative was given a global coherence score. Because the length of the
narratives differed between participants, the frequency with which each construct was present
was converted into percentages of the total of utterances (Foa et al., 1995; Jones et al., 2007).
Objective measure - Sensory and emotional content
The sensory and emotional content of the narratives was analysed with a software programme,
Linguistic Inquiry and Word Count (LIWC) for analysing verbal and written text. It is designed
to analyse a text word by word and to calculate the percentage of words in the text that match up
to the defined dimensions (Pennebaker, Francis & Booth, 2001). To index the sensory and
emotional content of the narratives, ‘sensory words’ (e.g. see, hear) and ‘negative emotion
words’ (e.g. afraid, threat) where the defined dimensions selected from LIWC’s database (Jones
et al., 2007).
Procedure
After the participants stated that they were willing to participate in this study, they received a
questionnaire at home which they had to complete and return to the researchers. The
questionnaire consisted of a demographic survey, inquiring about gender, age, educational level,
relationship with the deceased, time since the loss and the cause of death, the RVL, the PSS, the
BDI and the PDEQ. Subsequently, the participants were contacted by telephone to elicit the
narrative memories of the day their loved one died. After this first part of the interview, the
participants were asked to describe their memories of that day to elicit a narrative memory.
These narratives had a minimal duration of five minutes and a maximal duration of ten minutes.
Afterwards, the participants were told about the aims of the study.
Data Analysis with SPSS
Firstly, correlations of the predictor variables and CG were established to explore the data.
Secondly, research questions one to three were answered using regression analyses. Thirdly,
research questions four and five, which are mediation analyses, were carried out following the

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four steps of Baron and Kenny (1986), whereby correlation and regression analyses were used.
Lastly, for establishing the effect of a violent versus non-violent loss on CG in research question
5 a t-test was used.
Results
First, the correlations of the predictor variables (time since death, total disorganisation of
memories, repetition, non-consecutive chunks, confusion, global coherence, sensory content,
emotional content, PTSD, MDD and peritraumatic dissociation) and CG were established. As
shown in table 8, only two of the predictor variables, namely PTSD and MDD, were strongly
correlated with CG.
Table 8. Correlations for the predictor variables and CG
Predictor variables Complicated Grief
Time since loss (in months) -.481
Total disorganisation of the memories .305
Repetition .264
Non-consecutive chucks .309
Confusion .339
Global coherence .167
Sensory content -.369
Emotional content -.032
Posttraumatic stress .809**
Depression .702**
Peritraumatic dissociation .412
* p < .05, ** p < .01, *** p < .001
The first aim of this study was to examine if a poor elaboration of the loss into the
autobiographical memory results in more fragmented and disorganized memories of the loss,
whereby controlling for time since loss. Using linear multiple regression analysis with the enter
method, no significant model emerged (F (2,14) = 2.546, p = .114). Table 9 gives information
for the predictor variables of this model. Time since death and disorganisation of the memories
failed to predict CG. In addition, as can be seen in table 8, none of the separate disorganisation
scores, namely repetition, non-consecutive chunks, confusion and the global coherence score,
correlated significantly with CG. This means that all the disorganisation measures used in this
study failed to predict CG.
since death and the disorganisation of memories
Time since death (in months) -.905 .497 -.431
Total disorganisation of memories .284 .348 .194
* p < .05, ** p < .01, *** p < .001

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The second aim of this study was to examine if the poor elaboration of the loss also
results in a more sensory and emotional content of the loss related memories, while also
controlling for the time since loss. Using multiple regression analysis with the enter method, no
significant model emerged (F(3,13) = 1.931, p = .174). Time since loss and emotional and
sensory content did not seem to predict CG. Table 10 gives information for the predictor
variables of the model.
since death, emotional and sensory content
Time since death -.886 .495 -.422
Emotional content -7.478 6.257 -.288
Sensory content 1.217 8.348 .034
* p < .05, ** p < .01, *** p < .001
The third aim of this study was to examine if the relationship between disorganisation
of the loss memories and CG will still exist when, besides time since loss, PTSD and MDD are
controlled for. Although PTSD and MDD had a high and significant correlation with CG (as can
be seen in table 7), the above results show that there was no significant relationship between the
disorganisation of the narratives and CG, thus this aim cannot be further addressed here.
The fourth aim of this study was to investigate the possible mediating role of
fragmented and disorganized memories in the relationship between peritraumatic dissociation
and CG. The first step of the mediation-analysis, according to Baron and Kenny (1986) is to
demonstrate that there is a relationship between the predictor variable (peritraumatic
dissociation) and the dependent variable (CG). Correlation analysis showed that there was no
significant correlation between peritraumatic dissociation and CG (r = .412, N = 17, p = .100).
This means that there cannot be done any further mediation-analysis.
The fifth and last aim of this study was to examine if there is a relationship between the
violent versus the non-violent nature of a loss and CG, and if this relationship is mediated by the
fragmentation and disorganisation of the loss memories. An independent t-tests showed that
there was no significant difference in CG severity between violent and non violent losses (t =
-.701, df = 16, p = .494). Thereby, no further analysis can be done. The following table gives
the means and standard deviations of the CG scores for violent and non-violent losses.
Table 11. Mean and standard deviation of CG scores for violent versus non-violent loss group
Predictor variable Mean Standard deviation
Non-violent loss 70,45 25,53
Violent loss 78,50 15,11

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Discussion
Study 2 examined the relationship between CG and disorganized and fragmented loss memories
by using narratives of the memories. Unlike study 1, where questionnaires were used to measure
disorganisation of the memories, in study 2 no relationship was found between disorganisation
of loss memories and CG. This relationship still does not exist when controlling for time since
loss or when the separate measures of disorganisation (repetition, non-consecutive chunks,
confusion and global coherence) are considered. So, the first hypothesis that the more severe
symptoms of CG people have, the more fragmented and disorganized their loss memories will
be, when time since loss is controlled for, must be rejected.
The results neither confirmed the hypothesis that memories of people with more severe
symptoms of CG have a more sensory and emotional content than memories of people with less
severe symptoms of CG, when time since loss is controlled for. So, the second hypothesis needs
to be rejected. The correlations between CG and sensory and emotional content were not
significant and they even pointed into a negative direction. This suggests that in this sample, the
memories of people with more severe symptoms of CG possibly have less sensory and
emotional content than the memories of people with less severe symptoms of CG. A possible
explanation for the fact that people with more severe symptoms of CG have memories with less
sensory and emotional content is that they engage in more anxious avoidance strategies, which
was mentioned as one of the core processes in the conceptualization of CG given by Boelen et
al. (2006). Anxious avoidance strategies occur when mourners believe that confronting the
reality of the loss will lead to unbearable consequences, therefore they consequently engage in
attempts to avoid confrontation with the reality of the loss (Boelen et al., 2006). In this way the
sensory and emotional content of the memories may be decreased with more severe symptoms
of CG.
The hypothesis that the relationship between CG and fragmentation and disorganisation
of the autobiographical memories will still exist after controlling for PTSD and MDD must be
rejected because there was no relation between CG and disorganisation of the loss memories in
the first place. A strong correlation was found between PTSD and CG and MDD and CG. This
leads to the assumption that maybe CG is not that different from PTSD and MDD as suggested
by Lichtenthal et al. (2004), and that there is a significant overlap between these three disorders.
The last two hypotheses concerning the mediating role of fragmented and disorganized
loss memories in the relationship between peritraumatic dissociation and CG and the
relationship between the violent versus non-violent losses and CG needed to be rejected because
there was no significant relation between the predictor variables and CG. To conduct mediation-

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analysis it is essential that there is a relationship between the predictor variable and the
dependent variable.
The absence of the relationship between disorganisation of the loss memories and CG is
possibly caused by the sample of this study. As described in the method, this study included
only 17 participants and this is a relatively small sample. Also, participants were recruited in
two different ways: 11 participants were student recruited through advertisements on campus of
the University of Utrecht and six participants were recruited via grief counsellors, therapists and
other caretakers. Because of differences between these two groups of participants concerning
demographic (e.g. age) and loss-related (e.g. kinship to the deceased) variables, the sample was
very heterogenic, which in combination with the small sample size suppresses the possibility of
finding a relationship between disorganisation of the loss memories and CG.
Furthermore, correlation analyses concerning CG were based on scores on the ICG-r,
but it is not certain if any of these participants met the criteria for CG. A clinical population
would possibly give a better idea of the relationship between disorganized loss memories and
CG. Another possibility is that there was not enough variation in the scores on the ICG-r in this
sample, which caused the absence of the relationship between disorganisation of the loss
memories and CG.
Moreover, the narrative coding system seems to have a few limitations. First,
incomplete sentences were not addressed as a measure of disorganisation, while some
participants used them frequently. This seems to have interfered with the cohesiveness of the
narratives. Second, only sentences that were repeated literally were scored as repetition. This
may have suppressed the repetition scores, because participants often rephrased. Third, many
utterances indicated that participants experienced dissociation, while this category was not in
the narrative coding system. These limitations should be addressed in future research.
Unfinished sentences should be added to the narrative coding system together with a
dissociation score and the repetition measure should also contain non-literally repetitions.
Last, the procedure used in this study was possibly insufficient to register the most
traumatic and disorganized memories. In this study participants were asked to describe their
memories of the day their loved one died. In this way the study may have failed to capture the
most emotional and traumatic loss memories. This because the most emotional and traumatic
memories may have been captured in other moments surrounding the death, for example the day
of the funeral. Individual differences may play an important role in the traumatic and emotional
nature of the memories. Possibly, it would have been better to ask the participants to disclose
their most emotional and traumatic thoughts and memories about the days surrounding the death
of their loved one, in this way there would be a better chance to reveal the most disorganized
memories.

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General discussion
As mentioned above, the two studies in this research found a different result regarding the
relationship between the disorganisation of loss memories and CG. Study 1 found an indirect
relationship between the disorganisation of the loss memories and CG. Additionally, this study
found a mediating role for the disorganisation and fragmentation of loss memories in the
relationship between peritraumatic dissociation and CG. Unlike study 1, study 2 failed to find
any relationship between the predictor variables and CG. Both studies found a strong
relationship between PTSD, MDD and CG.
The discrepancy between the results of study 1 and study 2 is most likely due to the
sample sizes of the studies. Study 1 had a larger sample (N=60) than study 2 (N=17) and
thereby, had more power to detect a relationship. However, study 2 had a more reliable design
to measure the disorganisation of the loss memories. Whereas study 1 used a subjective manner,
namely questionnaires, study 2 measured the disorganisation of the memories more objectively
by using narratives of loss.
A limitation of both studies is that the sample did not exist of mourners diagnosed with
CG. There is a possibility that the non-clinical samples existed of only a few or none mourners
who met the diagnostic criteria for CG. By using a clinical sample, it is more likely to find a
relationship between the disorganisation of the loss memories and CG. More variation in the CG
scores would also enhance the possibility of detecting this relationship.
Both studies had a heterogenic sample. Amongst other things, this reflects in differences
in relationship to the deceased, cause of death and time since loss. Despite of the heterogeneity
of the sample of study 1, an indirect relationship was found between the disorganisation of the
loss memories and CG. This indicates a robust effect and increases the generalizability of these
results. On the contrary, study 2 did not find this relationship, which is possibly due to the
combination of the heterogeneity of the sample and the small sample size.
As stated before, the method used in study 2 is more reliable than study 1. Future
research concerning the relationship between the disorganisation of loss memories and CG
should therefore use the narrative methodology, while considering the above mentioned
limitations. A larger and clinical sample should be used and stricter inclusion criteria should be
set to reduce the heterogeneity, regarding at least time since loss.
Moreover, there seems to be a strong relationship between CG and PTSD and CG and
MDD in both studies. This could indicate that CG is not that different from PTSD and MDD as
suggested by Lichtenthal et al. (2004), and that there is a significant overlap between these three
disorders. The resemblance between PTSD and CG may be due to the fact that the death of a

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loved one can be considered as a traumatic event, and therefore that CG should be diagnosed as
PTSD (Figley, Bride, & Mazza, 1997; Simpson, 1997). The resemblance between MDD and
CG can be explained by the fact that the experience of grief often involves depressive symptoms
(Clayton, 1982). Although it seems more likely that the resemblances are caused by overlap
between the questionnaires measuring PTSD, MDD and CG. Future research should establish
the relationship between these three disorders.
In conclusion, the results of study 1 indicated that the cognitive theory of PTSD also
holds for the development of CG. There was a relationship between symptoms of CG and the
disorganisation and fragmentation of loss memories. Additionally, a mediating role for
disorganised loss memories was found in the relation between peritraumatic dissociation and
CG (Amir et al., 1998; Brewin et al., 1996; Ehlers & Clark, 2000; Foa et al., 1995; Halligan, et
al., 2002, 2003; Hellawell et al., 2004; Jones et al., 2007; van der Kolk & Fisler, 1995; Zoelner,
Alvarez-Conrad & Foa, 2000). Study 2 would possibly have yielded the same results when a
larger sample was used. In general it may be assumed that cognitive theories of PTSD may also
apply to CG and that the poor integration of the loss into the autobiographical memory plays a
role in the development of CG, as has been pointed out by Boelen et al. (2006).
These results have some clinical implications concerning the treatment of CG. This
treatment should especially focus on facilitating the integration of the loss into the
autobiographical memory (Boelen, et al., 2006; Ehlers & Clark, 2000). Exposure therapy has
been pointed out to be an effective intervention for this purpose. At the beginning, patients are
invited to tell their story about the loss. Meanwhile, the therapist can identify the most painful
feelings, thoughts and memories linked to the loss, which will be addressed and worked through
in the continuing therapy. Furthermore, repeated imaginal reliving of traumatic events
surrounding the loss could contribute to the integration of the loss into the autobiographical
memory. Consequently the loss will get more real and will be more integrated with knowledge
about the self, one’s life and the relationship with the lost person. In this way patients may
recover from their symptoms of CG (Boelen et al., 2006; Ehlers & Clark, 2000; Foa et al.,
1995).

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