"It is worth hanging in there" - Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany.

BACKGROUND: A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists' motivation and facilities to accept refugee clients. A model project called "Fearless" trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists' motivation and engagement in future treatment of refugees. METHODS: From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists' experience of challenges, enrichments, and motivation throughout the therapy. Therapists' responses were analyzed using content structuring qualitative content analysis. RESULTS: Three major challenges modulated therapists' future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients' motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10). CONCLUSION: Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists' motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists' motivation to work with refugee clients.

The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic.

Background: Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees' mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration - yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany. Methods: The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: "Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?" Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration. Results: Two regression analyses determined significant predictors of (1) emotional distress (adjusted R 2 = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R 2 = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = -0.28, p = 0.002). Conclusion: In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees.

BACKGROUND: Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy. METHODS: To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points. RESULTS: On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms. CONCLUSIONS: Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET. TRIAL REGISTRATION: NCT02852616.

Relations between traumatic stress, dimensions of impulsivity, and reactive and appetitive aggression in individuals with refugee status.

OBJECTIVE: Traumatic stressors and other forms of adversities, especially when experienced during childhood, shape aggressive behavior. Effects of differential dimensions of impulsivity on the relationship between psychological trauma, reactive aggression (defensive survival response to threat), and appetitive aggression (the pleasure of attacking and fighting) have not yet been assessed. METHOD: Using structural equation modeling, we sought to uncover precursors of reactive and appetitive aggression investigating a sample of 94 adult individuals with refugee status. We were interested in direct effects of childhood maltreatment and posttraumatic stress disorder (PTSD) and indirect effects via impulsivity dimensions. RESULTS: For reactive aggression there was a direct link between childhood maltreatment and (a) PTSD symptoms and (b) marginal sensation seeking. Childhood maltreatment and sensation seeking best predicted appetitive aggression. There was no evidence for indirect effects of impulsivity. CONCLUSIONS: Fear-driven response to perceived threat based on inadequate cognitive appraisal is assumed to cause pathological reactive aggression, whereas excessive appetitive aggression can be explained by repeated experiences of thrill and excitement during violent acts. Prevention of early traumatic stress and adversities seems key to breaking the cycle of violence. (PsycINFO Database Record

Are experiences of family and of organized violence predictors of aggression and violent behavior? A study with unaccompanied refugee minors.

BACKGROUND: There is strong support for familial abuse as a risk factor for later delinquency and violent offending, whereas empirical evidence about the contribution of experienced organized violence to the cycle of violence is less clear. Nevertheless not all abused children do become violent offenders. This raises the question of which factors influence these children's risk of future aggressive behavior. Recent evidence suggests that the trait of appetitive aggression plays an important role in the prediction of aggressive behavior. OBJECTIVE: The focus of the study is to investigate whether exposures to 1) organized; and 2) family violence equally contribute to aggressive behavior and how this is related to a trait of appetitive aggression. Furthermore it is of interest to uncover how the severity of posttraumatic stress disorder (PTSD) symptoms modulates associations between violent experiences and aggression. METHOD: To answer these questions, we investigated unaccompanied refugee minors who had been exposed to varying levels of both violence types. Using structured interviews, experiences of organized and familial violence, self-committed aggressive acts, the trait of appetitive aggression, and PTSD symptoms were assessed in 49 volunteers. RESULTS: A sequential regression analysis revealed that the trait of appetitive aggression and experienced family violence were independent and significant predictors of self-committed aggressive acts, altogether accounting for 70% of the variance. Exposure to organized violence, however, was not significantly associated with aggressive acts or appetitive aggression. PTSD symptom severity was not correlated with measures of aggression but with the exposure to familial and organized violence. CONCLUSIONS: Results suggest that in addition to the impact of family violence, an elevated trait of appetitive aggression plays a crucial role in aggressive behavior and should be considered in psychotherapeutic treatment.

Tuning the tinnitus percept by modification of synchronous brain activity.

PURPOSE: Tinnitus, the perception of sound without the presence of a physical stimulus, provides the opportunity to study neural codes of percepts without simultaneous processing of stimuli. Previously, we have found that tinnitus is associated with enhanced delta- and reduced tau-power in temporal brain regions. By operantly modifying corresponding aspects of spontaneous EEG activity, the aim of the present study was to corroborate the assumption that tinnitus should be reduced if patterns of ongoing synchronous brain activity are normalised. METHODS: In response to different variants of neurofeedback, a total of twenty-one patients produced significant changes in EEG frequency bands. RESULTS: Simultaneous alteration of both frequency bands was strongly related to changes in tinnitus intensity matched before and after the intervention (r=-0.74). In those two patients with the greatest modulatory success, the tinnitus sensation resided completely in response to the treatment. Comparing the neurofeedback-treated patients with a group of patients trained with a frequency discrimination task (n=27), the tinnitus relief in the neurofeedback group was significantly stronger. CONCLUSIONS: This study supports the notion that altered patterns of intrinsic ongoing brain activity lead to phantom percepts and offer new routes to the treatment of tinnitus.

The relevance of spontaneous activity for the coding of the tinnitus sensation.

In this chapter we will present support for the hypothesis that synchronous neuronal activity of cell assemblies within the auditory cortex could be the underlying neural code of tinnitus. Such synchronous activity is reflected in the ongoing oscillatory activation pattern that can be recorded non-invasively using MEG and EEG techniques. We conclude that such an oscillatory model of tinnitus can explain many different observations regarding tinnitus.

Neurofeedback for treating tinnitus.

Many individuals with tinnitus have abnormal oscillatory brain activity. Led by this finding, we have developed a way to normalize such pathological activity by neurofeedback techniques (Weisz et al. (2005). PLoS Med., 2: e153). This is achieved mainly through enhancement of tau activity, i.e., oscillatory activity produced in perisylvian regions within the alpha frequency range (8-12 Hz) and concomitant reduction in delta power range (0.5-4 Hz). This activity is recorded from electrodes placed on the frontal scalp. We have found that modification of the tau-to-delta ratio significantly reduces tinnitus intensity. Participants who successfully modified their oscillatory pattern profited from the treatment to the extent that the tinnitus sensation became completely abolished. Overall, this neurofeedback training was significantly superiorin reducing tinnitus-related distress than frequency discrimination training.

The neural code of auditory phantom perception.

Tinnitus is defined by an auditory perception in the absence of an external source of sound. This condition provides the distinctive possibility of extracting neural coding of perceptual representation. Previously, we had established that tinnitus is characterized by enhanced magnetic slow-wave activity (approximately 4 Hz) in perisylvian or putatively auditory regions. Because of works linking high-frequency oscillations to conscious sensory perception and positive symptoms in a variety of disorders, we examined gamma band activity during brief periods of marked enhancement of slow-wave activity. These periods were extracted from 5 min of resting spontaneous magnetoencephalography activity in 26 tinnitus and 21 control subjects. Results revealed the following, particularly within a frequency range of 50-60 Hz: (1) Both groups showed significant increases in gamma band activity after onset of slow waves. (2) Gamma is more prominent in tinnitus subjects than in controls. (3) Activity at approximately 55 Hz determines the laterality of the tinnitus perception. Based on present and previous results, we have concluded that cochlear damage, or similar types of deafferentation from peripheral input, triggers reorganization in the central auditory system. This produces permanent alterations in the ongoing oscillatory dynamics at the higher layers of the auditory hierarchical stream. The change results in enhanced slow-wave activity reflecting altered corticothalamic and corticolimbic interplay. Such enhancement facilitates and sustains gamma activity as a neural code of phantom perception, in this case auditory.

Tracking short-term auditory cortical plasticity during classical conditioning using frequency-tagged stimuli.

Animal studies indicate that short-term plasticity during classical conditioning is a fast process. The temporal details of this process in humans are unknown. We employed amplitude-modulated tones in order to elicit the steady-state field (SSF). Conditioned stimulus (CS+) and CS- had a common low carrier frequency, however, differed in their high-frequency component. Low and high frequencies within one tone were modulated at 29 and 45 Hz, respectively. Mean fast Fourier transformation analysis of each single trial allowed extraction of the cortical response to these modulation frequencies, allowing to track cortical responses trial by trial. Mutilation pictures were used as unconditioned stimulus. Furthermore, heart rate and contingency awareness were assessed. Our main findings are the following: 1) A rapid (within 5 trials) enhancement of the amplitude of the high frequencies in contrast to the low frequency, while the high frequencies differentiated later (toward end of acquisition). This partially replicates rapid plasticity as shown before in animals. 2) Those participants who were less aware of the stimulus contingencies showed a relative heart rate acceleration and greater SSF increase to the CS+. This could possibly imply a stronger early amygdala activation in these participants, which then mediates the development of conditioning-related reorganization in auditory cortical areas.

High-frequency tinnitus without hearing loss does not mean absence of deafferentation.

A broad consensus within the neuroscience of tinnitus holds that this audiologic condition is triggered by central deafferentation, mostly due to cochlear damage. The absence of audiometrically detectable hearing loss however poses a challenge to this rather generalizing assumption. The aim of this study was therefore to scrutinize cochlear functioning in a sample of tinnitus subjects audiometrically matched to a normal hearing control group. Two tests were applied: the Threshold Equalizing Noise (TEN) test and a pitch scaling task. To perform well on both tasks relatively normal functioning of inner hair cells is a requirement. In the TEN test the tinnitus group revealed a circumscribed increment of thresholds partially overlapping with the tinnitus spectrum. Abnormal slopes were observed in the pitch scaling task which indicated that tinnitus subjects, when presented with a high-frequency stimulus, relied heavily on input derived from lower-frequency inner hair cells (off-frequency listening). In total both results argue for the presence of a deafferentation also in tinnitus subjects with audiometrically normal thresholds and therefore favour the deafferentation assumption posed by most neuroscientific theories.

Neuromagnetic indicators of auditory cortical reorganization of tinnitus.

Animal studies show that following damage to inner-ear receptors, central representations of intact lesion-edge (LE) frequencies become enlarged (map reorganization). One theory of tinnitus holds that this process could be related to the tinnitus sensation. To test this hypothesis, neuromagnetic evoked fields of tinnitus participants with high-frequency hearing loss and normal hearing controls were measured, while subjects listened to monaurally presented LE or control (CO; an octave below LE) tones. The predictions made based on the map reorganization hypothesis of tinnitus were that neuronal responses to LE frequencies would be enhanced, and that source localizations for LE would be distorted. N1m equivalent dipole moments for LE were not supranormal in the tinnitus group, whereas responses to CO of tinnitus patients compared to controls were enlarged in the right hemisphere. This effect was positively associated with tinnitus-related distress. Abnormal source locations were found for generators activated by LE tones in the right hemisphere of the tinnitus group. This right-hemispheric map distortion was not associated with subjective variables of tinnitus. A positive correlation with tinnitus distress was found for the left hemisphere with more anterior sources being associated with enhanced distress. However, this result was independent of the frequency of the stimulus. Overall, the present study suggests that mechanisms of map reorganization, although present in the data, cannot satisfactorily explain the emergence of tinnitus and that differential hemispheric involvement must be considered.

Tinnitus perception and distress is related to abnormal spontaneous brain activity as measured by magnetoencephalography.

BACKGROUND: The neurophysiological mechanisms underlying tinnitus perception are not well understood. Surprisingly, there have been no group studies comparing abnormalities in ongoing, spontaneous neuronal activity in individuals with and without tinnitus perception. METHODS AND FINDINGS: Here, we show that the spontaneous neuronal activity of a group of individuals with tinnitus (n = 17) is characterised by a marked reduction in alpha (8-12 Hz) power together with an enhancement in delta (1.5-4 Hz) as compared to a normal hearing control group (n = 16). This pattern was especially pronounced for temporal regions. Moreover, correlations with tinnitus-related distress revealed strong associations with this abnormal spontaneous activity pattern, particularly in right temporal and left frontal areas. Overall, effects were stronger for the alpha than for the delta frequency band. A data stream of 5 min, recorded with a whole-head neuromagnetometer under a resting condition, was sufficient to extract the marked differences. CONCLUSIONS: Despite some limitations, there are arguments that the regional pattern of abnormal spontaneous activity we found could reflect a tinnitus-related cortical network. This finding, which suggests that a neurofeedback approach could reduce the adverse effects of this disturbing condition, could have important implications for the treatment of tinnitus.