Barriers and opportunities for implementation of a brief psychological intervention for post-ICU mental distress in the primary care setting - results from a qualitative sub-study of the PICTURE trial.

BACKGROUND: The results of critical illness and life-saving invasive measures during intensive care unit treatment can sometimes lead to lasting physical and psychological impairments. A multicentre randomized controlled trial from Germany (PICTURE) aims to test a brief psychological intervention, based on narrative exposure therapy, for post-traumatic stress disorder symptoms following intensive care unit treatment in the primary care setting. A qualitative analysis was conducted to understand feasibility and acceptance of the intervention beyond quantitative analysis of the main outcomes in the primary study. METHODS: Qualitative explorative sub-study of the main PICTURE trial, with eight patients from the intervention group recruited for semi-structured telephone interviews. Transcriptions were analysed according to Mayring's qualitative content analysis. Contents were coded and classified into emerging categories. RESULTS: The study population was 50% female and male, with a mean age of 60.9 years and transplantation surgery being the most frequent admission diagnosis. Four main factors were identified as conducive towards implementation of a short psychological intervention in a primary care setting: 1) long-term trustful relationship between patient and GP team; 2) intervention applied by a medical doctor; 3) professional emotional distance of the GP team; 4) brevity of the intervention. CONCLUSION: The primary setting has certain qualities such as a long-term doctor-patient relationship and low-threshold consultations that offer good opportunities for implementation of a brief psychological intervention for post-intensive care unit impairments. Structured follow-up guidelines for primary care following intensive care unit treatment are needed. Brief general practice-based interventions could be part of a stepped-care approach. TRIAL REGISTRATION: The main trial was registered at the DRKS (German Register of Clinical Trials: DRKS00012589) on 17/10/2017.

Cumulative trauma predicts hair cortisol concentrations and symptoms of depression and anxiety in pregnant women-an investigation of community samples from Greece, Spain and Perú.

Exposure to traumatic experiences across lifespan shapes the functioning of the hypothalamic pituitary adrenal (HPA) axis and sets individuals at risk to develop symptoms of depression and anxiety. Particularly, HPA axis regulation and the psychological health of the expectant mother have been of interest, as the health of the unborn child may be affected through changes in gestational biology. The present study investigated the potential associations between lifetime trauma, current symptoms (depression and anxiety) and hair cortisol concentrations (HCC) in pregnant women. A total of 149 pregnant women were interviewed in public outpatient clinics with varying gestational age in Greece, Spain and Perú. Lifetime trauma exposure and current symptoms of depression and anxiety were assessed. HCC was measured in scalp-near hair segments (2 cm length) reflecting cumulative cortisol secretion of the past two months. Results showed that trauma load is negatively associated with HCC and higher symptoms of depression and anxiety. There was a negative association between HCC and symptoms. The present findings support the notion that cumulative trauma exposure exerts long-lasting effects on the expectant mother's HPA axis activity functioning and mental health and may thereby potentially create risk trajectories for the unborn child via changes in gestational biology.

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.

Practical guidelines for online Narrative Exposure Therapy (e-NET) - a short-term treatment for posttraumatic stress disorder adapted for remote delivery.

Background: Online therapy has become increasingly desirable and available in recent years, with the current COVID-19 pandemic acting as a catalyst to develop further protocols enabling therapists to conduct online treatment safely and efficaciously. Offering online treatment potentially means that treatments are available to clients who would otherwise have no access, closing the gap in the provision of mental health services worldwide. Objective: This paper focuses on practical guidelines using online Narrative Exposure Therapy (e-NET). It aims to be an addition to the general manual of NET to enable therapists to deliver online treatment. The face-to-face version of NET is a well-known short-term and evidence-based treatment for posttraumatic stress disorder; e-NET is currently being tested in several additional trials. Methods: The differences between NET and e-NET are elaborated and depicted in detail. Results: Difficulties encountered in e-NET delivery, e.g. confidentiality, dealing with interruptions, comorbid symptoms among others, are similar to those that occur during face to face interventions but the solutions have to be adapted. Dissociation is often regarded as a challenge in face-to-face treatment, and requires particular attention within the online setting. Therefore, tools for addressing dissociation in this particular setting are presented. Conclusions: These practical guidelines show the advantages as well as the challenges therapists face when conducting e-NET. They aim to empower therapists working with trauma clients to conduct e-NET confidently and safely.

Antecedentes: La terapia online se ha vuelto deseable y disponible de forma creciente recientemente, con la actual pandemia del COVID-19 actuando como un catalizador para desarrollar protocolos permitiendo a los terapeutas a aplicar tratamiento online de forma segura y eficaz. Ofrecer tratamiento online significa que potencialmente los tratamientos están disponibles para los clientes que no tendrían acceso de otra forma, reduciendo la brecha en la provisión de los servicios de salud mental alrededor del mundo.Objetivo: Este artículo se centra en las guías prácticas usando la Terapia de Exposición Narrativa online (e-NET). Este busca ser una adición al manual general de NET para facilitar que los terapeutas entreguen tratamiento online. La versión presencial del NET es un tratamiento bien conocido basado en la evidencia y de corto plazo para el tratamiento del trastorno de estrés postraumático; e-NET está actualmente siendo evaluado en varios ensayos adicionales.Métodos: Las diferencias entre NET y e-NET están elaboradas y se describen en detalle.Resultados: Las diferencias encontradas en la entrega del e-NET, por ej. Confidencialidad, manejo de interrupciones, síntomas comórbidos, entre otros, son similares a aquellos que ocurren durante las intervenciones presenciales, pero las soluciones tienen que ser adaptadas. La disociación es frecuentemente mencionada como un desafío en el tratamiento presencial, y requiere de particular atención con el contexto online. Por lo tanto, se presentan herramientas para abordar la disociación en este contexto particular.Conclusiones: Estas guías practicas muestran las ventajas como también los desafíos que los terapeutas enfrentan cuando aplican e-NET. Ellas buscan empoderar a los terapeutas para el trabajo con clientes que han experimentado trauma para implementar e-NET de forma confidencial y segura.

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.

Rapid brain responses to affective pictures indicate dimensions of trauma-related psychopathology in adolescents.

A variety of mental disorders are related to deviant brain activity, but these neural alterations do not validate psychiatric diagnostic categories. High symptom overlap and variable symptom patterns encourage a dimensional approach. Following the logic of the Research Domain Criteria (RDoC), we investigated trauma survivors for symptom clusters that might be associated with characteristics of ERPs, in particular with the early posterior negativity (EPN) elicited during affective picture processing. In rapid serial visual presentation, 90 adolescents (40 male/50 female, age M = 15.0 ± 2.5 years) who had been exposed to varying amounts of traumatic stress passively viewed a stream of high-arousing positive and low-arousing neutral pictures taken from the International Affective Picture System (IAPS). Using standardized interviews, symptoms of trauma-related mental disorders were assessed (including those for PTSD, depression, borderline personality disorder, and behavioral problems). A principal component analysis was performed to derive potential dimensions of psychopathology. Multiple regression analysis confirmed a factor comprising problems concentrating, sleeping difficulties, and mistrust as a predictor of a larger EPN difference between high-arousing positive and low-arousing neutral IAPS pictures (ß = 0.19, p < 0.05). Sex predicted the magnitude of the EPN (ß = 0.45, p < 0.001). Male adolescents displayed a stronger EPN suppression than female adolescents. The result suggests that problems concentrating, sleeping difficulties, and mistrust seem to be trans-diagnostic elements related to diminished early emotional discrimination represented by the EPN. Furthermore, our findings indicate that the EPN in response to emotional processing is modulated by sex.

Long-term effects of psychotherapy in a context of continuous community and gang violence: changes in aggressive attitude in high-risk South African adolescents.

BACKGROUND: Post-traumatic stress but also aggressive attitudes and behaviour can be found in adolescents living in a context of ongoing community and gang violence in the low-income urban areas of Cape Town, South Africa. AIMS: We investigated the long-term effects (15-20 months after therapy) of (a) Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) and (b) the cognitive behavioural intervention 'Thinking for a Change' (CBT) on post-traumatic stress disorder (PTSD) and aggression compared with a waiting list. METHOD: Fifty-four young males participated in the treatment trial, of which 17 completed the FORNET intervention, 11 the CBT intervention, and 26 were on a waiting list. The primary outcome was the change score for the Appetitive Aggression Scale; secondary outcomes were the PTSD Symptom Scale-Interview change scores, and the number of perpetrated violent event types. RESULTS: The reduction in scores for PTSD that had been observed in FORNET completers at the first follow-up were still significant at the second long-term follow-up (Cohen's d = 0.86). In this treatment arm (FORNET), the scores for appetitive aggression were also significantly reduced (Cohen's d = 1.00). There were no significant changes observed for CBT or for the waiting list. CONCLUSIONS: The study indicates that FORNET can successfully reduce post-traumatic stress as well as the attraction to violence even for individuals living under conditions of continuous traumatic stress.

Does Prenatal Stress Shape Postnatal Resilience? - An Epigenome-Wide Study on Violence and Mental Health in Humans.

Stress during pregnancy widely associates with epigenetic changes and psychiatric problems during childhood. Animal studies, however, show that under specific postnatal conditions prenatal stress may have other, less detrimental consequences for the offspring. Here, we studied mental health and epigenome-wide DNA methylation in saliva following intimate partner violence (IPV) during pregnancy in São Gonçalo, a Brazilian city with high levels of violence. Not surprisingly, mothers exposed to pregnancy IPV expressed elevated depression, PTSD and anxiety symptoms. Children had similar psychiatric problems when they experienced maternal IPV after being born. More surprisingly, when maternal IPV occurred both during (prenatal) and after pregnancy these problems were absent. Following prenatal IPV, genomic sites in genes encoding the glucocorticoid receptor (NR3C1) and its repressor FKBP51 (FKBP5) were among the most differentially methylated and indicated an enhanced ability to terminate hormonal stress responses in prenatally stressed children. These children also showed more DNA methylation in heterochromatin-like regions, which previously has been associated with stress/disease resilience. A similar relationship was seen in prenatally stressed middle-eastern refugees of the same age as the São Gonçalo children but exposed to postnatal war-related violence. While our study is limited in location and sample size, it provides novel insights on how prenatal stress may epigenetically shape resilience in humans, possibly through interactions with the postnatal environment. This translates animal findings and emphasizes the importance to account for population differences when studying how early life gene-environment interactions affects mental health.

Effect of a combined brief narrative exposure therapy with case management versus treatment as usual in primary care for patients with traumatic stress sequelae following intensive care medicine: study protocol for a multicenter randomized controlled trial (PICTURE).

BACKGROUND: Traumatic events like critical illness and intensive care are threats to life and bodily integrity and pose a risk factor for posttraumatic stress disorder (PTSD). PTSD affects the quality of life and morbidity and may increase health-care costs. Limited access to specialist care results in PTSD patients being treated in primary care settings. Narrative exposure therapy (NET) is based on the principles of cognitive behavioral therapy and has shown positive effects when delivered by health-care professionals other than psychologists. The primary aims of the PICTURE trial (from "PTSD after ICU survival") are to investigate the effectiveness and applicability of NET adapted for primary care with case management in adults diagnosed with PTSD after intensive care. METHODS/DESIGN: This is an investigator-initiated, multi-center, primary care-based, randomized controlled two-arm parallel group, observer-blinded superiority trial conducted throughout Germany. In total, 340 adult patients with a total score of at least 20 points on the posttraumatic diagnostic scale (PDS-5) 3 months after receiving intensive care treatment will be equally randomized to two groups: NET combined with case management and improved treatment as usual (iTAU). All primary care physicians (PCPs) involved will be instructed in the diagnosis and treatment of PTSD according to current German guidelines. PCPs in the iTAU group will deliver usual care during three consultations. In the experimental group, PCPs will additionally be trained to deliver an adapted version of NET (three sessions) supported by phone-based case management by a medical assistant. At 6 and 12 months after randomization, structured blinded telephone interviews will assess patient-reported outcomes. The primary composite endpoint is the absolute change from baseline at month 6 in PTSD symptom severity measured by the PDS-5 total score, which also incorporates the death of any study patients. Secondary outcomes cover the domains depression, anxiety, disability, health-related quality-of-life, and cost-effectiveness. The principal analysis is by intention to treat. DISCUSSION: If the superiority of the experimental intervention over usual care can be demonstrated, the combination of brief NET and case management could be a treatment option to relieve PTSD-related symptoms and to improve primary care after intensive care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03315390 . Registered on 10 October 2017. German Clinical Trials Register, DRKS00012589 . Registered on 17 October 2017.

The neural dynamics of deficient memory control in heavily traumatized refugees.

Victims of war, torture and natural catastrophes are prone to develop posttraumatic stress disorder (PTSD). These individuals experience the recurrent, involuntary intrusion of traumatic memories. What neurocognitive mechanisms are driving this memory disorder? Here we show that PTSD symptoms in heavily traumatized refugees are related to deficits in the effective control of memory retrieval. In a think/no-think task, PTSD patients were unable to forget memories that they had previously tried to suppress when compared to control participants with the same trauma history but without PTSD. Deficits in voluntary forgetting were clinically relevant since they correlated with memory intrusions in everyday life. Magnetoencephalography (MEG) recorded during suppression attempts revealed that PTSD patients were unable to downregulate signatures of sensory long-term memory traces in the gamma frequency band (70-120 Hz). Thus, our data suggest that the inability to suppress unwanted memories through modulation of gamma activity is related to PTSD symptom severity.

Course of Mental Health in Refugees-A One Year Panel Survey.

Background: Cross-sectional studies indicate that a substantial proportion of refugees have psychiatric disorders. However, longitudinal studies on the course of psychiatric symptoms and on influencing factors are scarce. The current study investigates the development of symptoms in an untreated refugee sample in Germany and seeks to identify potential predictors. Methods: Over the course of 1 year, 57 refugees participated in monthly assisted self-reports on the phone assessing emotional distress. At the same time, semi-annual, semi-structured clinical interviews focusing on posttraumatic stress disorder (PTSD) and depression were conducted. The overall dropout rate for the year was 23% for the assisted self-reports and 33% for the clinical interviews. Results: Symptoms did not systematically change over the course of the year. On the individual level, a reliable change in PTSD symptoms was observed in 13% who showed improvement and 24% who showed worsening symptoms. Figures for depression symptoms were 24 and 16% respectively. A higher number of traumatic experiences was related to a greater intensity of PTSD symptoms. In addition, postmigrational stressors were associated with a worsening of PTSD symptoms over the course of the year. Emotional distress was associated with current negative life events, unemployment, and frequent visits to physicians. Conclusions: There is on average no improvement or worsening of symptoms over the period of 1 year. However, individual courses vary, and thus show the importance of risk factors. Accordingly, the identification of risk factors such as trauma load and postmigrational stressors can be useful to determine the need of further monitoring and to provide appropriate interventions when necessary.

Two pedals drive the bi-cycle of violence: reactive and appetitive aggression.

The Good: when you fight to counter threat, your aggression is a reactive defense, and often morally justifiable. The Bad: when you loot and rob, hurt and kill, to obtain social status or material goods, that is an extrinsic reward. This is instrumental aggression. And The Ugly: The intrinsic enjoyment of violence. This 'appetitive aggression' describes a lust for violence, underlying first-person shooter gamers, hunting, and extreme acts of violence, such as murder and massacres. Although violence often results from a combination of these forms of aggression, the differentiation is necessary to understand their interplay, as they drive two interconnected cycles of violence: the reactive cycle, fueled by the motivation to overcome negative feelings, and the hedonically driven appetitive cycle.

Efficient identification of mental health problems in refugees in Germany: the Refugee Health Screener.

Background: A substantial number of refugees present with mental disorders. This appears particularly acute in the currently increasing refugee populations in Europe. Although EU guidelines demand the identification and support of vulnerable individuals such as survivors of trauma, no adequately validated and comprehensive mental health screening instruments for refugees residing in Europe currently exist. Objective: We studied the feasibility, validity, and reliability of the Refugee Health Screener-15 (RHS-15) - a time-efficient and easy-to-implement screening developed by Hollifield et al. (2013) - as a self-rating and interview instrument. Methods: A sample of refugees from different countries (N = 86), representative of those who had arrived around the turn of the year 2015/2016 in Germany, filled in the RHS-15 on their own. A semi-structured clinical interview was later conducted with a random subsample (n = 56). Results: Fifty-two percent of the refugees examined screened positive in the RHS-15, thus indicating current mental health problems. The RHS-15 showed a good feasibility, reliability, and validity in both the self-rating and the interview version. It detected clinically relevant mental health problems when PTSD, depression, anxiety, or somatization problems were present. A shorter 13-item version proved to be equally valid. Conclusions: Together with previous research on the RHS in refugees living in the US, this suggests that the RHS is a time-efficient and accurate instrument that is able to detect common mental health problems in a wide range of refugees. Prospectively, the RHS could be used as an instrument for identifying vulnerable refugees, for example, by integrating it in the initial medical examination in the host community, thereby initiating support.

Planteamiento: Un número considerable de refugiados presenta trastornos mentales. Esto parece ser particularmente grave en poblaciones de refugiados que actualmente están aumentando en Europa. Aunque las directrices de la UE exigen identificar y apoyar a individuos vulnerables, como los sobrevivientes de trauma, actualmente no existen instrumentos de detección de salud mental adecuados e integrales para los refugiados que residen en Europa. Objetivo: Se estudió la viabilidad, la validez y la fiabilidad de la Pruebas de salud para refugiados - 15 (RHS-15, siglas en inglés de Refugee Health Screener) - una evaluación eficiente y fácil de implementar, desarrollada por Hollifield et al. (2013) - como instrumento de autoevaluación y entrevista. Métodos: Una muestra de refugiados de diferentes países (N = 86) ­representativa de aquellos que habían llegado a Alemania a finales de 2015 y principios de 2016­ rellenó el RHS-15 por su cuenta. Posteriormente se realizó una entrevista clínica semiestructurada con una submuestra aleatoria (n = 56). Resultados: El 52% de los refugiados examinados obtuvieron resultados positivos en la RHS-15, lo que indicaba que tenían problemas de salud mental en la actualidad. La RHS-15 mostró una buena viabilidad, fiabilidad y validez tanto en la autoevaluación como en la versión de la entrevista. Detectaba problemas de salud mental clínicamente relevantes cuando había TEPT, depresión, ansiedad o somatización. Una versión más corta de 13 ítems resultó ser igualmente válida. Conclusiones: Junto con investigaciones previas sobre la RHS en refugiados que viven en los Estados Unidos, esto sugiere que la RHS es un instrumento eficiente y preciso, capaz de detectar problemas de salud mental comunes en una amplia gama de refugiados. Posiblemente, la RHS podría ser utilizado como instrumento para identificar a refugiados vulnerables, por ejemplo, integrándolo en el examen médico inicial en la comunidad de acogida, con lo cual ya se comenzaría a apoyarles.

Sleep recordings in individuals with borderline personality disorder before and after trauma therapy.

Most individuals diagnosed with borderline personality disorder (BPD) have been exposed to severe and traumatic stressors and thus frequently present with symptoms of a posttraumatic stress disorder (PTSD). Severe sleep disturbances often accompany these complex cases, but changes of sleep parameters during therapy and the impact of sleep on treatment response have barely been studied. Narrative Exposure Therapy (NET) is an evidence-based approach for the treatment of trauma-related psychological disorders. To investigate the effect of NET on sleep in patients with BPD and comorbid PTSD, we screened 45 inpatients and outpatients who met the inclusion criteria of both diagnoses according to DSM-IV and who had a minimum of 2 weeks' stable medication. Patients were allocated to NET (N = 13) or treatment as usual (TAU; N = 8) in blocks. Polysomnographies and psychological questionares were performed before, directly and 6 months after the last therapy session. The aim of this pilot study was to investigate the effectiveness of trauma therapy by NET on sleep quantity (total sleep time) and sleep continuity (sleep efficiency and awakenings) in patients with comorbid BPD and PTSD. Participants of the NET group compared with those who received TAU showed an increased reduction in sleep latency from baseline to the end of therapy and a reduction in arousals over time. Patients with longer pre-treatment total sleep time and pre-treatment REM sleep duration showed a better outcome of NET with respect to PTSD symptoms. NET seems not lead to a change in sleep for the worse during therapy and seems to improve sleep as good as treatment as usual. Furthermore, our results provide evidence of an influence of sleep structure at baseline on treatment success later on.

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.

Prenatal screening for psychosocial risks in a high risk-population in Peru using the KINDEX interview.

BACKGROUND: Prenatal stress and other prenatal risk factors (e.g. intimate partner violence) have a negative impact on mother's health, fetal development as well as enduring adverse effects on the neuro-cognitive, behavioral and physical health of the child. Mothers of low socio-economic status and especially those living in crime-ridden areas are even more exposed to a host of risk factors. Societies of extreme violence, poverty and inequalities, often present difficulties to provide adequate mental health care to the most needed populations. The KINDEX, a brief standardized instrument that assesses 11 different risk factors was used by midwives to identify pregnant women at-risk, in a suburban area with one of the highest levels of domestic violence in Lima. The instrument was designed to be used by medical staff to identify high-risk child-bearing women and, based on the results, to refer them to the adequate psychological or social support providers. The aim of this study is to assess the feasibility of psychosocial screening using the KINDEX in a Latin American Country for the first time, and to explore the relationship of the KINDEX with thee major risk areas, maternal psychopathology, perceived stress and traumatic experiences. METHODS: The study was conducted in cooperation with the gynecological department of a general hospital in a suburban area of Lima. Nine midwives conducted interviews using the KINDEX of ninety-five pregnant women attending the gynecological unit of the hospital. From these, forty pregnant women were re-interviewed by a clinical psychologist using established instruments in order to assess the feasibility of the prenatal assessment in public health settings and the relationship of the KINDEX with maternal perceived stress, psychopathology symptoms and trauma load during pregnancy. RESULTS: We found high rates of risk factors in the examined pregnant women comparable with those found in the general population. Significant correlations were found between the KINDEX sum score and the three risks areas, stress, psychopathology and trauma load as assessed in the Clinical Expert interviews. The different risks assessed by the KINDEX are related to higher levels of stress, psychopathology and trauma load, depending on the risk. CONCLUSIONS: The relationship between past adverse experience and current stressors with perceived maternal stress, psychopathology symptoms and traumatic experiences confirm the importance of prenatal assessment for psychosocial risks. The use of KINDEX by midwives providing obstetrical care to pregnant women in urban Peru is feasible and can be used to identify high-risk women and refer them to the adequate mental health or social services for necessary attention and support. Early interventions are essential to mitigating the adverse effects of maternal stress, trauma and psychopathology on the fetus and child.

The relationship between trauma, shame, and guilt: findings from a community-based study of refugee minors in Germany.

BACKGROUND: The relationships between traumatic stress and self-conscious emotions, such as shame and guilt, remain to be fully explored, especially in refugees, who frequently are exposed to a multitude of stressors. OBJECTIVE: The aim of the present study was to investigate shame and guilt in refugee minors and to assess to what extent a greater cumulative exposure to traumatic stressors would result not only in more severe posttraumatic stress disorder (PTSD) symptoms but also in higher levels of shame and guilt. METHODS: Thirty-two male refugee minors, who were all below the age of 18 when they sought asylum in Germany, agreed to participate. At the time of the assessment, the age ranged from 11 to 20 years. Eighteen refugees had arrived without relatives in their host country ("unaccompanied minors"). In structured diagnostic interviews, a PTSD diagnosis was established using the UCLA PTSD Index. Posttraumatic guilt was assessed by means of the Trauma-related Guilt Inventory, and the Shame Variability Questionnaire was used to record the intensity, duration, and frequency of shame episodes. RESULTS: Feelings of guilt and shame as well as trauma symptoms were all associated with the number of traumatic event types subjects had experienced. Posttraumatic guilt and shame were both correlated with PTSD symptom severity. CONCLUSIONS: The findings indicate that cumulative stress such as exposure to multiple traumatic events poses a risk factor for the mental health including greater suffering and functional impairment due to shame and guilt.

The shutdown dissociation scale (shut-d).

The evolutionary model of the defense cascade by Schauer and Elbert (2010) provides a theoretical frame for a short interview to assess problems underlying and leading to the dissociative subtype of posttraumatic stress disorder. Based on known characteristics of the defense stages "fright," "flag," and "faint," we designed a structured interview to assess the vulnerability for the respective types of dissociation. Most of the scales that assess dissociative phenomena are designed as self-report questionnaires. Their items are usually selected based on more heuristic considerations rather than a theoretical model and thus include anything from minor dissociative experiences to major pathological dissociation. The shutdown dissociation scale (Shut-D) was applied in several studies in patients with a history of multiple traumatic events and different disorders that have been shown previously to be prone to symptoms of dissociation. The goal of the present investigation was to obtain psychometric characteristics of the Shut-D (including factor structure, internal consistency, retest reliability, predictive, convergent and criterion-related concurrent validity). A total population of 225 patients and 68 healthy controls were accessed. Shut-D appears to have sufficient internal reliability, excellent retest reliability, high convergent validity, and satisfactory predictive validity, while the summed score of the scale reliably separates patients with exposure to trauma (in different diagnostic groups) from healthy controls. The Shut-D is a brief structured interview for assessing the vulnerability to dissociate as a consequence of exposure to traumatic stressors. The scale demonstrates high-quality psychometric properties and may be useful for researchers and clinicians in assessing shutdown dissociation as well as in predicting the risk of dissociative responding.