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Eur J Psychotraumatol
Eur J Psychotraumatol
European Journal of Psychotraumatology
2000-8066
Taylor & Francis

2402627
10.1080/20008066.2024.2402627
Version of Record
Letter to the Editor
Letter to the Editor
Grief on pain and quality of life in combat veterans with PTSD
Duelo sobre el dolor y la calidad de vida en los veteranos de combate con TEPTEUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY
M. A. HERNANDEZ-TEJADA ET AL.
https://orcid.org/0000-0003-0732-1248
Hernandez-Tejada Melba A.
Desrochers Madeleine
https://orcid.org/0000-0001-8799-8210
Acierno Ron
Trauma and Resilience Center, Louis A. Faillace, MD. Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
CONTACT Melba A. Hernandez-Tejada melba.a.hernandeztejada@uth.tmc.edu Trauma and Resilience Center, Louis A. Faillace, MD. Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, 1941 East Road, Houston, TX 77054, USA https://med.uth.edu/psychiatry/
18 9 2024
2024
18 9 2024
15 1 240262712 4 2024
1 8 2024
1 9 2024
Nova techset9 9 2024
Converted to JATS 1.2 by Nova Techset9 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Background: Persistent Complex Bereavement Disorder (PCBD) comprises a set of grief symptoms that are often linked to other psychological conditions such as PTSD and depression, may be prevalent in Veterans with combat experience, and may also impact general health.

Objective: This study investigated the association between grief and sleep, pain, PTSD, and depression, among Veterans participating in a clinical trial for PCBD treatment.

Method: Data from 155 Veterans receiving treatments for PCBD were analysed to explore the association between PCBD and symptoms of sleep pain, PTSD, and depression. Veterans experiencing grief reported symptoms related to physical health, emotional problems, energy, and fatigue, emotional well-being, social functioning, presence of pain, and general health. PCBD appeared to have a specific association with pain and physical functioning, independent of other variables.

Conclusions: This study examined the potential independent association of PCBD on physical and mental health in Veterans with PTSD. PCBD appeared to have a very specific and significant association with pain and physical functioning. In other words, the pain of grief was related to ratings of physical pain. Future research on PCBD should address the potentially bidirectional association with bodily pain, particularly chronic pain, in relation to loss, with specific attention to potential mechanisms underlying this relationship.

HIGHLIGHTS

This study explored the distinct relationship of PCBD on aspects of physical, as well as mental health among Veterans with Persistent Complex Bereavement Disorder (PCBD).

Findings underscore the importance of addressing comorbid conditions of PCBD, such as PTSD, emphasising the need for tailored approaches that consider this intricate interaction between grief and other mental health and even physical health conditions.

This study calls for further research into the mechanisms underlying the relationship between PCBD and bodily pain and physical functioning as the most affected areas associated with PCBD.

Antecedentes: El Trastorno de Duelo Complejo Persistente (TDCP) incluye una serie de síntomas de duelo que se relacionan frecuentemente con otras condiciones psicológicas como el TEPT y la depresión, pueden ser frecuentes en veteranos con experiencia en combate y puede afectar también la salud general.

Objetivo: Este estudio investigó la interrelación entre duelo y sueño, dolor, TEPT, y depresión, entre veteranos que participaron en un ensayo clínico para el tratamiento del TDCP.

Método: Se analizaron los datos de 155 veteranos que estaban recibiendo tratamiento por TDCP para explorar el TDCP y los síntomas de dolor durante el sueño, TEPT, y depresión. Los veteranos que experimentaron duelo reportaron síntomas relacionados con salud física, problemas emocionales, energía, y fatiga, bienestar emocional, funcionamiento social, presencia de dolor, y salud general. El TDCP pareció tener una relación específica con el dolor y el funcionamiento físico, independientemente de otras variables.

Conclusiones: Este estudio examinó el potencial independiente del TDCP en la salud física y mental de los veteranos con TEPT. El TDCP pareció tener una asociación específica y significativa con el dolor y el funcionamiento físico. En otras palabras, el dolor del duelo estuvo asociado a los puntajes de dolor físico. Las futuras investigaciones sobre TDCP deberían abordar la asociación potencialmente bidireccional con el dolor corporal, particularmente el dolor crónico, en relación a la pérdida, con atención específica a los mecanismos potencialmente a la base de esta relación.

KEYWORDS

Complex bereavement
grief
pain
quality of life
PTSD
trauma
veteran
PALABRAS CLAVES

Duelo complejo
dolor
duelo
calidad de vida
TEPT
U.S. Department of Defense 10.13039/100000005 Department of Veterans Affairs 10.13039/501100000938 Clinical Science Research and Development 10.13039/100015728 CX001102 This work was supported by U.S. Department of Defense; Department of Veterans Affairs, Clinical Science Research and Development (CSRD) [grant number CX001102].
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pmc1. Introduction

Persistent Complex Bereavement-Related Disorder (PCBD) references a constellation of grief symptoms that are often linked to other health and mental health problems, such as sleep problems, posttraumatic stress disorder (PTSD) and depression (O’Connor et al., 2010; Prigerson et al., 2000). Veterans of recent theatres (since 1991) are particularly vulnerable to experiencing PCBD. While PCBD may follow traumatic events and have lasting effects, the relationship between extreme grief reactions and general mental and physical health is not thoroughly understood. The present study investigated the independent association of PCBD, over and above symptoms of sleep problems, PTSD, and depression on seven specific and one general area of functioning as measured by the Short Form-36 (SF-36), including: 1. Physical Functioning, 2. Role Limitations Due to Physical Health, 3. Role Limitations Due to Emotional Problems, 4. Energy/Fatigue, 5. Emotional Well Being, 6. Social Functioning, 7. Bodily (physical) Pain, and 8. General Health.

2. Methods

2.1. Participants

210 veterans were screened for eligibility, and 155 met inclusion criteria (significant symptoms of PCBD based on a score of 55 or higher on the Inventory of Complicated Grief-Revised). Exclusion criteria consisted of an active psychotic or dementia diagnosis or related impairing symptoms, suicidal ideation and/or intent, or substance dependence.

2.2. Procedures

All procedures were approved by the affiliated University Internal Review Board and the VA Medical Center (VAMC) Office of Research Development. The following instruments measured PCBD, depression, sleep quality, overall health functioning: 34 item Inventory of Complicated Grief-Revised (ICG-R; Guldin et al., 2011; Prigerson et al., 1995, clinical score >55 and higher); Beck Depression Inventory version II (BDI-II; Beck et al., 1996 clinical score >14 and higher). PTSD Checklist version 5 (PCL-5; Weathers et al., 1993, cutoff of 31–33 is indicative of probable PTSD); The Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989, higher scores indicate sleep problems at >5 and higher); and The Short-Form 36 Health Survey Questionnaire (SF-36; Brazier et al., 1992, higher scores in each dimension indicates presence of limitations or problems in that area).

2.3. Data analytic plan

Descriptive data for study variables were obtained. Hierarchical regression was conducted to show the additive variance accounted for in each SF-36 by subsequent variables/groups of variables (i.e. sleep, psychopathology, PCBD). In Step 1, PSQI was regressed on each SF-36 subscale to show the association of sleep problems on health and mental health functioning; in Step 2, PCL and BDI scores were added to PSQI scores and regressed on SF-36 subscales to show the additive effects of PTSD and Depression symptoms, over and above the effects of sleep problems; finally, in Step 3 baseline ICG scores were added to PSQI, PCL, BDI, scores and regressed on each SF-36 subscale to show the independent additive effects of PCBD, over and above sleep and psychological symptoms.

3. Results

One hundred and fifty-five participants met inclusion criteria and were enrolled. The average age was 46 years (SD = 12.24), a majority was black (56%), male (81%), married (59%) and served in Operations Iraqi/Enduring Freedom (46%) or in prior combat theatres. Average baseline psychological scale scores were in the clinical range and were as follows: PCL-5 (x̄ = 47.10; SD = 15.75); BDI (x̄ = 28.63; SD = 12.94); ICG (x̄ = 93.12; SD = 20.65) and PSQI (x̄ = 12.34; SD = 3.82). Baseline SF-36 scores also indicated problems with physical functioning (x̄ = 57.78; SD = 26.41), physical health (x̄ = 36.99; SD = 41.82). emotional problems (x̄ = 30.67; SD = 39.39), energy and fatigue (x̄ = 32.52; SD = 19.52), emotional well-being (x̄ = 44.76; SD = 29.36), social functioning (x̄ = 36.90; SD = 24.46), bodily pain (x̄ = 41.26; SD = 27.23), and poor general health (x̄ = 46.34; SD = 18.20).

As outlined earlier, we conducted stepwise regressions for each SF-36 subscale in terms of study variables (see Table 1). For the subscale Physical Functioning, sleep was statistically significant, albeit minimally predictive; and prediction was improved only by the addition of PCBD scores. For Physical Health, sleep was the only significant predictor. For Role Limits by Emotional Problems, Energy/ Emotional Well Being and Social Functioning, sleep was significantly predictive, as was the combined association, over and above sleep, of PTSD and depression symptoms, but PCBD did not add to variance accounted for. Finally, considering bodily pain, sleep was significantly predictive, as were effects of PTSD and Depression, over and above sleep. Moreover, PCBD significantly enhanced prediction of bodily pain levels over and above effects of other variables. Table 1. Stepwise regression of sleep quality, PTSD, depression and grief on SF-36 quality of life subscales.

Model	R	R Square	Adjusted R Square	Std. Error of the Estimate	Change Statistics	
R Square Change	F Change	df1	df2	Sig. F Change	
Physical Functioning	
Step 1	.18a	.03	.03	26.04	.03	5.29	1	153	.02	
Step 2	.19b	.04	.02	26.19	.00	.11	2	151	.89	
Step 3	.27c	.07	.07	25.78	.04	5.93	1	150	.01	
Physical Health	
Step 1	.25a	.06	.06	40.62	.06	10.24	1	153	.00	
Step 2	.26b	.07	.05	40.77	.00	.45	2	151	.64	
Step 3	.27c	.07	.05	40.81	.00	.70	1	150	.40	
Role Limits by Emotional Problems	
Step 1	.32a	.10	.10	37.44	.10	17.45	1	153	.00	
Step 2	.41b	.17	.12	36.28	.07	5.99	2	151	.00	
Step 3	.42c	.18	.16	36.19	.01	1.76	1	150	.19	
Energy/Fatigue	
Step 1	.31a	.10	.09	18.62	.10	16.22	1	153	.00	
Step 2	.54b	.30	.28	16.55	.20	21.43	2	151	.00	
Step 3	.54c	.30	.28	16.60	.00	.00	1	150	.98	
Emotional Well-being	
Step 1	.29a	.09	.08	19.52	.09	14.44	1	153	.00	
Step 2	.71b	.51	.50	14.46	.42	63.92	2	151	.00	
Step 3	.72c	.51	.50	14.41	.01	2.02	1	150	.16	
Social Functioning	
Step 1	.36a	.13	.12	22.90	.13	22.71	1	153	.00	
Step 2	.62b	.38	.37	19.45	.25	30.55	2	151	.00	
Step 3	.62c	.39	.37	19.42	.01	1.58	1	150	.21	
Pain	
Step 1	.31a	.10	.09	25.96	.10	16.42	1	153	.00	
Step 2	.46b	.21	.20	24.40	.12	11.07	2	151	.00	
Step 3	.50c	.25	.23	23.87	.04	7.75	1	150	.00	
General Health	
Step 1	.28a	.08	.07	17.54	.08	12.83	1	153	.00	
Step 2	.31b	.10	.08	17.49	.02	1.46	2	151	.24	
Step 3	.31c	.10	.07	17.53	.00	.32	1	150	.57	
a Predictors: (Constant), Baseline PSQI.

b Predictors: (Constant), Baseline PSQI, Baseline PCL, Baseline BDI.

c Predictors: (Constant), Baseline PSQI, Baseline PCL, Baseline BDI, Baseline ICG.

4. Discussion

This study sought to determine the independent association between PCBD, over and above the combined effects of sleep problems and symptoms of depression and PTSD on several emotional and physical function areas measured by the SF-36. It appears PCBD is associated with two highly related areas: Bodily Pain and Physical Functioning. In other words, the pain of grieving might manifest as physical pain and impaired functioning (Prigerson et al., 2009). Some evidence shows that certain responses to events such as trauma – related guilt (associated with PTSD, PCBD, among other disorders) are linked to reports of bodily pain (Herbert et al., 2020; Kross et al., 2011; Lahav et al., 2020; O’Connor et al., 2008). This intersection between psychological and physical symptoms underscores the importance of further research, assessment and consideration of integrated treatment approaches. Addressing both PCBD and physical pain through multilevel or integrated treatments may benefit individuals experiencing these concurrent conditions.

Pain is among the most prevalent health conditions among Americans, affecting about a third of the population (Dahlhamer et al., 2018; Zelaya et al., 2020). Pain is also an exceedingly costly condition, with estimates ranging between $560 to $635 million dollars annually for healthcare costs, disability days, and lost wages in the United States (Smith & Hillner, 2019). The definition of pain characterises it as unpleasant sensory and emotional experience associated typically, but not necessarily associated with actual or potential tissue damage (Raja et al., 2020). This definition of pain highlights the complex and dynamic interactions of biological, psychological, and social factors (Kross et al., 2011). Our findings indicate that psychological pain in the form of PCBD may be related to specific negative impacts on health. In other words, PCBD might play an important role in pain and subsequent functioning, or pain may exacerbate PCBD symptoms. As such, assessing and monitoring reports of physical pain may be useful in comprehensive PCBD management.

5. Limitations

The most noteworthy limitation of the present study was its cross-sectional design and the entirely self-report nature of all study assessments. Additionally, assessments were not measuring entirely independent constructs, with some symptom overlap between measures. Finally, while the change in variance accounted for by PCBD symptom level was statistically significant for physical functioning, it is important to note that the clinical significance of this finding may be minimal.

6. Conclusion

Physical functioning and bodily pain may be exacerbated by PCBD. Further research should explore the mechanisms by which PCBD may intensify ratings of pain, and in particular chronic pain, or vice versa. Findings may also suggest integrating interventions for PCBD and pain. While our study identified a statistically significant relationship between PCBD and changes in physical functioning and pain, the clinical significance of this finding remains to be determined. Future studies should investigate the clinical implications and potential treatment effects to better understand the impact on patient care.

Authors contribution statement

All authors have made substantial contributions to conception and design of the study, interpretation of the data, drafting and revision of the article and final approval for submission.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are available upon reasonable request.
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