title: Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees.
abstract: BACKGROUND
  Definitions of complicated grief vary across diagnostic systems, being represented as persistent complex bereavement (PCB) in DSM-5 and prolonged grief disorder (PGD) in the proposed revision of the ICD system. A past study in a high-income country has identified a six-factor structure for complicated grief, but there are no data testing this or any other model across cultures. The present study reports findings from a survey amongst West Papuan refugees (n = 230, response rate = 92 %) residing in Port Moresby, Papua New Guinea.
  
  
  METHODS
  We applied culturally adapted measures of conflict-related traumatic event (TEs) (drawing specifically on domains of conflict and loss), symptoms of complicated grief adapted and modified to the culture, and a multidimensional psychosocial index of the broader effects of conflict and displacement.
  
  
  RESULTS
  Confirmatory factor analysis yielded a single higher order construct of complicated grief comprising six factors of yearning/preoccupation; shock/disbelief; anger/negative appraisal; behavioural change; estrangement from others/impairment; and a novel dimension of confusion/diminished identity. In contrast, our analysis failed to support DSM or ICD models of PCB or PGD. A Multiple Indicators Multiple Causes (MIMIC) model revealed that traumatic loss and the sense of injustice each were associated with the unitary construct of complicated grief and its subdomains of yearning/preoccupation; shock/disbelief; anger/negative appraisal (exclusive to injustice); and estrangement from others/social impairment (exclusive to TE domain of conflict and loss).
  
  
  CONCLUSIONS
  Conflict and loss associated with feelings of injustice may be especially pathogenic in generating the anger/negative appraisal component of complicated grief amongst refugees.
authors.affiliation: Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia. alvin.tay@unsw.edu.au.|Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia. alvin.tay@unsw.edu.au.
authors.forename: Alvin Kuowei
authors.identifier: http://orcid.org/0000-0002-9330-3929
authors.initials: AK
authors.lastname: Tay
authors.affiliation: Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.|Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.|The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Rees
authors.affiliation: Simpson Centre for Health Services Research, University of New South Wales, Sydney, Australia.|The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia.
authors.forename: Jack
authors.initials: J
authors.lastname: Chen
authors.affiliation: Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.|Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.
authors.forename: Moses
authors.initials: M
authors.lastname: Kareth
authors.affiliation: Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.|Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.|The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia.
authors.forename: Derrick
authors.initials: D
authors.lastname: Silove
mesh_terms: D000328:Adult; D003466:Cultural Characteristics; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005163:Factor Analysis, Statistical; D005260:Female; D006117:Grief; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D008875:Middle Aged; D010219:Papua New Guinea; D012036:Refugees / Q000523:psychology* / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D013313:Stress Disorders, Post-Traumatic / Q000523:psychology*; D011795:Surveys and Questionnaires; D014857:Warfare
keywords: ADAPT; Complicated grief; Persistent complex bereavement; Prolonged grief; Refugee