The Underlying Structure of Grief: A Taxometric Investigation of Prolonged and Normal Reactions to Loss

  • Jason M. HollandEmail author
  • Robert A. Neimeyer
  • Paul A. Boelen
  • Holly G. Prigerson


Recent studies have supported the distinctiveness of complicated and prolonged forms of grief as a cluster of symptoms that is separate from other psychiatric disorders. The distinction between prolonged and normal reactions to loss remains unclear, however, with some believing that prolonged grief represents a qualitatively distinct clinical entity and others conceptualizing it as the extreme end of a continuum. Thus, in this study a taxometric methodology was used to examine the underlying structure of grief. Participants included 1,069 bereaved individuals who had lost a first-degree relative. Each participant completed the Dutch version of the Inventory of Complicated Grief–Revised, which was used to create indicators of prolonged grief. The mean above and mean below a cut (MAMBAC) and maximum eigenvalue (MAXEIG) tests supported a dimensional conceptualization, indicating that pathological reactions might be best defined by the severity of grief symptoms rather than the presence or absence of specific symptoms.


Complicated grief Prolonged grief disorder Bereavement Death and dying Taxometric method 


  1. Allumbaugh, D. L., & Hoyt, W. T. (1999). Effectiveness of grief therapy: a meta-analysis. Journal of Counseling Psychology, 46, 370–380.CrossRefGoogle Scholar
  2. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4thth ed.). Washington, DC: Author.Google Scholar
  3. Barry, L. C., Kasl, S. V., & Prigerson, H. G. (2002). Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death. American Journal of Geriatric Psychiatry, 10, 447–457.PubMedGoogle Scholar
  4. Boelen, P. A., & Lensvelt-Mulders, G. J. L. M. (2005). Psychometric properties of the grief cognitions questionnaire (GCQ). Journal of Psychopathology and Behavioral Assessment, 27, 291–303.CrossRefGoogle Scholar
  5. Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study. American Journal of Psychiatry, 162, 2175–2177.PubMedCrossRefGoogle Scholar
  6. Boelen, P. A., & van den Bout, J. (2008). Complicated grief and uncomplicated grief are distinguishable constructs. Psychiatry Research, 157, 311–314.PubMedCrossRefGoogle Scholar
  7. Boelen, P. A., de Keijser, J., & van den Bout, J. (2001). Psychometrische eigenschappen van de Rouw VragenLijst (RVL) [psychometric properties of the inventory of traumatic grief]. Gedrag & Gezondheid, 29, 172–186.Google Scholar
  8. Boelen, P. A., van den Bout, J., & de Keijser, J. (2003a). Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: a replication study with bereaved mental health care patients. American Journal of Psychiatry, 160, 1339–1341.PubMedCrossRefGoogle Scholar
  9. Boelen, P. A., van den Bout, J., de Keijser, J., & Hoijtink, H. (2003b). Reliability and validity of the Dutch version of the inventory of traumatic grief (ITG). Death Studies, 27, 227–247.PubMedCrossRefGoogle Scholar
  10. Boerner, K., Wortman, C. B., & Bonanno, G. A. (2005). Resilient or at risk? A 4-year study of older adults who initially showed high or low distress following conjugal loss. Journal of Gerontology, 60B, P67–P73.Google Scholar
  11. Bonanno, G. A., & Kaltman, S. (2001). The varieties of grief experience. Clinical Psychology Review, 21, 705–734.PubMedCrossRefGoogle Scholar
  12. Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., et al. (2002). Resilience to loss and chronic grief. Journal of Personality and Social Psychology, 83, 1150–1164.PubMedCrossRefGoogle Scholar
  13. Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to grief than depression and PTSD? A test of incremental validity. Journal of Abnormal Psychology, 116, 342–351.PubMedCrossRefGoogle Scholar
  14. Bowlby, J. (1980). Loss: Sadness and depression (attachment and loss) (vol. Vol. 3). New York: Basic Books.Google Scholar
  15. Burnett, P., Middleton, W., Raphael, B., & Martinek, N. (1997). Measuring core bereavement phenomena. Psychological Medicine, 27, 49–57.PubMedCrossRefGoogle Scholar
  16. Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavement-related distress in health outcomes. Psychological Medicine, 29, 367–380.PubMedCrossRefGoogle Scholar
  17. Currier, J. M., Holland, J. M., & Neimeyer, R. A. (2007). The effectiveness of bereavement interventions with children: a meta-analytic review of controlled outcome research. Journal of Clinical Child and Adolescent Psychology, 36, 1–7.Google Scholar
  18. Currier, J. M., Holland, J. M., Coleman, R. A., & Neimeyer, R. A. (2008a). Bereavement following violent death: An assault on life and meaning. In R. Stevenson, & G. Cox (Eds.), Perspectives on violence and violent death (pp. 177–202). Amityville, NY: Baywood.Google Scholar
  19. Currier, J. M., Neimeyer, R. A., & Berman, J. S. (2008b). The effectiveness of psychotherapeutic interventions for bereaved individuals: a comprehensive quantitative review. Psychological Bulletin, 134, 648–661.PubMedCrossRefGoogle Scholar
  20. Faschingbauer, T. R. (1981). Texas Revised Inventory of Grief manual. Houston, TX: Honeycomb.Google Scholar
  21. Goodkin, K., Lee, D., Molina, R., Zheng, W., Frasca, A., O’Mellan, S., et al. (2006). Complicated bereavement: disease state or state of being? Omega, 52, 21–36.Google Scholar
  22. Grove, W. M. (2004). The MAXSLOPE taxometric procedure: mathematical derivation, parameter estimation, consistency tests. Psychological Reports, 95, 517–550.PubMedCrossRefGoogle Scholar
  23. Hogan, N. S., Greenfield, D. B., & Schmidt, L. A. (2001). Development and validation of the Hogan Grief Reaction Checklist. Death Studies, 25, 1–31.PubMedCrossRefGoogle Scholar
  24. Hogan, N. S., Worden, J. W., & Schmidt, L. A. (2004). An empirical study of the proposed complicated grief disorder criteria. Omega, 48, 263–277.Google Scholar
  25. Kato, P. M., & Mann, T. (1999). A synthesis of psychological interventions for the bereaved. Clinical Psychology Review, 19, 275–296.PubMedCrossRefGoogle Scholar
  26. Kessler, R. C. (2002). Epidemiological perspectives for the development of future diagnostic systems. Psychopathology, 35, 158–161.PubMedCrossRefGoogle Scholar
  27. Latham, A. E., & Prigerson, H. G. (2004). Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide and Life Threatening Behavior, 34, 350–362.PubMedCrossRefGoogle Scholar
  28. Lichtenthal, W. G., Cruess, D. G., & Prigerson, H. G. (2004). A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clinical Psychology Review, 24, 637–662.PubMedCrossRefGoogle Scholar
  29. Meehl, P. E. (1995). Bootstraps taxometrics: solving the classification problem in psychopathology. American Psychologist, 50, 266–274.PubMedCrossRefGoogle Scholar
  30. Meehl, P. E., & Yonce, L. J. (1994). Taxometric analysis: I. Detecting taxonicity with two quantitative indicators using means above and below a sliding cut (MAMBAC procedure). Psychological Reports, 74, 1059–1274.Google Scholar
  31. Melhem, N. M., Rosales, C., Karageorge, J., Reynolds, C. F., Frank, E., & Shear, M. K. (2001). Comorbidity of axis I disorders in patients with traumatic grief. Journal of Clinical Psychiatry, 62, 884–887.PubMedGoogle Scholar
  32. Middleton, W., Burnett, P., Raphael, B., & Martinek, N. (1996). The bereavement response: a cluster analysis. British Journal of Psychiatry, 169, 167–171.PubMedCrossRefGoogle Scholar
  33. Ott, C. H. (2003). The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27, 249–272.PubMedCrossRefGoogle Scholar
  34. Prigerson, H. G., & Jacobs, S. C. (2001). Diagnostic criteria for traumatic grief: A rationale, consensus criteria, and a preliminary empirical test. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 613–645). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  35. Prigerson, H. G., & Maciejewski, P. K. (2006). A call for sound empirical testing and evaluation of criteria for complicated grief proposed for DSM-V. Omega, 52, 9–19.Google Scholar
  36. Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., Anderson, B., Zubenko, G. S., Houck, P. R., et al. (1995a). Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22–30.PubMedGoogle Scholar
  37. Prigerson, H. G., Maciejewski, P., Reynolds, C., Bierhals, A., Newsom, J., Fasiczka, A., et al. (1995b). Inventory of complicated grief. Psychiatry Research, 59, 65–79.PubMedCrossRefGoogle Scholar
  38. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., Shear, M. K., Newsom, J. T., et al. (1996). Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study. American Journal of Psychiatry, 153, 1484–1486.PubMedGoogle Scholar
  39. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., Shear, M. K., Day, N., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616–623.PubMedGoogle Scholar
  40. Prigerson, H. G., Vanderwerker, L. C., & Maciejewski, P. K. (2008). A case for inclusion of prolonged grief disorder in DSM-V. In M. Stroebe, R. Hansson, H. Schut, & W. Stroebe (Eds.), Handbook of bereavement research and practice: Advances in theory and intervention (pp. 165–186). Washington, DC: American Psychological Association.Google Scholar
  41. Ruscio, J. (2007). Taxometric analysis: an empirically grounded approach to implementing the method. Criminal Justice and Behavior, 34, 1588–1622.CrossRefGoogle Scholar
  42. Ruscio, J., & Ruscio, A. M. (2004). Clarifying boundary issues in psychopathology: the role of taxometrics in a comprehensive program of structural research. Journal of Abnormal Psychology, 113, 24–38.PubMedCrossRefGoogle Scholar
  43. Ruscio, J., Haslam, N., & Ruscio, A. M. (2006). Introduction to the taxometric method: A practical guide. Mahwah, NJ: Erlbaum.Google Scholar
  44. Ruscio, J., Ruscio, A. M., & Meron, M. (2007). Applying the bootstrap to taxometric analysis: generating empirical sampling distributions to help interpret results. Multivariate Behavioral Research, 42, 349–386.Google Scholar
  45. Schmidt, N. B., Kotov, R., & Joiner, T. E. (2004). Taxometrics: Toward a new diagnostic scheme for psychopathology. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  46. Schut, H., Stroebe, M. S., van den Bout, J., & Terheggen, M. (2001). The efficacy of bereavement interventions: Determining who benefits. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 705–737). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  47. Waller, N. G., & Meehl, P. E. (1998). Multivariate taxometric procedures: Distinguishing types from continua. Thousand Oaks, CA: Sage.Google Scholar
  48. Worden, J. W. (1982). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York: Springer.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Jason M. Holland
    • 1
    Email author
  • Robert A. Neimeyer
    • 2
  • Paul A. Boelen
    • 3
  • Holly G. Prigerson
    • 4
    • 5
    • 6
  1. 1.Center for Health Care Evaluation, VA Palo Alto Health Care SystemStanford University Medical CenterMenlo ParkUSA
  2. 2.University of MemphisMemphisUSA
  3. 3.Utrecht UniversityUtrechtThe Netherlands
  4. 4.Center for Psycho-Oncology and Palliative Care ResearchDana-Farber Cancer InstituteBostonUSA
  5. 5.Department of Psychiatry, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  6. 6.Harvard Medical School Center for Palliative CareHarvard Medical SchoolBostonUSA

Personalised recommendations