In the validation study of the SCI-CG conducted among treatment-seeking grievers who lost a loved one at least 6 months prior, yearning and longing for the deceased was found to be the most frequently endorsed symptom (88% of the sample), which is in line with its inclusion in all proposed diagnostic criteria sets. However, interestingly, the second most frequently endorsed symptom was intense feelings sorrow and emotional pain (endorsed by 86.1% of the sample). In fact, early conceptualizations of grief had emphasized the central role of emotional pain [13], and consistent with this, a recent network analysis study identified it as the most central symptom of PCBD [14]. It was thus surprising that it was not included as a core symptom of CG nor PGD.

Since these two reactions are core elements of CG/PGD/PCBD, their persistence may contribute to obstructing the evolution from acute grief towards integrated grief. Specifically, yearning for the deceased and emotional pain can be reinforced through two feedback loops (see Fig. 5.1) [14]: (1) yearning for the deceased may trigger approach behaviors (e.g., spending time looking at pictures), that subsequently trigger thoughts related to the deceased, that in turn reinforce yearning; while (2) loss-related emotional pain (pain when thinking about the death of the loved one) may trigger avoidance behaviors, that in turn produce the opposite effect [15], increasing thoughts related to the deceased. Importantly, these two feedback loops could also reinforce each other, thus both contributing to maintaining the whole syndrome of CG/PGD/PCBD.