Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows

Abstract

Objective: Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology. Methods: Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory–based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention. Results: No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age. Conclusions: While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.

ACKNOWLEDGMENTS

We appreciate all study participants for graciously sharing their time, knowledge, and personal recounts on sensitive and emotional issues presented in this paper. We also thank WHR staff and volunteers from various districts for their hospitality and continual support in assisting with data collection.

Additional information

Notes on contributors

Jane Kim

Jane Kim, MSPH, is affiliated with the Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore.

Wietse A. Tol

Wietse A. Tol, PhD, is affiliated with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore.

Abina Shrestha

Abina Shrestha, MS, Hari Maya Kafle, MA, Rajin Rayamajhi, MA, and Lily Thapa, MA, are affiliated with the Women for Human Rights, Single Women Group, Kathmandu, Nepal.

Hari Maya Kafle

Abina Shrestha, MS, Hari Maya Kafle, MA, Rajin Rayamajhi, MA, and Lily Thapa, MA, are affiliated with the Women for Human Rights, Single Women Group, Kathmandu, Nepal.

Rajin Rayamajhi

Abina Shrestha, MS, Hari Maya Kafle, MA, Rajin Rayamajhi, MA, and Lily Thapa, MA, are affiliated with the Women for Human Rights, Single Women Group, Kathmandu, Nepal.

Nagendra P. Luitel

Nagendra P. Luitel, MA, is affiliated with the Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.

Lily Thapa

Abina Shrestha, MS, Hari Maya Kafle, MA, Rajin Rayamajhi, MA, and Lily Thapa, MA, are affiliated with the Women for Human Rights, Single Women Group, Kathmandu, Nepal.

Pamela J. Surkan

Pamela J. Surkan, ScD, PhD, is affiliated with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore.