Does Complicated/Prolonged Grief Predict Chronic PTSD Among Bosnian Refugees?

Background and Purpose: Researchers have investigated relationships between complicated grief/prolonged grief and Post-traumatic Stress Disorder (PTSD) (Momartin et al., 2004). However, few have investigated the relationship of complicated grief to chronic PTSD, particularly among refugee populations. Research has indicated that refugee populations have high amounts of trauma exposure, PTSD, and complicated grief in general (Durakovic'-Bello et al., 2003; Rosner et al., 2003). Craig and Sossou (2008) found that Bosnian refugees who resettled in the United States for more than five year averaged five trauma exposures, nearly two-thirds of the refugees were still experiencing clinical levels of PTSD and over half had clinical levels of complicated grief. Therefore, refugee populations are a reasonable group in which to study both chronic PTSD and complicated grief. This study tests the hypothesis that complicated grief is a significant predictor of chronic PTSD using a sample of Bosnian refugees.

Methods:Survey packets (N = 500) with psychometrically validated measures of trauma exposure, PTSD, and complicated grief were randomly distributed by Bosnian research assistants to Bosnian Refugees who had been resettled in the United States for more than five years. The measures were translated into Bosnian using the translation-back translation method and consisted of the Trauma Life Events Questionnaire (TLEQ; Kubany, 2004), the PTSD Screening and Diagnostic Scale (PSDS; Kubany, 2004), and the Inventory of Complicated Grief (ICG; Prigerson, 1995). All translated measures were factor analyzed with alpha reliability coefficients above .70. All individuals who indicated at least one DSM-IV-TR (APA, 2000) criterion A trauma, who reported symptoms of PTSD for more than 3 months including the DSM-IV-TR criteria of one re-experiencing, three avoidance, and two hyper-arousal symptoms and who were above the clinical cut-off score on the PSDS (> 18) for PTSD were selected (N =80).

Results: The demographic variables of age, education, gender, complicated grief, trauma intensity (i.e., actual number of traumas) and PTSD were all significantly correlated. A three level hierarchical regression was conducted with age and gender entered onto step one and intensity of trauma exposure entered onto level two, and complicated grief as measured by the ICG was entered onto the third and final level. After step 1, with gender and age in the equation, R² = .13, F (2, 77) = 4.79, p = .01. After step two, with trauma intensity entered into the equation, this did not add significantly to prediction of PTSD. At step three with complicated grief added to prediction of chronic PTSD by gender, education, and trauma intensity, R² = .50 (adjusted R² = .48), F_inc(1, 75) = 55.74, p< .001. Addition of complicated grief to the equation resulted in a highly significant reliable improvement of the predictive variance of PTSD (37%).

Conclusions and Implications: Results indicate a need to focus on grief issues early in the treatment of PTSD in order to help prevent chronic PTSD reactions. Further implications indicate a need for implementing components on complicated/prolonged grief into evidence based practices for PTSD. Limitations of this study will be discussed.