Assessing post-traumatic stress disorder in South African adolescents: using the child and adolescent trauma survey (CATS) as a screening tool.

BACKGROUND: Several studies have demonstrated that South African children and adolescents are exposed to high levels of violent trauma with a significant proportion developing PTSD, however, limited resources make it difficult to accurately identify traumatized children. METHODS: A clinical interview (K-SADS-PL, selected modules) and self-report scale (CATS) were compared to determine if these different methods of assessment elicit similar information with regards to trauma exposure and post-traumatic stress disorder (PTSD) in adolescents. Youth (n = 58) from 2 schools in Cape Town, South Africa participated. RESULTS: 91% of youth reported having been exposed to a traumatic event on self-report (CATS) and 38% reported symptoms severe enough to be classified as PTSD. On interview (K-SADS-PL), 86% reported exposure to a traumatic event and 19% were found to have PTSD. While there were significant differences in the rates of trauma exposure and PTSD on the K-SADS and CATS, a cut-off value of 15 on the CATS maximized both the number of true positives and true negatives with PTSD. The CATS also differentiated well between adolescents meeting DSM-IV PTSD symptom criteria from adolescents not meeting criteria. CONCLUSIONS: Our results indicate that trauma exposure and PTSD are prevalent in South African youth and if appropriate cut-offs are used, self-report scales may be useful screening tools for PTSD.

Violent trauma among child and adolescent girls: current knowledge and implications for clinicians.

While the incidence and psychiatric correlates of violent trauma among children and adolescents have been well documented, there is less data on the specific ways in which girls are affected by violence. The present review examines current knowledge of the prevalence and effects of violent trauma on female children and adolescents. Domestic and community violence, sexual abuse and war trauma are included. Data on etiology and treatment are also reviewed. Current data indicate that violent trauma, particularly sexual victimization, is highly prevalent among child and adolescent girls. Furthermore, girls appear to be more vulnerable to post-traumatic stress reactions than boys. Some studies report that rates of posttraumatic stress disorder are six times higher in girls, possibly due to the sexual nature of girls' victimization. However, the nature of the exposure-distress relationship and the role of protective factors both bear further research. The implications of current findings for clinical practice are discussed, in order to facilitate optimal assessment and treatment of young female victims of violence.

An open trial of citalopram in adolescents with post-traumatic stress disorder.

In this preliminary, 12-week open-label study, eight adolescents with moderate to severe post-traumatic stress disorder (PTSD) were treated with citalopram (the most selective of the selective serotonin reuptake inhibitors) in a fixed daily dose of 20 mg, and rated at 2-week intervals. The Clinician-Administered PTSD Scale (Child and Adolescent Version) was the primary measure used to assess treatment outcome. Core PTSD symptoms (re-experiencing, avoidance, and hyperarousal symptoms) showed statistically significant improvement at week 12 on the Clinician-Administered PTSD Scale (Child and Adolescent Version) (CAPS-CA), with a 38% reduction in total CAPS scores between baseline and endpoint. Citalopram failed to effect improvement on self-reported depressive symptoms. All seven adolescent completers were rated as much improved or very much improved on Clinical Global Impression Improvement scores. Citalopram was well-tolerated overall with reported adverse experiences being relatively benign. However, larger, controlled trials are needed to consolidate these preliminary results.

Quality of life in the anxiety disorders.

Although quality of life (QOL) issues have long been recognized in severe psychiatric disorders, they have only recently come to be considered for the anxiety disorders. Conceptual and methodological developments in the study of QOL are briefly outlined, and the overlap among measures of QOL, functional impairment, and disability is discussed. Existing empirical studies on subjective and objective QOL dimensions in each of the anxiety disorders are then reviewed. QOL has been examined in panic disorder, social anxiety disorder, and posttraumatic stress disorder but has received little attention in generalized anxiety disorder and specific phobia. Despite substantial evidence showing that the anxiety disorders are associated with impaired QOL, data are scarce concerning the impact of treatments on QOL in many of the anxiety disorders. Future research on QOL in the anxiety disorders would benefit from greater conceptual clarity and methodological consistency, the use of prospective research designs, greater attention to QOL as a treatment outcome, and consideration of QOL in the caregiver and the family as well as the patient.

Sadistic personality disorder in perpetrators of human rights abuses: a South African case study.

Although state-sponsored human rights abuses have long been commonplace, the psychological profiles of perpetrators are not well delineated. This article examines the utility of the diagnosis of sadistic personality disorder (SPD) in explaining the commission of atrocities. The history of, and controversies surrounding, SPD are briefly reviewed. Using a case study from the amnesty trials of the Truth and Reconciliation Commission (TRC) in South Africa, the relevance of the SPD diagnosis for an infamous perpetrator of political violence is debated. Sources of data include the perpetrator's autobiography, transcripts from the amnesty trial, and Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Spitzer, Gibbon, & Williams, 1994) ratings provided by four people who had contact with the perpetrator during his trial. The authors provide arguments for and against the use of the SPD diagnosis in this case and in similar contexts of perpetration. It is proposed that neither psychological reductionism nor social reductionism can adequately account for the motivations of political perpetrators, and an integrative approach to the understanding of perpetrators is advocated. Implications for diagnostic criteria are discussed.

Association between the diagnosis of mental retardation and socioeconomic factors.

Clinic data from the regional hospital in Cape Town, South Africa, over 4 years for 538 children with a diagnosis of mental retardation were examined in order to establish whether differences in mental retardation referral patterns existed between low and high socioeconomic areas. Results indicate that mild mental retardation referrals were underrepresented in low socioeconomic areas and that paramedical agencies were the primary referral source in these areas. Differences in mild mental retardation referral patterns by area over time may stem from service difficulties or variations in referral thresholds. Cross-cultural implications of the findings were discussed with relevance to the development of culturally sensitive community-based intervention programs.

Forgiveness: toward an integration of theoretical models.

Studies on forgiveness have only recently emerged in the psychological literature. Despite evidence that forgiveness is associated with positive therapeutic outcomes, the concept has received little theoretical consideration in mainstream psychology. Existing definitions and models of forgiveness differ widely, and little attempt has been made to integrate these diverse approaches. Based on a review of the Medline and Psychlit databases, the present article evaluates current conceptualizations of forgiveness in the psychological literature. The values and limitations of each approach are discussed with reference to two case studies: a close interpersonal relationship and a human rights violation presented to the Truth and Reconciliation Commission in South Africa. A new theoretical model, integrating the most valuable aspects of existing approaches, is proposed.

Ethical aspects of research on psychological trauma.

Research in the area of psychological trauma raises a number of complex ethical issues. These include questions about unjustified medicalization of suffering, retraumatization of survivors, the morality of also investigating perpetrators of trauma, and neglecting to provide appropriate intervention. We discuss some of these issues against the backdrop of a study of trauma in South Africa, and the recent work of the Truth and Reconciliation Commission in that country.

Narrative themes in responses to trauma in a religious community.

OBJECTIVE: The development of a meaningful narrative of trauma experiences is an important factor in recovery, and religious beliefs may constitute an important meaning system for trauma survivors. The study examined the narrative themes which emerged from interviews with survivors of the massacre of a church congregation in South Africa (N = 19). DESIGN: A descriptive, retrospective study. SETTING: Community based study. SUBJECTS: A volunteer sample of 19 participants. OUTCOME MEASURES: An open ended interview and the Structured Clinical Interview for DSM-IV (SCID). RESULTS: Thematic analysis revealed that religious beliefs and practices were frequently utilised to construct a meaningful retrospective narrative of the massacre. The implications of the findings for future research with trauma survivors are discussed. CONCLUSIONS: Religion may provide a framework by which survivors of trauma construct a meaningful account of their experience, and may be a useful focus for intervention with trauma survivors.

Treatment utilisation and trauma characteristics of child and adolescent inpatients with posttraumatic stress disorder.

OBJECTIVE: Few empirical studies have addressed the impact of trauma exposure and posttraumatic stress disorder (PTSD) on treatment utilisation and outcome in South African youth. This study was undertaken to document demographic, clinical, and treatment characteristics of child and adolescent inpatients with PTSD. DESIGN: A retrospective chart study of all patients presenting to a child and adolescent inpatient unit was conducted between 1994-1996. For children and adolescents diagnosed with PTSD; demographic, diagnostic and treatment variables, including trauma type, family history, and delays in treatment seeking, were documented. SETTING: Child and Adolescent Psychiatric Inpatient Unit, Tygerberg Hospital, Cape Town. SUBJECTS: Children and adolescents (2 to 18 years) presenting to an inpatient unit (n = 737). RESULTS: 10.3% (n = 76) met diagnostic criteria for PTSD. Gender differences were clearly evident: PTSD was six times more prevalent in girls (65 with PTSD were female and 11 were male); girls were most likely to have experienced rape or sexual abuse while boys were most likely to have witnessed a killing. Psychotherapy was the most common intervention for PTSD, followed by treatment with a tricyclic antidepressant. 97.4% of children and adolescents who were treated demonstrated significant improvement. Delays in seeking treatment and problems with the primary support group were highly prevalent. CONCLUSION: PTSD is a common disorder that is responsive to treatment with psychotherapy and/or tricyclic antidepressants in child and adolescent inpatients. These findings underscore the importance of early identification and treatment of childhood PTSD in mental health settings, in particular tertiary service institutions.

Treatment utilisation and trauma characteristics of child and adolescent inpatients with posttraumatic stress disorder.

OBJECTIVE: Few empirical studies have addressed the impact of trauma exposure and posttraumatic stress disorder (PTSD) on treatment utilisation and outcome in South African youth. This study was undertaken to document demographic, clinical, and treatment characteristics of child and adolescent inpatients with PTSD. DESIGN: A retrospective chart study of all patients presenting to a child and adolescent inpatient unit was conducted between 1994-1996. For children and adolescents diagnosed with PTSD; demographic, diagnostic and treatment variables, including trauma type, family history, and delays in treatment seeking, were documented. SETTING: Child and Adolescent Psychiatric Inpatient Unit, Tygerberg Hospital, Cape Town. SUBJECTS: Children and adolescents (2 to 18 years) presenting to an inpatient unit (n = 737). RESULTS: 10.3% (n = 76) met diagnostic criteria for PTSD. Gender differences were clearly evident: PTSD was six times more prevalent in girls (65 with PTSD were female and 11 were male); girls were most likely to have experienced rape or sexual abuse while boys were most likely to have witnessed a killing. Psychotherapy was the most common intervention for PTSD, followed by treatment with a tricyclic antidepressant. 97.4% of children and adolescents who were treated were improved at treatment endpoint. Delays in seeking treatment and problems with the primary support group were highly prevalent. CONCLUSION: PTSD is a common disorder that is responsive to treatment with psychotherapy and/or tricyclic antidepressants in child and adolescent inpatients. These findings underscore the importance of early identification and treatment of childhood PTSD in mental health settings, in particular tertiary service institutions.

Issues in the identification of comorbidity of mental retardation and psychopathology in a multicultural context.

Identification of the comorbidity of mental retardation and psychopathology in a multicultural setting raises manifold difficulties. The present study explored the sampling and identification issues implicated in estimating the prevalence of this dual diagnosis in a South African clinic sample. The relations between the prevalence of dual diagnosis and socioeconomic status, gender, and severity level of retardation were investigated. The detection rate of 4.36% was significantly lower than that of other studies. Prevalence was found to be greater in areas of high socioeconomic status, among males, and among less severely retarded individuals. Implications of these findings for cross-cultural studies and for allocation of service resources for patients with dual diagnosis are considered.

The Truth and Reconciliation Commission in South Africa: relation to psychiatric status and forgiveness among survivors of human rights abuses.

BACKGROUND: The impact on individual survivors of human rights abuses of testifying before South Africa's Truth and Reconciliation Commission (TRC) has not been established. AIMS: To examine the degree to which participation in the TRC is related to current psychiatric status and forgiveness among survivors. METHOD: Survivors (n=134) who gave public, closed or no testimony to the TRC completed instruments measuring exposure to human rights abuses, exposure to other traumatic events, current psychiatric status and forgiveness attitudes towards the perpetrator(s). RESULTS: There was no significant association between TRC participation and current psychiatric status or current forgiveness attitudes, and low forgiveness was associated with poorer psychiatric health. CONCLUSIONS: Truth commissions should form part of, rather than be a substitute for, comprehensive therapeutic interventions for survivors of human rights abuses. Lack of forgiveness may be an important predictor of psychiatric risk in this population.