Exploring expectations of neurofeedback treatment among trauma-affected refugees.

BACKGROUND: The use of Neurofeedback (NF) to assist individuals in learning to regulate their brain wave activity has shown promising results in reducing symptoms of posttraumatic stress disorder (PSTD). However, few studies have focused on the patients' understandings of NF and even fewer explore the perspective of refugees. PURPOSE: To evaluate NF treatment for trauma-affected refugees by focusing on their expectations and understanding of NF. METHODS: This qualitative study was a part of a mixed method study carried out at an outpatient mental health centre in Denmark, offering 34 trauma-affected refugees 12 sessions of NF. In this qualitative study, a subsample of seven participants was interviewed. Using in-depth semi-structured interviews, the participants' thoughts and expectations prior to participating in NF treatment were examined. The analysis was carried out in four steps, using a hermeneutic and phenomenological approach. RESULTS: The analysis resulted in two themes: (1) Rationale and working mechanisms of NF and (2) Motivators for participating in the study. CONCLUSION: The findings show that NF treatment for trauma affected refugees was challenged by difficulties in communicating the message about the NF equipment capabilities as well as the expected treatment outcome. These challenges included e.g. health professionals' ability to explain and the participants' cultural frame of reference. This is consistent with previous research, showing that compared to the native population, the dissemination of health information to refugees is more difficult and comprehensive. Further studies on how to ensure mutual understanding of the content of NF and expected treatment outcome are needed. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05055037. Retrospectively registered on the 06/07-2021.

The structure of ICD-11 post traumatic stress disorder in a clinical sample of refugees based on the International Trauma Interview.

BACKGROUND: The ICD-11 proposes fundamental changes to the PTSD diagnostic criteria, prompting thorough validation. While this is ideally carried out based on diagnostic interviews, most-and in the case of transcultural psychiatry all-studies have relied on self-reported measures. In this study, we used the International Trauma Interview (ITI) to assess the factor structure of ICD-11 PTSD symptoms in a sample of trauma-affected refugees. METHOD: The ITI was administered with a sample of refugees (n = 198), originating mainly from the Greater Middle East. The symptom ratings were subjected to a confirmatory factor analysis (CFA), comparing the ICD-11 concordant three-factor model with alternative two- and one-factor models. RESULTS: The overall fit was adequate for both the two- and three-factor models, but favored the two-factor model. Results for both models indicated local misspecifications and that item 5, hypervigilance, displayed a suboptimal loading. CONCLUSION: The results generally support the use of the ITI in a severely trauma-affected refugee population, albeit with particular attention needed in the administration of item 5. The superior fit of a two-factor model warrants further testing across populations.

Protocol for the development and testing of the schiZotypy Autism Questionnaire (ZAQ) in adults: a new screening tool to discriminate autism spectrum disorder from schizotypal disorder.

BACKGROUND: Autism spectrum disorder (ASD) and schizotypal disorder (SD) both have a heterogenous presentation, with significant overlaps in symptoms and behaviour. Due to elevated recognition and knowledge of ASD worldwide, there is a growing rate of referrals from primary health professionals to specialised units. At all levels of assessment, the differential diagnostic considerations between ASD and SD exert major challenges for clinicians. Although several validated screening questionnaires exist for ASD and SD, none have differential diagnostic properties. Accordingly, in this study, we aim to develop a new screening questionnaire, the schiZotypy Autism Questionnaire (ZAQ), which provides a combined screening for both conditions, while also indicating the relative likelihood of each. METHODS: We aim to test 200 autistic patients and 100 schizotypy patients recruited from specialised psychiatric clinics and 200 controls from the general population (Phase 1). The results from ZAQ will be compared to the clinical diagnoses from interdisciplinary teams at specialised psychiatric clinics. After this initial testing phase, the ZAQ will be validated in an independent sample (Phase 2). CONCLUSIONS: The aim of the study is to investigate the discriminative properties (ASD vs. SD), diagnostic accuracy, and validity of the schiZotypy Autism Questionnaire (ZAQ). FUNDING: Funding was provided by Psychiatric Centre Glostrup, Copenhagen Denmark, Sofiefonden (Grant number: FID4107425), Trygfonden (Grant number:153588), Takeda Pharma. TRIAL REGISTRATION: Clinical Trials, NCT05213286, Registered 28 January 2022, clinicaltrials.gov/ct2/show/NCT05213286?cond = RAADS&draw = 2&rank = 1.

Chronicity of posttraumatic stress disorder and comorbid pain as predictors of treatment response for trauma-affected refugees.

Predictors of treatment outcomes have received limited attention in the field of trauma-affected refugees. Symptom chronicity is potentially a particularly relevant predictor, as it would instruct earlier interventions for a population less familiar with psychiatric treatment options, and its identification may also reduce or delay the onset of comorbidities, such as chronic pain. Accordingly, this study examined the impacts of posttraumatic stress disorder (PTSD) chronicity and baseline comorbid pain on treatment response in trauma-affected refugees. Multiple regression was used to analyze data from a randomized controlled trial of 318 trauma-affected refugees with PTSD that was conducted at a specialized psychiatric clinic in Denmark. Treatment response was measured by changes in symptoms of PTSD (Harvard Trauma Questionnaire) and depression (Hopkins Symptom Checklist-25). Duration of functional impairment was found to be a significant predictor of PTSD outcomes, p = .003, ΔR2  = .02, f2  = .03; it was not predictive of outcomes for depression. Baseline pain severity was a significant predictor of outcomes for both PTSD, p = .009, ΔR2  = .02, f2  = .02, and depression, p = .041, ΔR2  = .01, f2 = .01. These findings suggest that trauma-affected refugees with long-lasting functional impairment and a high pain score are likely to show less improvement from treatments for PTSD and depression. This points to a need for early intervention to prevent chronic functional impairment and suggests comorbid pain is an important therapeutic target.

Evaluating the procedural validity of the multilingual computer assisted self interview (MultiCASI) in a refugee population.

Multimedia-based administration of questionnaires, presenting items both in writing and spoken word, offers numerous potential benefits in transcultural psychiatry, such as improved comprehension of each question, ease of administration, prevention of missing or arbitrary responses, and obviating subsequent data entry. The concept has become known as "Computer-Assisted Self Interviewing" (CASI), and while preliminary results are promising, previous studies have not directly compared CASI to paper-and-pen administration in a large and representative sample of refugees. The aim of this study was to evaluate the procedural validity of multilingual CASI in comparison to paper-based-administration. The Hopkins Symptom Checklist-25 anxiety and depression subscales were administered in both modalities with a total of N = 281 participants from sites in Australia, New Zealand, and Denmark. We evaluated potential deviations in both the raw item and scale scores in each modality, while psychometric properties of each subscale were compared for an Arabic-speaking subsample (n = 125). Results showed no significant differences between raw item- or scale score across the two modalities, nor between the level of construct validity. In conclusion, this study supports a wider adaptation of multilingual CASI in the context of transcultural psychiatry, both for purposes of screening and treatment evaluation.

Social zeitgebers and circadian dysrhythmia are associated with severity of symptoms of PTSD and depression in trauma-affected refugees.

The relation of aspects of rest-activity patterns, i.e., social zeitgebers, physical activity and circadian rhythm, to the severity of PTSD and depressive symptoms has not previously been studied. Doing so could provide valuable insight into possible targets for treatment. Our study explored these links in a population of 219 trauma-affected refugees diagnosed with PTSD who were seeking treatment. Data regarding social zeitgebers, such as affiliation with the labor market and contact with social network, and symptoms of PTSD and depression were collected from them. Furthermore, their levels of physical activity and circadian rest-activity parameters were calculated from actigraphy data. Bivariate correlation analyses and multiple linear regression analyses were performed to examine various aspects of rest-activity regarding relation to severity of PTSD and depressive symptoms. Several social zeitgebers were associated with severity of PTSD and depressive symptoms. The level of physical activity was unrelated to symptom severity, whereas a rest-activity pattern, with early onset of the most active 10 h, was associated with severity of PTSD, and a circadian rhythm with a large difference between periods of rest and activity was associated with severity of depression. Social zeitgebers, levels of physical activity and circadian rhythm parameters were all associated with each other. Social zeitgebers and circadian rhythm parameters were significantly related to the severity of PTSD and depressive symptoms-a relationship indicating that interventions targeting regularity of daily routines have a potential role in treating PTSD and depression in trauma-affected refugees.Trial registration: ClinicalTrials.gov, ID: NCT02761161, April 27, 2016.

A Rasch-based validity study of the Harvard Trauma Questionnaire.

BACKGROUND: The Harvard Trauma Questionnaire (HTQ) is the predominant questionnaire for assessing PTSD in trauma-affected refugees. Although the scale is increasingly used for measuring treatment outcomes, it has never been specifically validated for such use. The current study does so by testing the HTQ with the Rasch model. METHODS: The analysis is based on 641 Arabic and Persian speaking refugees, diagnosed with PTSD and undergoing psychiatric treatment in Denmark. The responses were tested against the assumptions of the Rasch model, including unidimensionality, local independence and the absence of differential item function across subgroups. RESULTS: Results reveal two subscales that, when accounting for local dependence and differential item functioning, meet criteria for the Rasch model in the included samples: An arousal/intrusion subscale and an avoidance/numbing subscale. LIMITATIONS: The included sample was highly chronic and suffered from major depressive disorder. Results may not be fully representative of less chronic populations, e.g. recently arrived refugees. CONCLUSIONS: We recommend the use of the arousal/intrusion subscale and the avoidance/numbing subscale as an optimized way of summarizing responses to the HTQ, which remains simple to administer while effectively summarizing all the information available in the scores.

Startle habituation, sensory, and sensorimotor gating in trauma-affected refugees with posttraumatic stress disorder.

BACKGROUND: Impairments in mechanisms underlying early information processing have been reported in posttraumatic stress disorder (PTSD); however, findings in the existing literature are inconsistent. This current study capitalizes on technological advancements of research on electroencephalographic event-related potential and applies it to a novel PTSD population consisting of trauma-affected refugees. METHODS: A total of 25 trauma-affected refugees with PTSD and 20 healthy refugee controls matched on age, gender, and country of origin completed the study. In two distinct auditory paradigms sensory gating, indexed as P50 suppression, and sensorimotor gating, indexed as prepulse inhibition (PPI), startle reactivity, and habituation of the eye-blink startle response were examined. Within the P50 paradigm, N100 and P200 amplitudes were also assessed. In addition, correlations between psychophysiological and clinical measures were investigated. RESULTS: PTSD patients demonstrated significantly elevated stimuli responses across the two paradigms, reflected in both increased amplitude of the eye-blink startle response, and increased N100 and P200 amplitudes relative to healthy refugee controls. We found a trend toward reduced habituation in the patients, while the groups did not differ in PPI and P50 suppression. Among correlations, we found that eye-blink startle responses were associated with higher overall illness severity and lower levels of functioning. CONCLUSIONS: Fundamental gating mechanisms appeared intact, while the pattern of deficits in trauma-affected refugees with PTSD point toward a different form of sensory overload, an overall neural hypersensitivity and disrupted the ability to down-regulate stimuli responses. This study represents an initial step toward elucidating sensory processing deficits in a PTSD subgroup.

Cross-Cultural Psychometric Properties of the Hamilton Depression Rating Scale.

OBJECTIVE: The Hamilton Depression Rating Scale (HDRS) is considered the gold standard measure of depression. The factor structure of the HDRS is generally unstable, but 4 to 8 items appear to form a general depression factor. As transcultural studies of the HDRS have received little attention, and as most of the studies have taken a data-driven approach with a tendency to yield fragmented results, it is not clear if an HDRS general depression factor can also be found in non-Western populations. This is an important issue in deciding on the appropriateness of the scale as a gold standard in transcultural psychiatry. METHOD: A systematic review was carried out to compare previously reported factor structures of the HDRS in non-Western cultures. Overlapping clusters across studies were identified and subsequently tested with confirmatory factor analysis (CFA) of responses from an independent sample. RESULTS: Fourteen relevant studies were identified, 12 of which were obtained. A general depression factor was identified, consisting of the following symptoms: depressed mood, guilt, loss of interests, retardation, suicide, and psychological anxiety. The subsequent CFA analysis supported the fit of this model. CONCLUSIONS: This study indicates that a general depression cluster is manifest in responses to the HDRS across cultures. While psychometric properties of the full-length HDRS are still debated, the general depression cluster appears pertinent to the assessment of depression across cultures. We recommend that cross-cultural clinicians and researchers focus on the use of unidimensional depression scales, which are in agreement with this cluster.

Stress management versus cognitive restructuring in trauma-affected refugees-A pragmatic randomised study.

The aim of this randomised trial was to compare the effectiveness of stress management (SM) versus cognitive restructuring (CR) in trauma-affected refugees. The intention-to-treat sample comprised 126 refugees with PTSD (SM = 62, CR = 64). The treatment consisted of 16 sessions of psychotherapy with manualised SM or CR in addition to 10 sessions with a medical doctor (psychoeducation and pharmacological treatment). The primary outcome was PTSD symptom severity (Harvard Trauma Questionnaire). Secondary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist-25, Hamilton Depression and Anxiety Ratings), quality of life (WHO-5), functioning (Global Assessment of Functioning, Sheehan Disability Scale), pain (Visual Analogue Scale) and somatisation (Symptom Checklist). There was no difference in the primary outcome between groups. A significant group difference was found on the Hamilton Anxiety Rating with the SM group improving more than the CR group (effect size 0.46) indicating that methods in SM could potentially be helpful in this population.

Treatment of sleep disturbances in refugees suffering from post-traumatic stress disorder.

Sleep disturbances are often referred to as the hallmark of Post-Traumatic Stress Disorder (PTSD). Although PTSD is prevalent in refugees, studies on sleep disturbances in trauma-affected refugees are scarce. This article presents the results of two studies: a systematic review of the literature on treatment of sleep disturbances in adult trauma-affected refugees and a study of the role of sleep disturbances in the PTSD symptom structure. Study 1, the literature review, identified five studies on treatment of sleep disturbances: four studies were on pharmacological treatment and one study on music therapy. The identified studies had small sample sizes and few carried out statistical analysis. It was not possible from the available literature to recommend any specific treatment of sleep disturbances. In Study 2, a clinical sample of 752 refugees, fulfilling criteria for PTSD and enrolled in treatment at the Competence Centre for Transcultural Psychiatry, Denmark, completed the Harvard Trauma Questionnaire (HTQ) before and after treatment. To determine item discrimination, the data was tested with a Rasch model. 99.1% reported trouble sleeping and 98.7% reported recurrent nightmares. The Rasch analysis displayed fit residuals of 0.05 for trouble sleeping and -1.16 for nightmares, indicating sufficient discrimination. Trouble sleeping and nightmares proved important parts of the HTQ response structure. This study indicates that sleep disturbances are a prominent part of the PTSD symptom structure in refugees but that research on treatment of sleep disturbances is limited. Further research on sleep disturbances in trauma-affected refugees is therefore needed.

The latent structure of post-traumatic stress disorder among Arabic-speaking refugees receiving psychiatric treatment in Denmark.

BACKGROUND: Refugees are known to have high rates of post-traumatic stress disorder (PTSD). Although recent years have seen an increase in the number of refugees from Arabic speaking countries in the Middle East, no study so far has validated the construct of PTSD in an Arabic speaking sample of refugees. METHODS: Responses to the Harvard Trauma Questionnaire (HTQ) were obtained from 409 Arabic-speaking refugees diagnosed with PTSD and undergoing treatment in Denmark. Confirmatory factor analysis was used to test and compare five alternative models. RESULTS: All four- and five-factor models provided sufficient fit indices. However, a combination of excessively small clusters, and a case of mistranslation in the official Arabic translation of the HTQ, rendered results two of the models inadmissible. A post hoc analysis revealed that a simpler factor structure is supported, once local dependence is addressed. CONCLUSIONS: Overall, the construct of PTSD is supported in this sample of Arabic-speaking refugees. Apart from pursuing maximum fit, future studies may wish to test simpler, potentially more stable models, which allow a more informative analysis of individual items.

Psychosocial predictors of treatment outcome for trauma-affected refugees.

BACKGROUND: The effects of treatment in trials with trauma-affected refugees vary considerably not only between studies but also between patients within a single study. However, we know little about why some patients benefit more from treatment, as few studies have analysed predictors of treatment outcome. OBJECTIVE: The objective of the study was to examine possible psychosocial predictors of treatment outcome for trauma-affected refugees. METHOD: The participants were 195 adult refugees with posttraumatic stress disorder (PTSD) who were enrolled in a 6- to 7-month treatment programme at the Competence Centre for Transcultural Psychiatry (CTP), Denmark. The CTP Predictor Index used in the study included 15 different possible outcome predictors concerning the patients' past, chronicity of mental health problems, pain, treatment motivation, prerequisites for engaging in psychotherapy, and social situation. The primary outcome measure was PTSD symptoms measured on the Harvard Trauma Questionnaire (HTQ). Other outcome measures included the Hopkins Symptom Check List-25, the WHO-5 Well-being Index, Sheehan Disability Scale, Hamilton Depression and Anxiety Scales, the somatisation scale of the Symptoms Checklist-90, Global Assessment of Functioning scales, and pain rated on visual analogue scales. The relations between treatment outcomes and the total score as well as subscores of the CTP Predictor Index were analysed. RESULTS: Overall, the total score of the CTP Predictor Index was significantly correlated to pre- to post treatment score changes on the majority of the ratings mentioned above. While employment status was the only single item significantly correlated to HTQ-score changes, a number of single items from the CTP Predictor Index correlated significantly with changes in depression and anxiety symptoms, but the size of the correlation coefficients were modest. CONCLUSIONS: The total score of the CTP Predictor Index correlated significantly with outcomes on most of the rating scales, but correlations were modest in size, possibly due to the number of different factors influencing treatment outcome.

Psychotherapy with traumatised refugees--the design of a randomised clinical trial.

There is little evidence as to which kind of psychotherapy is the most effective in the treatment of traumatised refugees. At the Competence Center for Transcultural Psychiatry, a series of clinical trials have been conducted since 2008. The first results are pending publication. The aim of this paper is to discuss some of the challenges in adapting Cognitive Behavioural Therapy (CBT) to the treatment of traumatised refugees, as well as describe a randomised clinical trial designed to test two such adaptations. In the described trial one group receives CBT with a focus on cognitive restructuring while the other group receives CBT focusing on Stress Management. A main goal of this setup is to test whether some, perhaps even most, of the traumatised refugees referred to treatment, may benefit from a more direct focus on current stress, and its alleviation through simple, repetitive exercises, compared to a focus on analysing and changing thought patterns.