Grief's paradox: Approach and avoidance behaviour in prolonged grief

Approximately 10% of bereaved persons develops severe, disabling and persistent
grief, termed Prolonged Grief Disorder (PGD), included in the 11th
International Classification of Diseases* (ICD-11) in 2018. A similarly named
disorder is expected to be included in an upcoming revision of the Diagnostical
and Statistical Manual of Mental Disorders 5 (DSM-5, American Psychiatric
Association, 2020).
Approach of lost-person reminders is assumed to be a central mechanism
perpetuating PGD and laboratory research indeed demonstrates persons with PGD
show heightened approach of lost-person reminders. Yet, grief theorists also
near-universally assume that avoidance of lost-person reminders perpetuates PGD
and countering such avoidance is a critical ingredient of PGD treatment. This
yields what we term grief*s paradox: approach and avoidance of lost-person
reminders are both assumed to sustain PGD.
Current theories and empirical studies fail to explain grief*s paradox, for
three reasons. First, prior studies have often overlooked the fact that
cognitive-behavioural theories do not presume persons with PGD avoid
lost-person cues per se, but rather those cues that signal the permanence of
separation with the deceased (loss-reality). Second, pioneering research has
shown multiple lost person approach behaviors (e.g., rumination, yearning)
sustaining PGD may in fact serve to avoid this loss-reality. Third, such
behaviors are self-perpetuating not only because they avoid the loss-reality
(and related distress) but also because they are intrinsically rewarding (e.g.
because they increase feelings of loyalty and connectedness with the
deceased).
Therefore, we will test the new Approach-avoidance Processing Hypothesis (APH),
which holds that PGD is characterized by multiple, self-perpetuating,
repetitive behaviors that seem to reflect approach of the lost person, yet may
paradoxically serve as loss-reality avoidance. This study provides the first
test of APH in a study using behavioural measures to clarify which approach and
avoidance mechanisms underlie PGD. APH*s clinical translational implication
could be that effective exposure treatment for PGD reduces avoidance of
reminders of the loss-reality and thereby approach of the deceased.

The primary objective of this study is to test APH.
Study 1A will test the hypothesis that bereaved individuals with PGD (vs.
non-PGD), show heightened approach of lost-person cues and heightened avoidance
of loss-reality cues.
Study 1B will test the pervasiveness of these processes, by testing the
hypothesis that these group (PGD vs non-PGD) differences are mirrored in
automatic approach and avoidance tendencies for lost-person and loss-reality
cues

Observational study

During the study people will be interviewed, and will fill out questionnaires
on loss-related characteristics, feelings and cognitions. The interview and the
questionnaires have been validated previously in bereaved samples and used
repeatedly in prior research and generally elicit no or limited amounts of
negative emotions among participants. During two subsequent behavioral tasks,
participants will also be requested to repeatedly look at pictures of the
deceased, combined with loss-related words. The use of loss-related (or
trauma-related) cues in grief (and trauma) research is also common and
generally elicits negligible participant burden. This is also in line with our
experience from two prior similar studies.