Breaking The Substance Abuse Grief Stigma
The recent introduction of prolonged grief disorder (PGD) as a diagnostic category may cause negative social reactions (i.e. public stigma). Vignette experiments demonstrate that persons with both PGD symptoms and a PGD diagnosis elicit more public stigma than persons who experience integrated grief. However, the strength of the influence of the diagnosis itself remains unclear: We aimed to clarify if the diagnostic label PGD produces additional public stigma beyond PGD symptoms. We further compared whether public stigma varies between the label PGD and the label major depressive episode (MDE) (when PGD symptoms are present) and if gender of the bereaved person influences public stigma or moderates the aforementioned effects. Eight-hundred fifty-two participants (77% female; Mage = 32.6 years, SD = 13.3) were randomly assigned to read online one of eight vignettes describing either a bereaved male or female, with PGD symptoms and PGD diagnosis; PGD symptoms and MDE diagnosis; PGD symptoms and no diagnosis, or no PGD symptoms and no diagnosis (i.e., integrated grief). Following the vignettes, participants indicated which negative characteristics they ascribed to the person, their emotional reactions, and preferred social distance from the person. People with PGD symptoms and PGD (or MDE) diagnosis were attributed more negative characteristics, and elicited more negative emotions and a stronger desire for social distance than people with integrated grief. However, public stigma did not differ for people with both PGD symptoms and diagnosis compared to people only experiencing PGD symptoms. Gender of the bereaved only had an influence on desired social distance, which was larger towards men. Helping severely distressed bereaved people (regardless of diagnostic status) cope with negative social reactions may help them adapt to bereavement. Results demonstrate that the experience of severe grief reactions, yet not a diagnostic label per se, causes public stigma.
Breaking The Substance Abuse Grief Stigma
Classifying mental health phenomena such as prolonged grief reactions as disorders has important consequences on both the individual and the societal level. On the one hand, recognition of a phenomenon as disorder can facilitate provision and access to effective treatments . On the other hand, it carries the risk of stigmatization .
With regard to PGD, we consider stigma especially relevant. This is because stigma may lead to a decline in social support, which is considered an important factor in coping with bereavement . Regardless of diagnostic status, grief severity itself seems to be an important factor contributing to stigmatizing reactions towards bereaved persons: Johnson et al.  demonstrated that individuals with prolonged grief reactions who had not received any diagnosis experienced and expected more negative responses from their social environment (i.e. more perceived stigma). Relatedly, Kahler et al.  found that higher grief severity in a vignette (no diagnosis mentioned) was associated with greater reported social discomfort towards the bereaved person described in the vignette (i.e., more public stigma).
Apart from grief severity, diagnostic labeling appears an important factor in stigmatization. One argument against the introduction of PGD as a diagnosis is the fear, voiced by practitioners, researchers, and lay people alike, that the introduction of PGD as diagnostic category may cause stigma and could thereby additionally burden affected people [13, 22, 23]. The stigma studies mentioned above do not answer this important question: What (additional) harm does the diagnostic label PGD do in the presence of severe grief reactions?
Third, we were interested in the effect of gender of the bereaved on stigmatization of bereaved people with or without severe mental health problems after loss. A meta-analysis of Parcesepe and Cabassa  across different mental health conditions reported no influence of gender of the person suffering from a mental illness on public stigma. Evidence from more grief-specific research is inconclusive: One vignette study that did not provide any information on grief severity of the bereaved person, demonstrated that a male person elicited a stronger desire for social distance than a female person when the type of death was a stroke . Similar, Kubitz, Thornton and Robertson  found that when the vignette described a sudden death, participants were more willing to interact with a female than a male bereaved person. In this study, however, the effect was only evident for vignettes describing high grief intensity (vs. low grief intensity).
Targeting primarily attitudes towards non-pathological grief, Versalle and McDowell  found no differences in sympathy for male vs. female grievers. Logan, Thornton, Kane and Breen  also reported no effect of gender on likeability of the bereaved, blame attributions and behavioral intentions. A review by Logan et al.  reported mixed results with some studies showing that bereaved women were offered more social support and other studies demonstrating no such effect. Studies of gender effects on stigma in non-normative grief patterns (e.g., PGD) are lacking.
To summarize, our study used a vignette experiment to cross-validate the findings of Eisma  and Eisma et al.  on public stigma for PGD, and expand on these findings by examining the effects of diagnostic labeling and gender of the bereaved. We had the following hypotheses: (1) A person with PGD symptoms and a mental health diagnosis (PGD or MDE) evokes more public stigma than a person with integrated grief (i.e., no PGD symptoms and no diagnosis). (2) A person with PGD symptoms and a mental health diagnosis (PGD or MDE) elicits more public stigma than a person with only PGD symptoms. We further explored the following questions: (3) When PGD symptoms are present, does public stigma differ between persons with PGD diagnosis and MDE diagnosis? (4) Does the gender of the bereaved influence (or (5) modulate group differences in) public stigma? Drawing on former research in non-pathological grief, we suspected a higher desire for social distance towards bereaved men than women. This effect might only be present in response to vignettes presenting integrated grief.
Negative attributions were assessed by items previously used by Eisma  and Eisma et al. , which were selected based on research of public stigma in MDE , a German pilot study on stigma following bereavement, and research findings on personality characteristics that are commonly associated with grief severity [40, 41]. A back-translation method  was used to establish a German version. Respondents indicate on a 4-point Likert scale from completely disagree (1) to completely agree (4) to what extent they agree with the statement that the person described in the vignette is competent, warm, emotionally stable, dependent and sensitive.
Contrast 1 (PGD symptoms and PGD diagnosis vs. no symptoms and no diagnosis) and Contrast 2 (PGD symptoms and MDE diagnosis vs. no symptoms and no diagnosis) aimed to answer hypothesis 1: A person with PGD symptoms and a mental health diagnosis elicits more public stigma than a person with integrated grief. Group differences were significant for all dependent variables. These results indicate higher stigmatizing responses for vignettes describing either diagnosis (PGD and MDE) in combination with PGD symptoms when compared to integrated grief.
To sum up, while PGD symptoms paired with a PGD (or MDE) diagnosis were consistently associated with more public stigma compared to integrated grief, we found no robust additional effect of diagnostic labeling on public stigma when PGD symptoms were present. We also found no difference in public stigma between PGD symptoms and PGD diagnosis vs. PGD symptoms and MDE diagnosis. Gender of the bereaved person affected only preferred social distance. This effect was small.
Our last hypotheses 4) and 5) concerned the influence of the gender of the bereaved person, i.e. whether public stigma differs between vignettes that describe a male vs. female bereaved person. In our study, we found no significant differences for gender for any attributes or emotional reactions. This negative finding is in line with similar studies from the field of non-pathological grief [33, 35]. Our study had sufficient statistical power to detect respective effects and our results thus corroborate the finding that these indicators of stigma do not vary with the gender of the bereaved person and extend the investigation of gender effects on these stigma indicators to pathological grief.
For the behavioral component of public stigma, on the other hand, we found that preferred social distance was relatively higher towards bereaved men than women. When interpreting this finding, however, its small absolute magnitude (ɳp2 = .01) and the characteristics of our sample need to be taken into account. In our sample, female participants formed the majority. It is possible that female participants felt more sympathy for female grievers and indicated a lower preferred social distance towards them because of social proximity. Additionally, previous research has also demonstrated that gender effects on preferred social distance towards a bereaved person may be qualified by both: the grief severity of the bereaved person  and the cause of death . Concerning grief severity, Kubitz et al.  found that in the case of non-pathological grief, participants were less willing to interact with men than women only if grief severity was high. In contrast, in our study the effect of gender of the bereaved on preferred social distance was independent of the presence or absence of PGD symptoms and label. Differences both in the respective operationalization of social distance and in the age of the bereaved person described in the vignette (Kubitz et al. : early adulthood) may contribute to these contrasting findings. Concerning the role of cause of death, Penman et al.  reported that a vignette describing a male bereaved person elicited a stronger desire for social distance only when the death of the partner was caused by a sudden, natural cause; i.e. stroke. It could be that our findings align with this study, because stroke was uniformly the type of death in our vignettes.