Anxiety, Stress, & Coping

ISSN: 1061-5806 (Print) 1477-2205 (Online) Journal homepage: https://www.tandfonline.com/loi/gasc20

Cognitive behavioral variables mediate the

associations of neuroticism and attachment
insecurity with Prolonged Grief Disorder severity

Paul A. Boelen & Irene Klugkist

To cite this article: Paul A. Boelen & Irene Klugkist (2011) Cognitive behavioral
variables mediate the associations of neuroticism and attachment insecurity with
Prolonged Grief Disorder severity, Anxiety, Stress, & Coping, 24:3, 291-307, DOI:
10.1080/10615806.2010.527335

To link to this article: https://doi.org/10.1080/10615806.2010.527335

Published online: 10 Nov 2010.

Submit your article to this journal

Article views: 1019

View related articles

Citing articles: 19 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=gasc20
Anxiety, Stress, & Coping
Vol. 24, No. 3, May 2011, 291
307

Cognitive behavioral variables mediate the associations of neuroticism

and attachment insecurity with Prolonged Grief Disorder severity
Paul A. Boelena* and Irene Klugkistb
a
Department of Clinical and Health Psychology, Utrecht University, PO Box 80140, 3508 TC,
Utrecht, The Netherlands; bDepartment of Methodology and Statistics, Utrecht University,
PO Box 80140, 3508 TC, Utrecht, The Netherlands
(Received 28 April 2010; final version received 22 September 2010)

Prolonged Grief Disorder (PGD) is a debilitating syndrome of grief. A recent

cognitive behavioral model asserts that three processes are critical to this
condition: (1) insufficient integration of the loss with autobiographical knowledge
about the self and the lost person; (2) negative cognitions; and (3) anxious and
depressive avoidance behaviors. These processes are assumed to contribute to
PGD symptoms and to mediate the influence of personality-related vulnerabilities
on the development and maintenance of these symptoms. The present study
examined the mediational role of these three processes in the linkage between
neuroticism, attachment anxiety, and attachment avoidance on the one hand and
PGD symptom severity on the other hand. Self-reported data from 348 bereaved
people were used. The results showed that the three personality variables were
significantly associated with PGD symptom severity. Moreover, the results
provided support for the mediating effects of indices of insufficient integration,
negative cognitions, as well as avoidance behaviors
even after controlling for the
shared variance between mediators. Theoretical and clinical implications are
discussed.
Keywords: grief; attachment; neuroticism; cognitions; avoidance; mediation

There is growing evidence that a sizeable number of bereaved people develop

Prolonged Grief Disorder (PGD, also called complicated grief) after the death of a
loved one. Symptoms of PGD include persistent yearning, difficulties accepting the
loss and moving on without the lost person, bitterness, and numbness (Prigerson
et al., 2009). There is evidence that these symptoms are distinct from depression and
anxiety and, if left untreated, predict chronic health impairments (Prigerson et al.,
2009). Given the debilitating nature of PGD symptoms, it is important to search for
variables contributing to their development and maintenance.
Recently, Boelen, van den Hout, and van den Bout (2006) developed a cognitive
behavioral model of PGD. This model proposes that three interrelated processes
underlie PGD symptomatology. The first of these processes is insufficient integration
of the loss with autobiographical knowledge about the self and the lost person. This
process refers to a lack of connectivity in autobiographical memory between factual
knowledge about the reality and irreversibility of the separation on the one hand and
schematic knowledge about self-identity and the relationship with the lost person on

*Corresponding author. Email: P.A.Boelen@uu.nl

ISSN 1061-5806 print/1477-2205 online
# 2010 Taylor & Francis
DOI: 10.1080/10615806.2010.527335
http://www.informaworld.com
292 P.A. Boelen and I. Klugkist

the other hand. This lack of connectivity is assumed to maintain a sense of shock about
the loss as well as a sense that the separation is temporary rather than permanent,
resulting in yearning and persistent urges to restore proximity to the lost person. The
second of these processes is persistent negative thinking, specifically negative cognitions
about the self, life, and the future, and catastrophic misinterpretations of one’s own grief
reactions. The model postulates that negative thoughts about the self, life, and the
future directly contribute to a persistent focus on what is lost, whereas catastrophic
misinterpretations of grief reactions contribute to distress and avoidance behaviors
that block adjustment. Finally, the third of these processes is avoidance behavior,
including the avoidance of stimuli that remind of the loss (called ‘‘anxious avoidance’’)
and the avoidance of activities that could facilitate adjustment (called ‘‘depressive
avoidance’’). The model proposes that, among other reasons, anxious avoidance
maintains PGD symptoms by preventing elaboration and integration of the loss,
whereas depressive avoidance maintains these symptoms by blocking the correction of
negative views of the self, life, and future that may develop following loss.
The three processes that are distinguished within the cognitive behavioral model
are assumed to directly contribute to symptoms of PGD. Moreover, they are assumed
to mediate the impact of various risk factors for poor bereavement outcome,
including personality features such as neuroticism and insecure attachment, char-
acteristics of the loss event (e.g., unexpectedness of the loss), and characteristics of the
loss sequelae (e.g., lack of support from the social environment). Stated otherwise, it is
proposed that the three processes are intermediate mechanisms that explain why, for
instance, people high in neuroticism have an elevated chance of developing PGD (cf.
Wijngaards-de Meij et al., 2007). According to the cognitive behavioral model, this is
so because people high in neuroticism have an elevated tendency to experience
negative thoughts and feelings across different situations (Watson & Clark, 1984), as a
result of which they are likely more prone to develop negative cognitions (Process 2)
and more inclined to engage in avoidance (Process 3) following loss, which, in turn
renders them vulnerable to get stuck in their process of mourning. As another
example, the model proposes that anxiously attached individuals are more prone to
develop emotional difficulties following loss, because they likely have more difficulties
to accept and integrate the reality of the loss (Process 1), to maintain a positive view of
self (Process 2), and to engage in helpful coping behaviors (Process 3) as a result of
which they have a greater chance of developing PGD (Boelen et al., 2006). The notion
of mediation that is implicated in the model is important because it sheds light on
changeable mechanisms (e.g., negative cognitions) that can be targeted in treatment to
curb the effect of more static, less easily changeable risk factors (e.g., personality
features) on the development and maintenance of PGD.
There is some evidence that negative cognitions and avoidance behaviors mediate
the linkages of personality-related and situational risk factors with PGD symptoms.
For instance, in a recent cross-sectional study, Boelen and van den Bout (2010) found
evidence that anxious avoidance and depressive avoidance mediate the linkages of
neuroticism and insecure attachment with PGD symptom severity. Van der Houwen
et al. (in press) collected longitudinal data from 195 bereaved individuals to examine
the extent to which rumination and catastrophic misinterpretations of grief reactions
(e.g., ‘‘If I allow my feelings to run loose, I will lose control’’) mediated the
associations between neuroticism, insecure attachment, and unexpectedness of death
on the one hand, and PGD severity, depression severity, emotional loneliness, and
 Anxiety, Stress, & Coping 293

positive mood on the other hand. Among other things, outcomes showed that the
effect of neuroticism on PGD severity was mediated by both rumination and
catastrophic misinterpretations. In addition, earlier studies have examined the
meditational role of negative views of self and self-blame. For instance, Field and
Sundin (2001) found that the linkage between attachment anxiety and emotional
problems following loss was mediated by appraised inability to cope. In addition, the
capacity to find meaning in one’s loss has been found to mediate the effects of cause
of death (Currier, Holland, & Neimeyer, 2006) and dispositional optimism (Davis,
Nolen-Hoeksema, & Larson, 1998) on bereavement outcomes.
No studies have yet examined the possible mediational role of ‘‘insufficient
integration of the loss’’ and negative cognitions about the self, life, and the future as
conceptualized in the cognitive behavioral model, nor have studies examined the
specific mediational role of the three processes distinguished in the model, when
controlling for the shared variance between the processes. Thus, there is a need to
further examine the degree to which these three processes play a role in explaining
how particular risk factors lead to elevated PGD symptom severity. The present
study aimed to do so. With regard to risk factors, we focused on the personality-
related variables of neuroticism, attachment anxiety (i.e., a person’s predisposition
toward anxiety and vigilance about rejection and abandonment), and attachment
avoidance (i.e., a person’s discomfort with closeness and dependency or a reluctance
to be intimate with others) as potential risk factors. The reason for doing so is that
these personality variables have been found to be associated with elevated PGD in
several studies (e.g., van der Houwen et al., 2010; Wijngaards-de Meij et al., 2007).
Notably, research findings on the impact of attachment avoidance on grief have been
mixed (e.g., Mancini, Robinaugh, Shear, & Bonanno, 2010). However, the three
studies we know that examined this variable in relation to PGD symptoms, all found
increased attachment avoidance to be associated with elevated PGD symptom
severity (Boelen & van den Bout, 2010; van der Houwen et al., 2010; Wijngaards-de
Meij et al., 2007). Among other reasons, people high in attachment avoidance could
be at risk for emotional problems following loss because they are more inclined to
use avoidant strategies to regulate their emotions and to withdraw from supporting
social relationships (cf. Field & Sundin, 2001).
Thus, the central question that this study addressed was: do the cognitive
behavioral variables that are distinguished in the aforementioned cognitive behavior-
al model of PGD (Boelen, van den Bout, & van den Hout, 2006) mediate the linkages
between personality variables and PGD severity? We predicted that this was indeed
so. Specifically, our hypotheses were that (1) neuroticism, attachment anxiety, and
attachment avoidance would be significantly associated with elevated PGD symptom
severity, and that (2) these associations would be mediated by indices of insufficient
integration of the loss, negative thinking, and avoidance behavior. To index
insufficient integration of the loss with autobiographical knowledge, we used a
measure tapping a sense of ‘‘unrealness’’ about the loss. Although insufficient
integration primarily refers to an implicit process, there is evidence that it has an
introspectively accessible counterpart in the form of a sense of ‘‘unrealness’’

defined as a subjective sense of uncertainty and ambivalence about the irreversibility
of the separation that is manifested in the endorsement of items such as ‘‘It feels
unreal that [
] is gone forever’’ and ‘‘I still can hardly image that [
] will never be here
again’’ (Boelen, 2010). Negative cognitions were indexed by four distinct classes of
294 P.A. Boelen and I. Klugkist

cognitions postulated to be critical to PGD in the cognitive behavioral model (i.e.,

negative cognitions about the self, life, the future, and catastrophic misinterpreta-
tions of grief reactions). With regard to avoidance behavior, we included measures of
both anxious avoidance behavior and depressive avoidance behavior.

Method
Participants and procedure
Self-reported data were available from 348 bereaved people. All were recruited
through announcements on Dutch Internet sites about loss and grief that solicited
people who lost a close relative to participate. People could express their willingness
to participate by sending an email to the first author, who subsequently sent a digital
or paper version of the questionnaire. In total, 586 questionnaires were sent out and
409 (69.8%) were returned. We excluded data of 17 people with missing values on the
personality measures that were used. Moreover, to increase homogeneity of the
sample, we excluded data from 44 people whose losses had occurred more than
10 years ago. The final sample thus included 348 bereaved individuals. Table 1
summarizes their characteristics. Most participants were female and losses were
mostly due to illness. Informed consent was obtained from all participants.

Measures
Inventory of complicated grief-revised (ICG-R)
The ICG-R is a 30-item questionnaire that taps symptoms of PGD (also called
complicated grief) and other maladaptive grief reactions. Participants rate the

Table 1. Background and loss characteristics (N 348).

Gender, N (%)
Men 33 (9.5)
Women 315 (90.5)
Age (years), M (SD); range 42.4 (12.2); 18
74
Highest education, N (%)
Primary school 17 (4.9)
Secondary school 107 (30.7)
College/university 219 (62.9)
Deceased is, N (%)
Partner 117 (33.6)
Child 55 (15.8)
Parent 108 (31.0)
Other relative 65 (18.7)
Cause of death is, N (%)
Illness 180 (51.7)
Violent (accident, suicide, and homicide) 36 (10.3)
Unexpected medical cause (e.g., heart attack) 83 (23.9)
Other cause 46 (13.2)
Time from loss in months, M (SD); range 24.9 (27.5); 1
120
 Anxiety, Stress, & Coping 295

presence of symptoms in the last month on five-point scales ranging from ‘‘never’’ to
‘‘always.’’ Items are summed to form an overall PGD symptom severity score. The
English version (Prigerson & Jacobs, 2001) and the 29-item Dutch version (Boelen,
van den Bout, de Keijser, & Hoijtink, 2003) have adequate psychometric properties.
It was deemed important to rule out that associations between mediators and PGD
symptom severity were due to confounds in content between measures. Therefore, in
the present analyses, items that overlapped with ‘‘unrealness’’ (one item representing
disbelief about the loss), negative cognitions (seven items representing negative
cognitions about trust in others, life, the future, the world, safety, trust, and
controllability), and avoidance (one item) were removed from the ICG-R.
Cronbach’s a of this 20-item version was .91.

Relationship questionnaire (RQ)

The RQ is a measure of attachment as applying to close (not necessarily romantic)
relationships in general (Griffin & Bartholomew, 1994a, 1994b). It contains four short
descriptions of attachment prototypes (secure, fearful, preoccupied, and dismissing).
Participants rate each description on seven-point scales ranging from ‘‘not at all like
me’’ to ‘‘very much like me.’’ Scores on the dimensions of attachment anxiety and
attachment avoidance were obtained from these ratings
the former by subtracting
the secure and dismissing scores from the summed fearful and preoccupied scores, the
latter by subtracting the secure and preoccupied scores from the summed fearful and
dismissing scores (Griffin & Bartholomew, 1994b). The RQ has been found to have
adequate validity (Griffin & Bartholomew, 1994a, 1994b). Because the RQ includes
four distinct single item scales, tapping correspondence to four distinct attachment
prototypes, it was not useful to calculate inter-item consistency.

Neuroticism scale from the Eysenck personality questionnaire revised and short scale
version (EPQ-RRS)
The 12-item Neuroticism subscale from the EPQ-RRS (Eysenck & Eysenck, 1991)
was used to assess neuroticism. Respondents indicate their agreement with 12
statements (e.g., ‘‘I am a nervous person’’) using a dichotomous (yes/no) response
format. The questionnaire’s psychometric properties are adequate (Eysenck &
Eysenck, 1991; Sanderman, Arrindell, Ranchor, Eysenck, & Eysenck, 1995). In the
present study, Cronbach’s a was .81.

Experienced unrealness scale

This is a five-item measure constructed by Boelen (2010) to tap a sense of
‘‘unrealness’’ about the loss. Items include ‘‘It feels unreal that [
] is gone forever’’
and ‘‘I still can hardly image that [
] will never be here again’’ and are rated on
eight-point scales ranging from ‘‘not at all true for me’’ to ‘‘completely true for me.’’
A recent study supported the reliability and validity of this scale (e.g., strong
correlations with indices of loss-related disbelief and with PGD symptom severity,
independent from indices of negative thinking and avoidance; Boelen, 2010). In the
present study, its Cronbach’s a was .88.
296 P.A. Boelen and I. Klugkist

Grief cognitions questionnaire (GCQ) subscales self, life, future, and catastrophic
misinterpretations
Negative cognitions were assessed using subscales from the GCQ, a well-validated
38-item measure of negative bereavement-related cognitions (Boelen & Lensvelt-
Mulders, 2005). We administered the subscales Self (six items, e.g., ‘‘Since [
] is dead,
I am of no importance to anybody anymore’’), Life (four items, e.g., ‘‘My life has no
purpose anymore, since [
] died’’), Future (five items, e.g., ‘‘In the future I will never
become really happy anymore’’), and Catastrophic Misinterpretations of grief (four
items, e.g., ‘‘If I would fully realize what the death of [
] means, I would go crazy’’).
Items are rated on six-point scales ranging from ‘‘disagree strongly’’ to ‘‘agree
strongly.’’ Internal consistencies of these four scales in the current sample were .89,
.95, .90, and .90, respectively.

Measure of avoidance strategies

This is a 10-item measure of loss-related avoidance behavior (Boelen, 2010). Items tap
the tendency to keep attention away from the reality of the loss (e.g., ‘‘I avoid the place
where [
] died’’ and ‘‘I try to keep my feelings and thoughts about the loss under
control’’) and can thus be regarded as indices of anxious avoidance behavior as
conceptualized in Boelen et al.’s (2006) cognitive behavioral model of PGD. Participants
rate how often they usually engage in these behaviors on 11-point scales ranging from
0 (never) to 10 (all the time). Previous studies (e.g., Boelen, 2010) have supported the
psychometric properties of the measure. In the present sample, Cronbach’s a was .72.

Depressive avoidance scale

Five items were constructed to assess depressive avoidance behavior (e.g., ‘‘I avoid
doing activities that used to bring me pleasure, because I feel unable to carry out
these activities,’’ ‘‘I develop very few new activities since [
] died, because I am unable
to do so’’). Items are rated on eight-point scales ranging from ‘‘not at all true for
me’’ to ‘‘completely true for me.’’ A recent study (Boelen & van den Bout, 2010)
showed that the Depressive Avoidance Scale has adequate reliability and validity
(e.g., strong correlations with PGD symptoms and other measures of avoidance).
In the present sample, Cronbach’s a was .90.

Statistical analyses
First, we examined the degree to which ICG-R scores varied as a function of gender,
age, education, kinship to the deceased, cause of loss, and time from loss. We did so
because we wished to control for relevant background variables, i.e., those that were
associated with PGD symptom severity, in our mediational analyses. Secondly, we
consecutively examined if the linkage between neuroticism and PGD symptom
severity was mediated by: (1) a sense of ‘‘unrealness’’ (tapped by the Experienced
Unrealness Scale); (2) negative thoughts about self, life, the future, and catastrophic
misinterpretations (GCQ); (3) anxious avoidance behavior (Measure of Avoidance
Strategies) and depressive avoidance behavior (Depressive Avoidance Scale); and (4)
all these seven cognitive behavioral variables together. Thirdly, three similar analyses
 Anxiety, Stress, & Coping 297

were performed with attachment anxiety serving as independent variable (IV).

Fourthly, similar analyses were done with attachment avoidance as IV.
In mediational analyses, it is assumed that the total effect of an IV on a
dependent variable (DV), denoted as weight c, is composed of a direct effect of the IV
on the DV (weight c?) and the indirect effect of the IV on the DV via the mediator M
(i.e., the product of the effect of the IV on the M [a weight] and the effect of the M on
the DV [b weight]). In case of multiple mediators, the total indirect effect (the
summed ab weights) as well as the unique effect of each individual mediator can be
estimated (MacKinnon, Fairchild, & Fritz, 2007; Preacher & Hayes, 2008). Figure 1
represents a graphic representation of the meditational models that we tested.
Mediational analyses were conducted using the bootstrapping procedure for
multiple mediators developed by Preacher and Hayes (2008). Bootstrapping is a non-
parametric resampling method that generates an empirical approximation of the
sampling distribution of a statistic from the data and, as such, avoids the power
problems associated with non-normality in the sampling distribution. The procedure
provides point estimates and 95% confidence intervals for the total and individual
indirect effects. The output provides three types of confidence intervals. In the
present analyses, we used 5000 bootstrap resamples and focused on the bias corrected
and accelerated confidence interval. This is the most stringent test of mediation, with
point estimates of indirect effects being considered significant (at pB.05) if zero is
not included in the interval.

Results
Descriptive statistics
PGD symptom severity was inversely related with time from loss (r
.26, p B.001)
and varied as a function of educational level (F[2, 342] 6.07, pB.01). Post-hoc tests

“Unrealness”

Negative cognitions about self

Negative cognitions about life

Neuroticism Prolonged Grief Disorder

Attachment Anxiety Negative cognitions about symptom severity
Attachment Avoidance future

Catastrophic misinterpretations

Anxious avoidance

Depressive avoidance

Figure 1. Graphic representation of the mediational model with cognitive behavioral

variables mediating the linkage of neuroticism, attachment anxiety, and attachment avoidance,
with Prolonged Grief Disorder symptom severity.
298 P.A. Boelen and I. Klugkist

(Tukey) showed that those who went to primary school had higher scores than those
who went to college or university (p B.05). Moreover, there was an effect of kinship
(F[3, 344]  4.04, pB.01) due to spousally bereaved participants reporting higher
PGD scores than those who lost a parent or someone from the category ‘‘other
relatives’’ (psB.05). PGD symptom severity did not vary as a function of cause of
loss, neither when subdivided into categories of ‘‘illness,’’ ‘‘violent cause,’’ ‘‘un-
expected medical cause,’’ and ‘‘other cause’’ (see Table 1), nor when we compared
those who suffered a violent loss with all other participants (Fs B1). PGD symptom
severity also did not vary as a function of age and gender.1 Thus, in all mediational
analyses described below, we only controlled for time from loss, educational level,
and kinship to the deceased.
The mean score on the ICG-R, calculated as the summation of its 29 items, was
72.0 (SD22.2) and fell within the subclinical range (cf. Boelen et al., 2003). In
total, 76 participants (21.7%) scored above 90 on the ICG-R, which is a cut-off score
for a diagnosis of PGD (Boelen et al., 2003). This also indicated that the current
sample was best regarded as a subclinical sample.

Mediational analyses
Summaries of the mediational analyses with neuroticism, attachment anxiety, and
attachment avoidance as IVs are shown in Tables 2, 3, and 4, respectively. As predicted
by hypothesis a, all total effects of the three personality variables on PGD symptom
severity were statistically significant. Thus, we went on to examine the meditational
role of the cognitive behavioral variables to test hypothesis b. As noted, with each IV,
four models were consecutively tested, in which ‘‘unrealness’’ (Model 1), the four
negative cognitions (Model 2), anxious and depressive avoidance behavior (Model 3),
and all seven cognitive behavioral variables together (Model 4) served as mediating
variables. In all models, we controlled for time since loss, education, and kinship
relationship.
Findings were fairly straightforward. First, ‘‘unrealness’’ was a significant
mediator of the linkages of all three personality variables with PGD symptom
severity (Model 1 in Tables 2
4). Secondly, the total indirect effect of the four
cognitive variables was significant, with negative cognitions about the future, life, and
catastrophic misinterpretations of grief reactions, but not negative cognitions about
the self, emerging as specific mediators (Model 2 in Tables 2
4). Thirdly, the total
indirect effect of anxious avoidance behavior and depressive avoidance behavior was
significant, with both forms of avoidance behavior also emerging as specific
mediators (Model 3 in Tables 2
4). Fourthly, the analyses in which all seven
cognitive behavioral variables were entered together showed that the total indirect
effects of the three personality variables on PGD symptom severity through these
cognitive behavioral variables were significant. Moreover, indices of ‘‘unrealness,’’
negative thoughts about the future and catastrophic misinterpretations, and anxious
and depressive avoidance behavior were all significant independent mediators of the
linkages between neuroticism and PGD symptom severity (Model 4, Table 2),
attachment anxiety and PGD symptom severity (Model 4, Table 3), and attachment
avoidance and PGD symptom severity (Model 4, Table 4).
The analyses in which all cognitive behavioral variables were entered together
showed that the direct effect of neuroticism on PGD symptom severity, but not the
 Anxiety, Stress, & Coping 299
Table 2. Summary of mediational analyses with cognitive behavioral variables mediating the
linkage of neuroticism with Prolonged Grief Disorder severity.

Bias corrected
and
Total Unique accelerated
Total Direct indirect indirect 95% CI
effect effect effect effects
Model Mediating variable(s) (c) (c?) (aa b) (a b) Lower Upper

1 2.482a 2.047a .435a

‘‘Unrealness’’ .435a .193 .690
a a a
2 2.482 .957 1.524
Negative self .113 .337 .095
Negative life .285a .059 .532
Negative future .494a .212 .794
Catastrophic .859a .642 1.121
misinterpretations
3 2.482a .929a 1.552a
Anxious avoidance .817a .608 1.062
Depressive avoidance .735a .540 .976
4 2.482a .721a 1.760a
‘‘Unrealness’’ .231a .099 .381
Anxious avoidance .446a .290 .631
Depressive avoidance .342a .210
Negative self .072 .245 .086
Negative life .152 .027 .361
Negative future .339a .095 .604
Catastrophic .322a .154 .523
misinterpretations
Note: aSignificant point estimate (p B.05).

direct effects of attachment anxiety and attachment avoidance remained significant.

This indicates that the cognitive behavioral variables were partial mediators of the
linkage between neuroticism and PGD symptom severity and complete mediators of
the associations of attachment anxiety and attachment avoidance with PGD
symptom severity.

Magnitude of mediational effects

Partial correlations showed that
when controlling for time since loss, kinship, and
educational level
neuroticism explained 32.4% of the variance in PGD symptom
severity. This was reduced to 7.2% when we controlled for the seven cognitive
behavioral variables. Thus, 25.2% of the 32.4% (i.e., 77.8%) variance in PGD
symptom severity that was explained by neuroticism was accounted for by the
cognitive behavioral variables. Attachment anxiety explained 9.1% of the variance in
PGD symptom severity, 8.7% of which (i.e., 95.6%) was accounted for by the
cognitive behavioral variables. Attachment avoidance explained 5% of the variance in
PGD symptom severity and 4.4% of this (i.e., 88%) was accounted for by the
cognitive behavioral variables.
300 P.A. Boelen and I. Klugkist

Table 3. Summary of mediational analyses with cognitive behavioral variables mediating the
linkage of attachment anxiety with Prolonged Grief Disorder severity.

Bias corrected
and
Total Unique accelerated
Total Direct indirect indirect 95% CI
effect effect effect effects
Model Mediating variable(s) (c) (c?) (aa b) (a b) Lower Upper

1 .955a .716a .240a

‘‘Unrealness’’ .240a .047 .433
a a a
2 .955 .149 .807
Negative self .007 .110 .082
Negative life .113a .020 .245
Negative future .256a .107 .452
Catastrophic .445a .278 .634
misinterpretations
3 .955a .293a .663a
Anxious avoidance .389a .232 .575
Depressive avoidance .273a .098 .439
4 .955a .110 .845a
‘‘Unrealness’’ .107a .021 .208
Anxious avoidance .220a .118 .343
Depressive avoidance .112a .049 .224
Negative self .003 .087 .070
Negative life .061 .014 .170
Negative future .169a .047 .324
Catastrophic .170a .086 .286
misinterpretations
Note: aSignificant point estimate (p B.05).

As another way of estimating effect sizes of the mediational effects, we used the
effect size measure put forth by MacKinnon et al. (2007), calculated as [1
c?/c], that
provides the proportion of the effect of an IV on a DV that is accounted for by the
mediators. Based on this effect size measure (with possible values lying between 0
and 1), the effects sizes for the cognitive behavioral variables mediating the linkages
of neuroticism, attachment anxiety, and attachment avoidance with PGD symptom
severity were .71, .89, and .83, respectively.

Mediational analyses controlling for the shared variance between neuroticism,

attachment anxiety, and attachment avoidance
We were specifically interested in the degree to which the associations of neuroticism,
attachment anxiety, and attachment avoidance with PGD symptom severity were
mediated by the cognitive behavioral variables. However, the personality variables
were correlated; the correlation of neuroticism with attachment anxiety was r.46
(pB.001) and with attachment avoidance was r .18 (p B.01), whereas the
 Anxiety, Stress, & Coping 301

Table 4. Summary of mediational analyses with cognitive behavioral variables mediating the
linkage of attachment avoidance with Prolonged Grief Disorder severity.

Bias corrected
and
Total Unique accelerated
Total Direct indirect indirect 95% CI
effect effect effect effects
Model Mediating variable(s) (c) (c?) (aa b) (a b) Lower Upper

1 .698a .451a .247a

‘‘Unrealness’’ .247a .056 .451
a a a
2 .698 .226 .472
Negative self .001 .050 .047
Negative life .051a .001 .152
Negative future .147a .052 .295
Catastrophic .275a .121 .447
misinterpretations
3 .698a .238a .460a
Anxious avoidance .294a .141 .455
Depressive avoidance .166a .007 .335
4 .698a .121 .577a
‘‘Unrealness’’ .108a .024 .205
Anxious avoidance .163a .080 .269
Depressive avoidance .073a .004 .162
Negative self .000 .037 .040
Negative life .027 .004 .103
Negative future .099a .026 .218
Catastrophic .107a .045 .203
misinterpretations
Note: aSignificant point estimate (p B.05).

correlation between attachment anxiety and attachment avoidance was r .12

(pB.05). Thus, in an additional series of analyses we examined: (1) the degree to
which the total effects of each of the three personality variables on PGD symptom
severity remained significant when controlling for the variance explained by the other
two personality variables, and (2) the degree to which these associations were
mediated by the cognitive behavioral variables. To this end, we repeated all the
analyses described in the section ‘‘mediational analyses,’’ controlling for attachment
anxiety and attachment avoidance in the analyses where neuroticism was the IV,
controlling for neuroticism and attachment avoidance in the analyses where
attachment anxiety was the IV, and controlling for neuroticism and attachment
anxiety in the analyses where attachment avoidance was the IV. In doing so, we
followed recommendations from Preacher and Hayes (2008) who note that in models
with k IVs, one has to estimate k models and in each of these models, one variable is
treated as IV and the remaining k
1 variables are treated as covariates (p. 887).
With respect to neuroticism, outcomes were identical to outcomes reported
earlier. That is, the total effect of neuroticism on PGD severity was significant (point
302 P.A. Boelen and I. Klugkist

estimate .294, p B.001) and in all four models that we tested, the cognitive
behavioral variables emerged as mediators in the same way as reported in Table 2.
Thus, neuroticism remained significantly associated with PGD severity when
controlling for attachment anxiety and attachment avoidance and this association
was mediated by the cognitive behavioral variables when included in separate models
as well as when included in a single model together (as in Table 2).
With respect to attachment anxiety, outcomes changed considerably such that
this variable was no longer associated with PGD symptom severity when controlling
for neuroticism and attachment avoidance (point estimate of total effect.139,
p.39). Moreover, none of the cognitive behavioral variables emerged as mediators.2
Finally, looking at attachment avoidance, in all four models that we tested, the
total effect of this variable on PGD severity remained significant (point
estimate .375, p B.01) when controlling for neuroticism and attachment anxiety.
However, when looking at the meditational effects in each of the four models that we
consecutively examined, some differences emerged, compared to the findings
reported in Table 4: in Model 1 ‘‘unrealness’’ was no longer a significant mediator;
in Model 2 ‘‘negative thinking about life’’ was no longer a significant mediator; in
Model 3 anxious avoidance but not depressive avoidance emerged as unique
mediator; and
in line with these results
in Model 4, negative thoughts about
the future, catastrophic misinterpretations, and anxious avoidance but none of the
other variables were unique mediators. Thus we found that, in comparison with the
findings reported in Table 4, when controlling for neuroticism and attachment
anxiety, attachment avoidance was still associated with PGD severity and this
association was still uniquely mediated by some, but not all of the cognitive
behavioral variables that we examined.

Discussion
In the present study, we tested the hypotheses that (1) neuroticism, attachment
anxiety, and attachment avoidance would be positively associated with PGD
symptom severity and that (2) these associations would be mediated by indices of
insufficient integration of the loss with existing autobiographical knowledge,
negative cognitions, and anxious and depressive avoidance behaviors as defined in
a recent cognitive behavioral model of PGD (Boelen et al., 2006).
In keeping with our first prediction, PGD symptom severity was significantly
associated with all three personality variables. In accord with prior research (e.g.,
Wijngaards-de Meij et al., 2007), neuroticism was a stronger correlate of PGD
symptom severity than attachment anxiety and attachment avoidance. As noted,
prior research findings have been inconsistent about the role of attachment avoidance
in bereavement outcome (Mancini et al., 2010). This may be due, in part, to
differences in DVs that were used as indices of poor bereavement outcome. That is,
studies focusing on PGD symptom severity (Boelen & van den Bout, 2010; van der
Houwen et al., 2010; Wijngaards-de Meij et al., 2007) but not studies examining
other emotional problems following loss (e.g., Field & Sundin, 2001; Wayment &
Vierthaler, 2002) have found attachment avoidance to predict poorer post-loss
functioning. In accord with these former studies, we found PGD symptom severity to
be significantly associated with attachment avoidance, again suggesting that it may
well be involved in symptoms of PGD, but not necessarily other debilitating
 Anxiety, Stress, & Coping 303

outcomes of grief. Notably, we even found that, when controlling for the shared
variance between the three personality variables, attachment avoidance but not
attachment anxiety was significantly associated with PGD severity. This suggests that
attachment avoidance makes a more important contribution to PGD symptomatol-
ogy than does attachment anxiety.
Importantly, findings supported our second prediction in showing that the
linkages between the personality variables and PGD symptom severity were
mediated by cognitive behavioral variables. Specifically, in separate sets of media-
tional analyses these linkages were mediated by: (1) a sense of ‘‘unrealness’’ about the
irreversibility of the loss; (2) negative cognitions about life, the future, and
catastrophic misinterpretations of grief reactions; (3) and anxious and depressive
avoidance behaviors. Moreover, when entered in a single mediational model together,
all cognitive behavioral variables
except negative cognitions about the self and life

emerged as significant unique mediators of the associations of neuroticism,
attachment anxiety, and attachment avoidance with PGD symptom severity. In an
additional round of analyses we examined: (1) the degree to which the three
personality variables were associated with PGD symptom severity when controlling
for the shared variance among these variables, and (2) the degree to which these
unique linkages were mediated by our cognitive behavioral variables. Outcomes of
these analyses showed that neuroticism and attachment avoidance but not attach-
ment anxiety remained significantly associated with PGD severity and that the
impacts of neuroticism and attachment avoidance but not attachment anxiety on
PGD severity was mediated by most of the cognitive behavioral variables that we
assessed. Thus, not only did our findings suggest that attachment anxiety does not
make a unique contribution to PGD symptom severity, but we also found that our
cognitive behavioral variables played no role in mediating this (statistically non-
significant) contribution. How can we explain the finding that attachment anxiety
emerged as a less important correlate of PGD and the cognitive behavioral variables
than attachment avoidance? In part, this is due to attachment anxiety being more
strongly associated with neuroticism than attachment avoidance, reducing the
amount of unique variance in attachment anxiety and its relationship with PGD
and the cognitive behavioral variables. Apart from that, this particular finding
suggests that negative views of other people (that underlie increased attachment
avoidance) are more important in emotional problems following loss than are
negative views of self (that underlie increased attachment anxiety; cf. Griffin &
Bartholomew, 1994b). However, conclusions about the relative importance of
attachment anxiety and attachment avoidance must remain tentative pending
replication of the present findings.
That being said, the present findings do support a key prediction from Boelen
et al.’s (2006) cognitive behavioral model that its three core processes of insufficient
integration, negative cognitions, and avoidance behaviors mediate the linkages
between personality-related vulnerabilities and PGD symptomatology. As such, they
complement earlier studies supporting the mediating role of catastrophic misinter-
pretations (Van der Houwen et al., in press) and anxious and depressive avoidance
behavior (Boelen & van den Bout, 2010). Importantly, the findings suggest that each
of these three processes plays a unique role in explaining how people high
in neuroticism and insecure attachment become more prone to develop PGD
symptoms
supporting the incremental validity of the three processes. Negative
304 P.A. Boelen and I. Klugkist

cognitions about the self and life did not emerge as significant unique mediators.
This may be due, in part, to the fact that the four negative cognitive are strongly
correlated, reducing their unique association with PGD symptom severity. Yet, these
findings can also be interpreted as indicating that negative beliefs about self and life
are not among the most important cognitive behavioral variables in PGD. That is, it
is possible that grief symptoms and the inclination to hold onto what was lost are
more strongly fueled by a pessimistic outlook on the future than by generalized
beliefs about the self and life as being less worthy since the loss. It is also possible that
negative views of self and life are more strongly linked with bereaved-related
depression than with PGD symptoms.
Although the cognitive behavioral variables were complete mediators of the
linkages of attachment anxiety and attachment avoidance with PGD, they only
partially mediated the linkage of neuroticism with PGD symptom severity. This
indicates that neuroticism not only contributes directly to PGD symptoms, but could
also mean that other intermediate variables, apart from the ones that we assessed,
contribute to PGD symptoms in those with elevated levels of neuroticism.
There are several limitations to this study. First and foremost, conclusions must
remain tentative pending replication of the present findings in prospective studies.
Mediation assumes an ordering of variables such that personality vulnerabilities
temporally precede maladaptive cognitive behavioral processes which, in turn,
temporally precede increases in PGD. Although the present findings are in line
with the notion of mediation, our cross-sectional data do not allow drawing
conclusions about temporal precedence. In this context it is noteworthy that,
although no longitudinal studies have yet examined the meditational models put
forth in the present article, there is evidence that negative cognitions and avoidance
behaviors in the early months following a loss temporally precede increases in PGD
severity (Boelen et al., 2006, 2010).
Secondly, this study mostly relied on data from relatively highly educated women
with Internet access, who were bereaved by the loss of their partner due to an illness
and who suffered subclinical levels of distress. Thus, generalization of the findings to
non-assessed groups remains to be determined. Specifically, because only 10% of our
sample was male, conclusions about the degree to which our findings apply to men
should remain tentative pending replication with larger groups of male bereaved
individuals. A third limitation is that all data were based on self-report.
Consequently, shared method variance may have inflated correlations between the
variables. A fourth and related limitation is that we only used self-reported
‘‘unrealness’’ as an index of insufficient integration of the loss within autobiogra-
phical memory. However, ‘‘unrealness’’ is just one manifestation of a process that
mainly operates at an implicit, not directly accessible, level. Hence, future studies
using implicit measures of this process are needed. Finally, this study only focused on
PGD symptoms. It would be interesting for future studies to examine the
mediational role of the cognitive behavioral variables in affecting other emotional
problems following loss including depression and anxiety. It would also be
informative for future studies to examine the degree to which neuroticism and
attachment insecurity have a specific linkage with PGD severity when partialling out
 Anxiety, Stress, & Coping 305

shared variance with depression and anxiety, as well as to test the role of the
cognitive behavioral variables in mediating these specific linkages.
Notwithstanding these limitations, this study contributes to our understanding of
why people with higher levels of neuroticism and those who are insecurely attached
have a greater chance of getting stuck in the process of mourning. If future
prospective studies replicate the present findings, this could have clinical implica-
tions. Among other things, it would suggest that targeting negative cognitions and
avoidance behaviors in bereaved people with higher levels of neuroticism and
insecure attachment could help to prevent the exacerbation of grief among these
people. In addition, if future prospective studies would replicate the finding that
attachment avoidance is more important in PGD than is attachment anxiety, it could
be relevant to develop specific interventions targeting vulnerabilities implicated in
elevated attachment avoidance (e.g., negative views of others, reduced social
orientation). Cognitive behavioral interventions have proven effective in the
treatment of PGD (Boelen, de Keijser, van den Hout, & van den Bout, 2007). It
would be interesting for future research to examine the use of these interventions in
preventing emotional difficulties following loss.

Acknowledgements
This research was supported by an Innovative Research Incentive Veni Grant (451-06-011)
from the Netherlands Organization for Scientific Research (NWO) awarded to the first author.
J.D. Pieterse is thanked for his help with the collection of data for this study.

Notes
1. Notably, there were also no gender differences on the personality variables and seven
cognitive behavioral variables that we assessed. We tested whether or not the results
reported in the ‘‘mediational analyses’’ section changed when the relatively small group of
men (n 33) were removed from the sample. There was only one change: in the analyses
with attachment avoidance as IV, ‘‘depressive avoidance’’ no longer emerged as a unique
mediator. All other outcomes with men being removed from the sample were similar to the
ones reported in Tables 2
4. We did not conduct analyses on the male subsample as this
subsample was too small to perform the present analyses.
2. Although it may appear strange to look at the statistical significance of indirect effects
(a b paths) in the absence of a significant total effect (c path), various authors have argued
that a significant total effect of an IV on a DV is not necessary for mediation to occur (see
Preacher & Hayes, 2008, p. 880).

References
Boelen, P.A. (2010). A sense of ‘‘unrealness’’ about the death of a loved-one: An exploratory
study of its role in emotional complications among bereaved individuals. Applied Cognitive
Psychology, 24, 238
251. doi:10.1002/acp.1557
Boelen, P.A., de Keijser, J., van den Hout, M.A., & van den Bout, J. (2007). Treatment of
complicated grief: A comparison between cognitive behavioral therapy and supportive
counseling. Journal of Consulting and Clinical Psychology, 75, 277
284. doi:10.1037/0022-
006X.75.2.277
306 P.A. Boelen and I. Klugkist

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. doi:10.1007/s10862-005-2409-5
Boelen, P.A., & van den Bout, J. (2010). Anxious and depressive avoidance and symptoms of
prolonged grief, depression, and posttraumatic stress-disorder. Psychologica Belgica, 50,
49
67.
Boelen, P.A., van den Bout, J., de Keijser, J., & Hoijtink, H. (2003). Reliability and validity of
the Dutch version of the inventory of traumatic grief. Death Studies, 27, 227
247.
doi:10.1080/07481180302889
Boelen, P.A., van den Bout, J., & van den Hout, M.A. (2006). Negative cognitions and
avoidance in emotional problems after bereavement: A prospective study. Behaviour
Research and Therapy, 44, 1657
1672. doi:10.1016/j.brat.2005.12.006
Boelen, P.A., van den Bout, J., & van den Hout, M.A. (2010). A prospective examination of
catastrophic misinterpretations and experiential avoidance in emotional distress following
loss. Journal of Nervous and Mental Disease, 198, 252
257. doi:10.1097/NMD.0b013e3181d
619e4
Boelen, P.A., van den Hout, M.A., & van den Bout, J. (2006). A cognitive behavioral
conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13, 109

128. doi:10.1111/j.1468-2850.2006.00013.x
Currier, J.M., Holland, J.M., & Neimeyer, R.A. (2006). Sense-making, grief, and the
experience of violent loss: Toward a meditational model. Death Studies, 30, 403
428.
doi:10.1080/07481180600614351
Davis, C.G., Nolen-Hoeksema, S., & Larson, J. (1998). Making sense of loss and growing from
the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75,
561
574.
Eysenck, H.J., & Eysenck, S.B.G. (1991). Manual of the Eysenck Personality Scales (EPS
adult). London: Hodder & Stoughton.
Field, N.P., & Sundin, E.C. (2001). Attachment style in adjustment of conjugal bereavement.
Journal of Social and Personal Relationships, 18, 347
361. doi:10.1177/0265407501183003
Griffin, D., & Bartholomew, K. (1994a). The metaphysics of measurement: The case of adult
attachment. In K. Bartholomew & D. Perlman (Eds.), Attachment processes in adulthood:
Advances in personal relationships (Vol . 5, pp. 17
52). London: Jessica Kingsley.
Griffin, D., & Bartholomew, K. (1994b). Models of the self and other: Fundamental
dimensions underlying measures of adult attachment. Journal of Personality and Social
Psychology, 67, 430
445. doi:10.1037/0022-3514.67.3.430
MacKinnon, D.P., Fairchild, A.J., & Fritz, M.S. (2007). Mediation analysis. Annual Review
Psychology, 58, 593
614. doi:10.1146/annurev.psych.58.110405.085542
Mancini, A.D., Robinaugh, D., Shear, M.K., & Bonanno, G.A. (2010). Does attachment
avoidance help people cope with loss? The moderating effects of relationship quality.
Journal of Clinical Psychology, 65, 1127
1136. doi:10.1002/jclp.20601
Preacher, K.J., & Hayes, A.F. (2008). Asymptotic and resampling strategies for assessing and
comparing indirect effects in multiple mediator models. Behavior Research Methods, 40,
879
891. doi:10.3758/BRM.40.3.879
Prigerson, H.G., Horowitz, M.J., Jacobs, S.C., Parkes, C.M., Aslan, M., Goodkin, K., . . .
Maciejewski, P.K. (2009). Prolonged grief disorder: Psychometric validation of criteria
proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121. doi:10.1371/jour-
nal.pmed.1000121
Prigerson, H.G., & Jacobs, S.C. (2001). Traumatic grief as a distinct disorder: A rationale,
consensus criteria, and a preliminary empirical test. In M.S. Stroebe, R.O. Hansson, W.
Stroebe, & H.A.W. Schut (Eds.), Handbook of bereavement research. Consequences, coping,
and care (pp. 613
647). Washington, DC: APA.
Sanderman, R., Arrindell, W.A., Ranchor, A., Eysenck, H.J., & Eysenck, S.B.G. (1995). Het
meten van persoonlijkheidskenmerken met de Eysenck personality questionnaire: een
handleiding [Measuring personality characteristics with the Eysenck personality question-
naire: A manual]. Groningen: Noordelijk Centrum voor Gezondheidsvraagstukken.
 Anxiety, Stress, & Coping 307

Van der Houwen, K., Stroebe, M., Schut, H., Stroebe, W., & Van den Bout, J. (in press).
Mediating processes in bereavement: The role of rumination, threatening misinterpreta-
tions, and deliberate grief avoidance. Social Science and Medicine.
Van der Houwen, K., Stroebe, M., Stroebe, W., Schut, H., van den Bout, J., & Wijngaards-de
Meij, L. (2010). Risk factors for bereavement outcome: A multivariate approach. Death
Studies, 34, 195
220. doi:10.1080/07481180903559196
Watson, D., & Clark, L.A. (1984). Negative affectivity: The disposition to experience aversive
emotional states. Psychological Bulletin, 96, 465
490.
Wayment, H.A., & Vierthaler, J. (2002). Attachment style and bereavement reactions. Journal
of Loss & Trauma, 7, 129
149. doi:10.1080/153250202753472291
Wijngaards-de Meij, L., Stroebe, M., Schut, H., Stroebe, W., van den Bout, J., van der
Heijden, P., & Dijkstra, I.C. (2007). Neuroticism and attachment insecurity as predictors of
bereavement outcome. Journal of Research in Personality, 41, 498
505. doi:10.1016/
j.jrp.2006.06.001