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C 2011) Journal of Traumatic Stress, Vol. 24, No. 4, August 2011, pp. 456–464 (

Prolonged Grief Among Traumatically Bereaved Relatives Exposed and Not Exposed to a Tsunami Kerstin Bergh Johannesson and Tom Lundin National Center for Disaster Psychiatry, Uppsala

Christina M. Hultman Karolinska Institutet

Thomas Fr¨ojd and Per-Olof Michel National Center for Disaster Psychiatry, Uppsala Numerous studies on the mental health consequences of traumatic exposure to a disaster compare those exposed to those not exposed. Relatively few focus on the effect of the death of a close relative caused by the disaster—suffering a traumatic bereavement. This study compared the impact on 345 participants who lost a close relative in the 2004 Indian Ocean tsunami, but who were themselves not present, to 141 who not only lost a relative, but also were themselves exposed to the tsunami. The focus was on psychological distress assessed during the second year after the sudden bereavement. Findings were that exposure to the tsunami was associated with prolonged grief ( B = 3.81) and posttraumatic stress reactions ( B = 6.65), and doubled the risk for impaired mental health. Loss of children increased the risk for psychological distress (prolonged grief: B = 6.92; The Impact of Event Scale-Revised: B = 6.10; General Health Questionnaire-12: OR = 2.34). Women had a higher frequency of prolonged grief. For men, loss of children presented a higher risk for prolonged grief in relation to other types of bereavement ( B = 6.36 vs. loss of partner). Further long-term follow-up could deepen the understanding of how recovery after traumatic loss is facilitated. In the event of a major disaster, such as the Indian Ocean tsunami of 2004, where more than 227,000 people were estimated to have died (Telford, Cosgrove, & Houghton, 2006), improving knowledge about how survivors and relatives are affected could be considered an obligation. In the tsunami disaster, approximately 7,000 Swedish tourists were on holiday in the most affected areas on the western coast of Thailand. After the tsunami, 1,970 Europeans from 23 countries were reported dead or missing of whom 543 were Swedish. With the level of current knowledge, bereavement is considered one of the most painful experiences of life (Shear et al., 2007). Sudden and unexpected loss, and especially bereavement due to traumatic circumstances, is more detrimental for health than normal bereavement (Bonanno et al., 2007; Bonanno & Kaltman, 1999; Kaltman & Bonanno, 2003; Lundin, 1984a, 1984b, Neria

et al., 2007; Norris et al., 2002; Raphael & Martinek, 1997). Traumatic bereavement, in combination with exposure to life danger, is probably a risk factor for negative mental health sequelae after a natural disaster (Johannesson, Lundin, et al., 2009; Johannesson, Michel, et al., 2009; Neria & Litz, 2004; Pfefferbaum et al., 2001). Less is known about whether the rupture of attachment through traumatic loss for a person remaining in a safe and familiar surrounding has a similar impact as for the person being both exposed to the threat and suffering a personal loss. The concept of traumatic grief (Gray, Prigerson, & Litz, 2004) has been important for improving understanding of traumatic bereavement and different names for the grief condition have been introduced. Horowitz, Bonanno, and Holen (1993) suggest the establishment of a pathological grief disorder. Prigerson and colleagues (Prigerson, 2004; Prigerson, Frank, et al., 1995) propose the term complicated grief, now termed prolonged grief disorder (Boelen & Prigerson, 2007). In the planned fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Prigerson et al. (2009) present recommendations for criteria for the syndrome, prolonged grief disorder. These include yearning for the deceased, and at least five of nine symptoms experienced daily or to a disabling degree: preoccupation with the deceased that interrupts normal activities, trouble accepting the loss, detachment, bitterness, loneliness, feeling part of one’s self died, feeling life is empty, and loss of security or safety.

Kerstin Bergh Johannesson, Tom Lundin, Thomas Fr¨ojd, and Per-Olof Michel, National Center for Disaster Psychiatry, Department of Neuroscience, Uppsala University; Christina M. Hultman, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet. The authors would like to thank Hans Arinell for valuable contributions to the data analyses. The study was financed by the Swedish Emergency Management Agency, Swedish Board of Health and Welfare, and the Swedish Council for Working Life and Social Research. Correspondence concerning this article should be addressed to Kerstin Bergh Johannesson, National Center for Disaster Psychiatry, Department of Neuroscience, Uppsala University, SE-751 85, Uppsala, Sweden. E-mail: [email protected] C 2011 International Society for Traumatic Stress Studies. View this article online at

wileyonlinelibrary.com DOI: 10.1002/jts.20668

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Traumatic Bereavement and Prolonged Grief Associations between grief reactions and posttraumatic stress symptoms are reported (Bonanno et al., 2007; Neria et al., 2007; Johannesson, Lundin, et al., 2009; Pfefferbaum et al., 2001); however, in contrast to posttraumatic stress disorder (PTSD), nightmares are not considered a prominent symptom in prolonged grief disorder (Shear, Frank, Houck, & Reynolds, 2005). Grief might also fuel depressive states (Bonanno et al., 2007; Green et al., 1990). The biggest difference between prolonged grief disorder and PTSD is in Criterion D for PTSD (hyperarousal; Gray et al., 2004). A violent nature of death, rather than suddenness, is considered a key factor for later PTSD symptoms (Kaltman & Bonanno, 2003; Green et al., 2001). Loss from motor vehicle accidents (Lehman, Wortman, & Williams, 1987), suicides (Feigelman, Jordan, & Gorman, 2008), and loss through natural disasters and accidents (Carlier & Gersons, 1997; Ghaffari-Nejad, AhmadiMousavi, Gandomkar, & Reihani-Kermani, 2007; Johannesson, Lundin, et al., 2009; Johannesson, Stefanini, Lundin, & Anchisi, 2006; Souza, Bernatsky, Reyes, & de Jong, 2007) incur substantial levels of distress among bereaved relatives. Closeness in relationship to the deceased is important (Neria et al., 2007). Loss of children is a suggested cause of more intense grief (Cleiren, Diekstra, Kerkhof, & Wal, 1994; Kristensen, Weisaeth, & Heir, 2009; Lundin, 1984b), which might complicate the grief process (Shear et al., 2005). Whether the age of the dead child is associated with subsequent trauma symptoms or not is less explored. Women may be more vulnerable to traumatic stress (Breslau, 2009; Olff, Langeland, Draijer, & Gersons, 2007) and prolonged grief (Bonanno et al., 2007; Ghaffari-Nejad et al., 2007; Murphy, Johnson, Chung, & Beaton, 2003), but findings are inconsistent (Chiu et al., 2010). The aim of this study was to examine the impact of traumatic bereavement on prolonged grief reactions, posttraumatic stress symptoms, and general mental health in a Swedish sample all of whom had a close relative who was killed in the 2004 tsunami. A group who was at home during the disaster was compared to a group who were present at the tsunami. The hypothesis was that direct exposure to the disaster would increase distinct signs of prolonged grief, posttraumatic stress reactions, and impaired mental health. Further, it was hypothesized that the loss of children, compared to loss of parents or siblings, would increase the risk for distress, and that loss of a nonadult child would cause more distress than for an adult child. Females were predicted to be more vulnerable than males.

METHOD Participants Swedish citizens returning from the affected region in Southeast Asia were registered by the national police upon arrival at Swedish airports. A questionnaire, with one mailed reminder to nonresponders, was distributed 14 months after the disaster. Responses from

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4,932 people (49%) were received (Johannesson, Lundin, et al., 2009). The questionnaire included items on background information, exposure to the tsunami, health conditions, bereavement, and experience of support received after the tsunami. From the cohort studied, 141 individuals were identified who were exposed to the tsunami and had had a close relative killed. Being exposed to the tsunami was defined as one or more of the following: (a) having been present at the site, (b) having been physically flooded, (c) having witnessed the flooding, and (d) having witnessed the disastrous consequences of the wave. There were 546 bereaved close family members who had not accompanied their relatives to Southeast Asia, who were identified through the Swedish police. After agreeing to participate in the study, questionnaires were mailed 21 months after the tsunami, followed by one reminder to nonresponders. The questionnaire was similar to the one used at 14 months, but items regarding exposure to the tsunami were omitted. Out of 353 returned questionnaires (65%), 345 could be used for the statistical analyses. For this study, the definition of a close relative was a spouse or partner, a parent, a sibling, or a child. Among those exposed to the tsunami, 27 couples sharing the same address responded (38% of those exposed). Among those at home, there were 33 couples (19%). The Regional Ethical Vetting Board in Uppsala, Sweden, formally approved the study after a written application. Identities were checked to verify that no individual was represented in both groups.

Measures Gender, age, marital status, education, and earlier stressful life events were used as control variables. Age was coded into four categories (16–24, 25–40, 4–60, and ≥61); family situation (married or partner vs. no partner) and education (≤12 years vs. >12 years) were dichotomized. Thirteen stressful life events were presented in the questionnaire: traffic accident, disaster, war or terror, serious violence or abuse, own serious bodily illness or injury, relative’s serious bodily injury or illness, serious family conflicts or own divorce, parents’ divorce, death of parent, death of sibling, death of own child, death of partner, and death of other close family members. Three categories of frequency were coded, 0, 1–2, and ≥3 at each of two time intervals: childhood (0–16 years) and pretsunami adulthood (between 16 and 26 years of age by December 26, 2004). Three categories were used to code the relationship of study participants to the dead relative: child, partner, and parent or sibling. For those who had lost more than one relative, the most intimate relationship from child, through partner, to parent or sibling was used. To measure prolonged grief, the Inventory of Complicated Grief (Prigerson, Maciejewski, et al., 1995) was used. Nine items are recommended (Prigerson, 2004) for constituting the concept of

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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prolonged grief: yearning for the deceased, preoccupation with the deceased that interrupts normal activities, trouble accepting the loss, detachment, bitterness, loneliness, feeling part of one’s self died, feeling life is empty, and loss of security or safety. To measure this variable we constructed the new variable, Prolonged Grief (PG). This was performed by using the nine items from the Inventory best corresponding to the concept (Items 1, 3, 4, 9, 10, 13, 16, 17, and 19). The respondents indicated the frequency of symptoms during the past month on a 5-point scale (0 = almost never, 1 = rarely, 2 = sometimes, 3 = often, 4 = always). Cronbach’s α for PG was .87. In line with Prigerson (2004), a response of often or always to at least five of the nine symptoms, one of which must include yearning, was considered a sign of PG (minimum score = 15). The Impact of Event Scale-Revised (IES-R; Weiss, 2004) was used to estimate posttraumatic stress reactions. With reference to their perception of the tsunami, the respondents evaluated how disturbing the symptoms were during the past 7 days. The respondents were instructed to rate each item on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely disturbing). To measure the prevalence of moderate posttraumatic reactions, the proportion of respondents with a chosen cutoff mean score of ≥41.6, was calculated. Cronbach’s α was .94 in this study. The General Health Questionnaire 12, (GHQ-12; Goldberg et al., 1997), was used to evaluate the respondents’ mental health. Directions give a timeframe of “the past few weeks.” The GHQ12 has an internationally accepted cutoff score of ≥3, indicating impaired mental health (Connor, Foa, & Davidson, 2006). Cronbach’s α was .93 in this study.

Data Analysis In accordance with previous publications from the Swedish tsunami database (Johannesson, Lundin, Frojd, Hultman, & Michel, 2011; Johannesson, Michel, et al., 2009, Johannesson, Lundin, et al., 2009), response to at least 70% of the items of the IES-R (missing values = 6) and the PG score (missing values = 22) was a minimum criterion for being included in analyses where these variables were the outcome variables. Both t-test and χ2 analyses were used to compare the two groups on age, gender, education, relationship to the deceased, signs of prolonged grief, posttraumatic stress symptoms, and impaired mental health. A logistic regression model using demographic characteristics, exposure, and type of loss to predict mental health was applied. Analyses were repeated for the PG score and the IES-R as the dependent variable in an ordinary linear regression model. Correlations between outcome variables were calculated with Spearman’s correlation coefficient. To evaluate the association between the age of the lost child and later grief reactions and impaired mental health, the loss of a child category was split into young child (≤18 years) and adult

child (>18 years), yielding four categories. Loss of a young child was chosen as a reference category. To examine if gender affected outcome measures differently depending on the type of loss, a post hoc subgroup analysis was performed by including an interaction term of loss and gender into the basic model. As time from loss to survey differed between the two subsamples, 14 months for those present and 21 months for those at home, the regression analyses were first conducted on the combined sample, and then repeated on each subsample separately. This was to investigate whether parameter estimates of demographic factors differed between the two samples. In the separate analyses, the confidence intervals became wider, as can be expected when sample size is reduced, but there were no large differences in estimated parameters between the samples. Thus, except for the exposure variable, the combined sample was used for the regression analyses. To examine the intercorrelations between couples, Cohen’s κ was calculated. All hypothesis tests were two-sided, with 95% confidence intervals. The SAS version 9.2 software (SAS Institute, 2009) was used for the statistical analyses.

RESULTS The distribution of gender was similar in both groups (Table 1). The mean age was lower in the exposed group and a higher proportion had lost a partner. The median age of lost offspring was 14.5 years for those at the site and 34.5 years for those at home. The rate of prolonged grief reactions, according to PG, and the rate of mental health problems, was higher among those exposed. Posttraumatic stress reactions above the cutoff score of 41.6 were identified in 46% of tsunami-exposed relatives and 33% of nondirectly exposed relatives. The correlation between PG and total IES-R was .55; the corresponding correlation between PG and GHQ-12 was .42. The intercorrelation between couples (tsunami exposed = 27 couples, non-directly exposed = 33 couples) were low for all outcome measures: for PG, κ = .19, for IES-R, κ = .24, and for GHQ-12, κ = .31. Adjusting for background variables, linear regression analysis revealed direct exposure to the tsunami was associated with higher levels of prolonged grief and posttraumatic stress reactions (Table 2) and a logistic regression analysis indicated a heightened risk for impaired mental health (Table 3). Loss of children, compared to loss of parents/siblings, predicted higher levels of prolonged grief and posttraumatic stress reactions and increased the risk for impaired mental health. In a separate logistic regression analysis, results indicated a lower risk for impaired mental health for those who had lost adult children (≥19 years), OR = 0.32, 95% CI [0.14, 0.78], p = .012, than for those losing young children. Female gender was associated with higher levels of prolonged grief and posttraumatic stress reactions and presented an


Traumatic Bereavement and Prolonged Grief

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Table 1. Demographic Variables, Relationship to the Deceased, and Presence of Psychological Distress in Relatives Exposed and Not Exposed to the 2004 Tsunami Exposed to tsunami (n = 141) Measure Gender Men Women Education >12 years Married/cohabitant Life events 0–16 years 0 1–2 ≥3 Life events >16 years – Dec. 26, 2004 0 1–2 ≥3 Deceased Child Spouse/partner Parents/siblings Prolonged grief (PG ≥15) Affected mental health(GHQ-12 ≥3) Posttraumatic stress symptoms (≥41.6)

Not exposed (n = 345)

n

%

n

%

57 84 66 75

40 60 47 53

146 199 124 251

42 58 37∗ 73∗∗∗

93 44 3

66 31 2

232 96 17

67 28 5

51 52 37

36 37 26

100 147 98

29 43 28

58 37 46 61 95 64

41 26 32 45 69 46

172 13 160 84 168 111

50 4∗∗∗ 46 26∗∗ 50∗ 33

Note. GHQ-12 = General Health Questionnaire-12. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.

increased risk for impaired mental health. In the younger age groups (16–24; 25–40), an increased risk for prolonged grief and impaired general mental health was found; higher levels of posttraumatic stress reactions were identified in both younger and older ages (61+). Education (≤12 years) and previous stressful life events were associated with prolonged grief and higher levels of posttraumatic stress reactions. Gender differences on how bereavement affected outcome measures, depending on the different types of relationship, were examined through multiple linear regression analysis. The model included demographic variables, exposure, and relationship to the deceased as independent variables, with an interaction term of gender and type of bereavement included. The analysis indicated that for male gender, loss of children yielded higher score on prolonged grief than other types of losses (Table 4). For female gender, loss of children increased the score for prolonged grief reactions, but with less magnitude. For women, the analyses indicated no significant difference regarding loss of children versus loss of partner.

DISCUSSION Direct exposure to the tsunami, compared to being at home, heightened the risk of prolonged grief and impaired mental health, and was associated with higher levels of posttraumatic stress reactions in a trauma-bereaved population. Loss of children increased the risk for psychological distress in all three of the outcome measures. Men who had lost children, compared to other types of loss, were at increased risk of prolonged grief; for women, different types of loss appeared more equally distressing. Human made/technological disasters are suggested as having a more profound effect on victims than natural disasters (Galea, Nandi, & Vlahov, 2005; Norris & Sloane, 2007). However, this study highlighted that 18 months after the tsunami disaster, bereaved relatives presented distinct signs of psychological distress. In contrast to others (Kristensen, Weisæth, & Heir, 2010), the levels of distress were higher in the tsunami-exposed group, indicating direct exposure in combination with own life danger has more serious consequences. However, a substantial proportion


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Table 2. Multivariate Linear Regression Analyses Predicting Prolonged Grief and PTSD Symptoms from Exposure, Loss, and Demographic Variables PG Variable Exposure Tsunami-exposed Not directly exposed Loss of Children Partner Parent/sibling Age 16–24 25–40 41–60 61+ Gender Male Female Education 12 years Family Married/ partner No partner Stressful life events 0–16 years 0 1–2 ≥3 Stressful life events ≥ 16 years – 26 Dec 2004 0 1–2 ≥3

B

SE

IES-R β

B

SE

β

3.81 ref

0.77∗∗∗

.20

6.65 ref

2.0∗∗∗

.36

4.30 1.27 ref

0.89∗∗∗ 1.31

.29 .22

6.10 5.14 ref

2.26∗∗ 3.34

.33 .28

3.45 2.56 ref 1.72

1.45∗ 0.89∗∗

.42 .31

3.74∗∗ 2.30∗

.57 .25

0.89

.24

10.53 4.65 ref 5.22

2.27∗

.28

ref 4.05

0.64∗∗∗

.27

ref 9.80

1.64∗∗∗

.53

−.15

ref −3.89

−3.89∗

−.21

0.76∗

.13

−0.09 ref

1.93

−.01

0.71 1.62∗

.09 .16

ref 2.03 8.62

1.85 4.14∗

.11 .46

−.05 .20

ref 0.92 3.70

1.96 2.18

.05 .20

ref −2.36 1.61 ref ref 0.57 3.26 ref −0.43 0.39

0.67∗∗

0.76 0.85

Note. PG = Prolonged grief (tsunami-exposed: n = 136; not directly exposed: n = 328); R 2 = .246. IES-R = Impact of Event Scale-Revised (tsunami-exposed: n = 139; not directly exposed: n = 340); R 2 = .272. ref = reference value. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.

of non-directly exposed relatives displayed problems: This result concurred with other studies (Neria et al., 2007). The proportion of exposed relatives (45%) and non-directly exposed relatives (25%) with signs of prolonged grief was similar to findings by Bonanno et al. (2007). Two-thirds of bereaved relatives exposed to the tsunami and half of the non-directly exposed relatives displayed impaired mental health, which concurred with followup findings of earthquake victims in Japan (Ohta et al., 2003). In a comparison with an epidemiological Swedish survey (Wamala, Bostrom, & Nyqvist, 2007), the levels of affected mental health appeared higher in the present study, and in contrast to

previous reports (Bonanno et al., 2007), signs of PTSD reactions were almost as frequent as for prolonged grief. The burden for an individual in managing the combined load of exposure to a traumatic event and a traumatic loss was evident, as has been found in other studies (Gray et al, 2004). The correlation of .55 between PG and IES-R, and the correlation of .42, between PG and GHQ-12 suggested PG reflects unique aspects of griefrelated psychopathology after traumatic bereavement (Boelen & Prigerson, 2007; Boelen, van de Schoot, van den Hout, de Keijser, & van den Bout, 2010; Bonanno et al., 2007; Golden, & Dalgleish, 2010).



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Table 3. Logistic Regression Analyses of Exposure, Loss, and Demographic Characteristics in Relation to Mental Health Symptoms GHQ-12 Variable Exposure Tsunami-exposed Not directly exposed Loss of Children Partner Parent/sibling Age 16–24 25–40 41–60 61+ Gender Male Female Education 12 years Family Married/ partner No partner Stressful life events 0–16 years 0 1–2 ≥3 Stressful life events >16 years – Dec. 26, 2004 0 1–2 ≥3

n

% cases

OR

95% CI

95 168

69 50

2.11∗∗ 1.0

[1.29, 3.45]

222 48 204

60 60 50

2.34∗∗ 1.61 1.00

[1.34, 4.09] [0.70, 3.68]

42 122 188 122

69 55 55 52

3.08∗ 1.53 1.0 0.89

[1.21, 7.82] [0.88, 2.71]

200 274

46 62

1.0 1.87∗∗

[1.26, 2.77]

279 188

55 56

1.0 1.14

[0.75, 1.73]

320 154

53 61

1.03 1.0

315 139 20

54 57 70

1.0 1.04 2.30

[0.67, 1.64] [0.81, 6.54]

147 196 131

57 53 58

1.0 0.95 1.20

[0.60, 1.52] [0.71, 2.03]

[0.52, 1.54]

[0.64, 1.64]

Note. GHQ-12 = General Health Questionnaire-12; CI = confidence interval. Adjusted for demographic variables. ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.

In accordance with other studies (Cleiren et al., 1994; Kristensen, et al, 2009; Neria et al., 2007; Shear et al., 2005), loss of children was associated with higher levels of distress. In this respect, the groups did not differ: loss of children had a similar effect on the tsunami-exposed and the non-directly exposed group, indicating that being onsite did not appear to increase later reactions. As the groups differed in age, the effect of the age of the dead child was considered; for prolonged grief and posttraumatic stress reactions, the age of lost children did not influence the outcome. However, those who were bereaved of young children (15 ) Contrasts between types of loss Men Children vs. parents/siblings Children vs. partner Women Children vs. parents/siblings Children vs. partner

B

SE

95% CI

−4.85 −6.36

1.40∗∗ 1.99∗∗

[−7.60, −2.09] [10.28, −2.43]

−3.29 −0.35

1.16∗∗ 1.56

[5.57, −0.99] [3.41, 2.72]

Note. CI = Confidence interval. Adjusted for exposure level, age, gender, education, family situation, history of traumatic events in childhood and adulthood. Men bereaved of children (n = 92), men bereaved of parents/siblings (n = 83), men bereaved of partner (n = 19). Women bereaved of children (n = 125), women bereaved of parents/siblings (n = 117), women bereaved of partner (n = 28). ∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.

Primarily younger age predicted higher risk for different forms of distress. There are inconsistent results concerning age, which could depend on differences in methodology, populations, types of events, and cultural aspects. Education and previous stressful life events were associated with posttraumatic stress reactions and prolonged grief, but did not predict impaired mental health. It is suggested previous trauma experience may complicate the grieving process (Neria & Litz, 2004). The time difference in assessing outcome between the tsunamiexposed group and the home-staying relatives might have affected outcome, and is one reason the differences between the two groups should be interpreted with caution. However, the differences in tsunami-exposed and home-staying bereaved relatives resembled a Norwegian interview study of tsunami-bereaved relatives (Kristensen et al., 2009). The influence of time on the two current subsamples appeared limited, especially regarding prolonged grief reactions. The anniversary of both the disaster and the bereavement had passed for both groups, and the assessments were within the second year of loss. Stability and even increase in PTSD symptoms after sudden loss is reported elsewhere (Murphy, Brown, Tillery, Cain, Johnson, & Beaton, 1999). Some of the most affected victims might not have responded, not wanting to be reminded of the trauma or the traumatic loss, which could result in an underestimation of prolonged grief, posttraumatic stress reactions, and affected mental health. Conversely, a Norwegian study after the 2004 tsunami (Hussain, Weisaeth, & Heir, 2009) reports that nonresponse is generally related to lack of interest and lack of relevant experience, and to a lesser extent, to the fear of retraumatization. A proportion of respondents in the present study shared addresses and their reactions may have interacted. However, analyses of response patterns reveal low correlations (Landis & Koch, 1977) between couples and did not appear to influence outcome. In this study, the respondents were overrepresented by women, which could have affected the results, as women may be more vulnerable to traumatic stress (Breslau, 2009; Olff et al., 2007). A

factor that should be considered when interpreting the data is that self-report questionnaires are not diagnostic measures and only provide an indication of effects on mental health and PTSD. The present findings were the consequence of a cross-sectional investigation, which rendered the establishment of causal or temporal relationships not possible. A possible influencing factor, such as access to psychotherapy, was not examined and was not the focus of this study. In conclusion, this study highlighted the accentuated impact of both suffering the sudden loss of a significant other and of being exposed to a traumatic situation. Loss through a disaster in itself causes substantial suffering for close relatives. Direct exposure to the tsunami, compared to nondirect exposure, heightened the risk for prolonged grief and impaired mental health, and was associated with higher levels of posttraumatic stress reactions. The current results confirmed earlier findings that loss of children implies extensive difficulty. From a clinical trauma perspective, these findings emphasized the importance of understanding that loss through violent causes may result in symptoms of prolonged grief and PTSD, which without treatment may develop into chronic conditions of prolonged grief reactions and impaired mental health. In addition, this can have implications for how clients are educated in understanding their own reactions, and for how clinicians apply effective treatment alternatives. Further long-term follow-up would deepen our understanding of how recovery after traumatic loss is promoted.

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