Towards a more comprehensive understanding of PTSD and parenting.

BACKGROUND: The impact of post-traumatic stress disorder (PTSD) on parenting and the parent-child relationship has been well-documented in the scientific literature. However, some conceptual and methodological challenges within this research field remain. PROCEDURE: We reflect on a number of challenges that we identified while examining the literature in preparation of an individual participant data meta-analysis on the relationships between PTSD and parenting. FINDINGS: We address 1) the presence of 'trauma-islands'; 2) the need for transdiagnostic theoretical frameworks for mechanisms between PTSD and parenting; 3) the lack of developmental perspectives; 4) the overuse of self-reported retrospective measures; 5) the need to study more diverse samples and cultural contexts; and 6) the lack of research on resilience and post-traumatic growth in parenting. Based on these reflections, we offer suggestions on strategies for responding to these challenges through: 1) welcoming open science; 2) working towards shared theoretical frameworks; 3) doing more longitudinal research 4) expanding the methodological palette; 5) centering lived experience; and 6) taking systemic inequality into account. CONCLUSION: With this commentary, we aim to open a discussion on next steps towards a more comprehensive understanding of the association between PTSD and parenting, and inspire collaborative research.

Symptomatology following loss and trauma: Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample.

BACKGROUND: Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population. METHOD: In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables. RESULTS: Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life. CONCLUSIONS: PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.

Reducing consequences of child maltreatment during adulthood by public health actions: a Delphi study.

BACKGROUND: Child maltreatment (CM) is associated with long-lasting poor health outcomes, as well as increased levels of disability and health-services consumption across the life-span. However, less is known about how CM consequences can be reduced during adulthood. We investigated professional opinions on how to mitigate long-term consequences of CM in a public health (PH) perspective. METHODS: Using the Delphi method in three rounds, we inquired 91 professionals, mostly European researchers and clinicians about potential PH actions to mitigate CM consequences during adulthood. RESULTS: Most experts agreed that PH actions are needed. Increasing community awareness and training emotional regulation in affected adults were prioritized strategies. Enlarging curricular knowledge about CM for professionals and developing evidence-based interventions were considered preferred methods. Reducing the barriers for access to interventions for adults, such as those provided by trauma-informed services were also suggested. Participants highlighted the possibility to reduce CM consequences across generations as a significant benefit. CONCLUSIONS: PH programmes to reduce the burden of CM can be enhanced by specific actions to facilitate the recognition of difficulties in affected adults and to expand the availability of helpful resources. The application of these programmes could be assisted by the use of modern information-technology.

Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study.

Research showed that more than 30% of patients with Posttraumatic Stress Disorder (PTSD) do not benefit from evidence-based treatments: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These are patients with prolonged and multiple traumatization, with poor verbal memory, and patients with emotional over-modulation. Retelling traumatic experiences in detail is poorly tolerated by these patients and might be a reason for not starting or not completing the recommended treatments. Due to lack of evidence, no alternative treatments are recommended yet. Art therapy may offer an alternative and suitable treatment, because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often wordless and visual nature of traumatic memories. The objective of this pilot study was to test the acceptability, feasibility, and applicability of trauma-focused art therapy for adults with PTSD due to multiple and prolonged traumatization (patients with early childhood traumatization and refugees from different cultures). Another objective was to identify the preliminary effectiveness of art therapy. Results showed willingness to participate and adherence to treatment of patients. Therapists considered trauma-focused art therapy feasible and applicable and patients reported beneficial effects, such as more relaxation, externalization of memories and emotions into artwork, less intrusive thoughts of traumatic experiences and more confidence in the future. The preliminary findings on PTSD symptom severity showed a decrease of symptoms in some participants, and an increase of symptoms in other participants. Further research into the effectiveness of art therapy and PTSD is needed.

Do prolonged grief disorder symptoms predict post-traumatic stress disorder symptoms following bereavement? A cross-lagged analysis.

BACKGROUND: Bereavement can precipitate different forms of psychopathology, including prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptoms. How these symptoms influence each other is unclear. The aim of this study was to examine the temporal relationship of symptoms of PGD and PTSD following bereavement. METHODS: We included 204 individuals, confronted with the loss of a loved one within the past year, who completed self-report measures of PGD and PTSD and again completed these measures one year later. We conducted a cross-lagged analysis to explore cross-lagged and autoregressive relationships. RESULTS: A significant cross-lagged relationship was found between PGD symptoms at time point 1 (T1) and PTSD symptoms at time point 2 (T2) (ß=0.270, p<0.001). Furthermore, PGD symptoms at T1 predicted PGD symptoms at T2 and PTSD symptoms at predicted PTSD symptoms at T2 (ß=0.617 and ß=0.458, ps<0.001, respectively). In addition, PGD and PTSD symptoms were significantly correlated on both time points. CONCLUSIONS: We found that PGD symptoms predict PTSD symptoms after a loss. Potentially, this could help to design new strategies and interventions for bereaved individuals. Additionally, PGD symptom levels predicted PGD symptom levels one year later, independently of the PTSD levels. This finding adds to the accumulating evidence that PGD is a distinct disorder.

The dissociative post-traumatic stress disorder (PTSD) subtype: A treatment outcome cohort study in veterans with PTSD.

OBJECTIVES: Dissociation is a prevalent phenomenon among veterans with post-traumatic stress disorder (PTSD) that may interfere with the effectiveness of treatment. This study aimed to replicate findings of a dissociative PTSD subtype, to identify corresponding patterns in coping style, symptom type, and symptom severity, and to investigate its impact on post-traumatic symptom improvement. METHODS: Latent profile analysis (LPA) was applied to baseline data from 330 predominantly (97%) male treatment-seeking veterans (mean age 39.5 years) with a probable PTSD. Multinomial logistic models were used to identify predictors of dissociative PTSD. Eighty veterans with PTSD that commenced with psychotherapy were invited for a follow-up measure after 6 months. The majority (n = 64, 80% response rate) completed the follow-up measure. Changes in post-traumatic stress between baseline and follow-up were explored as a continuous distal outcome. RESULTS: Latent profile analysis revealed four distinct patient profiles: 'low' (12.9%), 'moderate' (33.2%), 'severe' (45.1%), and 'dissociative' (8.8%) PTSD. The dissociative PTSD profile was characterized by more severe pathology levels, though not post-traumatic reactions symptom severity. Veterans with dissociative PTSD benefitted equally from PTSD treatment as veterans with non-dissociative PTSD with similar symptom severity. CONCLUSIONS: Within a sample of veterans with PTSD, a subsample of severely dissociative veterans was identified, characterized by elevated severity levels on pathology dimensions. The dissociative PTSD subtype did not negatively impact PTSD treatment. PRACTITIONER POINTS: The present findings confirmed the existence of a distinct subgroup veterans that fit the description of dissociative PTSD. Patients with dissociative PTSD subtype symptoms uniquely differed from patients with non-dissociative PTSD in the severity of several psychopathology dimensions. Dissociative and non-dissociative PTSD patients with similar post-traumatic severity levels showed similar levels of improvement after PTSD treatment. The observational design and small sample size caution interpretation of the treatment outcome data. The IES-R questionnaire does not assess all PTSD DSM-IV diagnostic criteria (14 of 17), although it is considered a valid measure for an indication of PTSD.

Predicting post-traumatic stress disorder treatment response in refugees: Multilevel analysis.

OBJECTIVES: Given the recent peak in refugee numbers and refugees' high odds of developing post-traumatic stress disorder (PTSD), finding ways to alleviate PTSD in refugees is of vital importance. However, there are major differences in PTSD treatment response between refugees, the determinants of which are largely unknown. This study aimed at improving PTSD treatment for adult refugees by identifying PTSD treatment response predictors. DESIGN: A prospective longitudinal multilevel modelling design was used to predict PTSD severity scores over time. We analysed data from a randomized controlled trial with pre-, post-, and follow-up measurements of the safety and efficacy of eye movement desensitization and reprocessing and stabilization in asylum seekers and refugees suffering from PTSD. METHODS: Lack of refugee status, comorbid depression, demographic, trauma-related and treatment-related variables were analysed as potential predictors of PTSD treatment outcome. Treatment outcome data from 72 participants were used. RESULTS: The presence (B = 6.5, p = .03) and severity (B = 6.3, p < .01) of a pre-treatment depressive disorder predicted poor treatment response and explained 39% of the variance between individuals. CONCLUSIONS: Refugee patients who suffer from PTSD and severe comorbid depression benefit less from treatment aimed at alleviating PTSD. Results highlight the need for treatment adaptations for PTSD and comorbid severe depression in traumatized refugees, including testing whether initial targeting of severe depressive symptoms increases PTSD treatment effectiveness. PRACTITIONER POINTS: There are differences in post-traumatic stress disorder (PTSD) treatment response between traumatized refugees. Comorbid depressive disorder and depression severity predict poor PTSD response. Refugees with PTSD and severe depression may not benefit from PTSD treatment. Targeting comorbid severe depression before PTSD treatment is warranted. This study did not correct for multiple hypothesis testing. Comorbid depression may differentially impact alternative PTSD treatments.

Perceived support at work after critical incidents and its relation to psychological distress: a survey among prehospital providers.

INTRODUCTION: Prehospital providers are at increased risk for psychological distress. Support at work after critical incidents is believed to be important for providers, but current guidelines are in need of more scientific evidence. This study aimed to investigate: (1) to what extent prehospital providers experience support at work; (2) whether support at work is directly associated with lower distress and (3) whether availability of a formal peer support system is related to lower distress via perceived colleague support. METHODS: This cross-sectional study surveyed prehospital providers from eight western industrialised countries between June and November 2014. A supportive work environment was operationalised as perceived management and colleague support (Job Content Questionnaire), availability of a formal peer support system and having enough time to recover after critical incidents. The outcome variable was psychological distress (Kessler 10). We conducted multiple linear regression analyses and mediation analysis. RESULTS: Of the 813 respondents, more than half (56.2%) were at moderate to high risk of psychological distress. Participants did not consistently report support at work (eg, 39.4% were not aware of formal peer support). Perceived management support (b (unstandardised regression coefficient)=-0.01, 95% CI -0.01 to 0.00), having enough time to recover after critical incidents (b=-0.07, 95% CI -0.09 to -0.04) and perceived colleague support (b=-0.01, 95% CI -0.01 to 0.00) were related to lower distress. Availability of formal peer support was indirectly related to lower distress via increased perceived colleague support (ß=-0.04, 95% CI -0.02 to -0.01). CONCLUSIONS: Prehospital providers at risk of psychological distress may benefit from support from colleagues and management and from having time to recover after critical incidents. Formal peer support may assist providers by increasing their sense of support from colleagues. These findings need to be verified in a longitudinal design.

Attachment Representation and Sensitivity: The Moderating Role of Posttraumatic Stress Disorder in a Refugee Sample.

It has been hypothesized that adult attachment representations guide caregiving behavior and influence parental sensitivity, and thus affect the child's socio-emotional development. Several studies have shown a link between posttraumatic stress disorder (PTSD) and reduced parental sensitivity, so it is possible that PTSD moderates the relationship between insecure attachment representations and insensitivity. In this study symptoms of PTSD (Harvard Trauma Questionnaire), parental sensitivity (Emotional Availability Scales), and attachment representations (Attachment Script Assessment) were assessed in 53 parents who were asylum seekers or refugees. Results showed that when parents were less able to draw on secure attachment representations, symptoms of PTSD increased the risk of insensitive parenting. These findings suggest that parental sensitivity is affected not just by attachment representations, but by a conjunction of risk factors including symptoms of PTSD and insecure attachment representations. These parents should therefore be supported to establish or confirm secure models of attachment experiences, to facilitate their ability interact sensitively and form a secure relationship with their children.

Lives on hold: A qualitative study of young refugees' resilience strategies.

Although the literature on positive adjustment following traumatic events is growing, only a few studies have examined this phenomenon in young refugees. Using the social-ecological framework, the aim of this study was to identify factors and processes that according to young refugees promote their resilience. A total of 16 treatment-seeking refugees aged 13-21 years, living in the Netherlands, were interviewed. Data analysis revealed four resilience strategies: (1) acting autonomously, (2) performing at school, (3) perceiving support from peers and parents, and (4) participating in the new society. These strategies interacted with one another and demonstrated the interrelatedness between individuals and their social context. Having to wait long for a residence permit and being older appeared to negatively influence participants' resilience strategies. These findings suggest that resilience refers to a dynamic process that is context and time specific.

Eye movement desensitisation and reprocessing therapy v. stabilisation as usual for refugees: randomised controlled trial.

BACKGROUND: Eye movement desensitisation and reprocessing (EMDR) therapy is a first-line treatment for adults with post-traumatic stress disorder (PTSD). Some clinicians argue that with refugees, directly targeting traumatic memories through EMDR may be harmful or ineffective. AIMS: To determine the safety and efficacy of EMDR in adult refugees with PTSD (trial registration: ISRCTN20310201). METHOD: In total, 72 refugees referred for specialised treatment were randomly assigned to 12 h of EMDR (3×60 min planning/preparation followed by 6×90 min desensitisation/reprocessing) or 12 h (12×60 min) of stabilisation. The Clinician-Administered PTSD Scale (CAPS) and Harvard Trauma Questionnaire (HTQ) were primary outcome measures. RESULTS: Intention-to-treat analyses found no differences in safety (one severe adverse event in the stabilisation condition only) or efficacy (effect sizes: CAPS -0.04 and HTQ 0.20) between the two conditions. CONCLUSIONS: Directly targeting traumatic memories through 12 h of EMDR in refugee patients needing specialised treatment is safe, but is only of limited efficacy.

Between power and powerlessness: a meta-ethnography of sources of resilience in young refugees.

OBJECTIVE: This article reviews available qualitative studies that report young refugees' ways of dealing with adversity to address their sources of resilience. DESIGN: We searched five electronic databases. Twenty-six empirical studies were included in the review. A meta-ethnography approach was used to synthesize these qualitative studies. RESULTS: Six sources of resilience emerged: (1) social support, (2) acculturation strategies, (3) education, (4) religion, (5) avoidance, and (6) hope. These sources indicated social as well as personal factors that confer resilience in young refugees, but most of them also had counterproductive aspects. CONCLUSION: The results, from an ecological developmental perspective, stressed the interplay between protective and risk processes in the mental health of young refugees who had resettled in Western countries, and they emphasized the variability as well as the universality of resilience-promoting processes. Further research is needed to explore the cultural shape of resilience and the long-term consequences of war and migration on young refugees.

Parental PTSD, adverse parenting and child attachment in a refugee sample.

In contrast with traumatic experiences, there is a dearth of studies on the link between trauma symptoms, disconnected (frightened, threatening and dissociative) parenting behavior, extremely insensitive parenting behavior and child attachment. This study extends previous work on the impact of posttraumatic stress disorder (PTSD) on families by studying the unique contribution of disconnected and extremely insensitive parenting behavior on child attachment in a highly traumatized sample of 68 asylum seekers and refugees and their children (18-42 months). The results show that parental symptoms of PTSD are directly related to children's insecure attachment and disorganized attachment. The greatest proportion of the risk could be attributed to factors related to the dyad and not the family. A mediation effect of adverse parenting behavior was not confirmed. On the one hand the results indicate the need for an effective treatment of PTSD symptomatology while on the other hand the results indicate the need for clinical attention to insecure attachment relationships.

Child maltreatment and psychological symptoms in a Portuguese adult community sample: the harmful effects of emotional abuse.

Child maltreatment (CM) is associated with poor long-term health outcomes. However, knowledge about CM prevalence and related consequences is scarce among adults in South European countries. We examined the self-reported prevalence of five different forms of CM in a community sample of 1,200 Portuguese adults; we compared the results with similar samples from three other countries, using the same instrument. We also explored the relationship between CM and psychological symptoms. Cross-sectional data using the Childhood Trauma Questionnaire-Short Form and the Brief Symptom Inventory were analyzed. Moderate or severe CM exposure was self-reported by 14.7% of the sample, and 67% was exposed to more than one form of CM. Emotional neglect was the most endorsed experience, with women reporting greater emotional abuse and men reporting larger physical abuse. Physical and sexual abuse was less self-reported by Portuguese than by American or German subjects. CM exposure predicted 12.8% of the psychological distress. Emotional abuse was the strongest predictor for psychological symptoms, namely for paranoid ideation, depression, and interpersonal sensitivity. Emotional abuse overlapped with the exposure to all other CM forms, and interacted with physical abuse, physical neglect, and emotional neglect to predict psychological distress. Low exposure to emotional abuse was directly associated with the effects of physical abuse, physical neglect, and emotional neglect to predict adult psychological distress. Verbal abuse experiences were frequently reported and had the highest correlations with adult psychological distress. Our results underline the potential hurtful effects of child emotional abuse among Portuguese adults in the community. They also highlight the need to improve prevention and intervention actions to reduce exposure and consequences of CM, particularly emotional abuse.

Somatization in refugees: a review.

PURPOSE: To present a review of the literature concerning medically unexplained physical symptoms in refugees. METHODS: We outline a variety of definitions and explanations of somatization, as well as the role of culture in the concept of disease. In addition, we present a review of the epidemiological literature about somatization in refugees. RESULTS: Refugees from non-Western countries exhibit more unexplained somatic symptoms than the general Western population. Although different studies have employed different methodologies and are therefore difficult to compare, it can be concluded that refugees form a particular population in which somatization is prominent. CONCLUSIONS: Potential, not mutually exclusive, explanations of the high number of somatic symptoms in the refugee population include general psychopathology, specifically traumatisation, results of torture, and stigmatisation of psychiatric care. There are implications for assessment, clinical treatment and further research concerning somatization in refugees.

Seven-year follow-up study of symptoms in asylum seekers and refugees with PTSD treated with trauma-focused groups.

OBJECTIVE: To examine sustainability of symptom outcomes of a 1-year phase-based trauma-focused, multimodal, and multicomponent group therapy in a day treatment program for posttraumatic stress disorder (PTSD) over an average period of 7 years. METHOD: Iranian and Afghan patients (N = 69) were assessed with self-rated symptom checklists for PTSD, anxiety, and depression symptoms before (T1), after (T2), and up to 11 years upon completion of the treatment (T3). A series of mixed model regression analyses was applied to determine the course of the measured symptoms over time. RESULTS: At T2, all symptoms were reduced, but PTSD symptoms showed the strongest reduction. The trend of symptom reduction continued up to 5 years posttreatment and was similar for all the examined symptoms. After 5 years, all symptoms started to worsen, but remained under baseline levels at T3. CONCLUSIONS: The applied treatment appears to improve mental health of the studied sample on both the short and longer term.

Is legal status impacting outcomes of group therapy for posttraumatic stress disorder with male asylum seekers and refugees from Iran and Afghanistan?

BACKGROUND: Legal status and other resettlement stressors are known to impact mental health of asylum seekers and refugees. However, the ways in which they interact with treatment of posttraumatic stress disorder (PTSD) with these populations is still poorly understood. The aim of this study was to examine whether legal status and other resettlement stressors influence outcomes of a trauma-focused group PTSD treatment within a day-treatment setting with asylum seekers and refugees. METHODS: Sixty six male Iranian and Afghan patients with PTSD residing in the Netherlands were assessed with self-rated symptom checklists for PTSD, anxiety and depression, and a demographic questionnaire one week before and two weeks after the treatment. Multivariate linear regression analysis was used to examine the impact of legal status and living arrangements on the treatment outcomes per symptom domain. RESULTS: The results suggest that both asylum seekers and refugees can be helped with their mental health complaints with a trauma-focused group therapy for PTSD regardless of their legal status. Obtaining a refugee status in a course of the treatment appears to improve the treatment outcomes. CONCLUSIONS: Legal status is impacting outcomes of group therapy for PTSD with male asylum seekers and refugees. Asylum seekers may benefit from group treatment regardless of unstable living conditions.

The significance of experiences of war and migration in older age: long-term consequences in child survivors from the Dutch East Indies.

BACKGROUND: This study examines late consequences of war and migration in both non-clinical and clinical samples of child survivors of World War II. This is one of the very few studies on the mental health of children who were subjected to internment in camps, hiding, and violence under Japanese occupation in the Far East. It provides a unique case to learn about the significance of experiences of war and migration in later life. METHODS: Long-term sequelae of the Japanese persecution in the Dutch East Indies (DEI) in child survivors were studied by analyzing sets of standardized questionnaires of 939 persons. Instruments dealt with post-traumatic responses, general health, and dissociation. Participants were recruited through community services and registers of clinical services. Discriminant analyses were conducted to evaluate the significance of early experiences in determining group belonging. RESULTS: Compared with age-matched controls that lived through the German occupation in the Netherlands during World War II, the child survivors from the DEI reported both more trauma-related experiences and mental health disturbances in later life. In particular, the number of violent events during the war, among which especially internment in a camp, contributed to the variation among groups, in support of the significance of these disruptive experiences at older age. CONCLUSION: The results underline the long-term significance of World War II-related traumatic experiences in the population of elderly child survivors who spent their childhood in the former DEI.

The role of stress sensitization in progression of posttraumatic distress following deployment.

PURPOSE: Military personnel exposed to combat are at risk for experiencing post-traumatic distress that can progress over time following deployment. We hypothesized that progression of post-traumatic distress may be related to enhanced susceptibility to post-deployment stressors. This study aimed at examining the concept of stress sensitization prospectively in a sample of Dutch military personnel deployed in support of the conflicts in Afghanistan. METHOD: In a cohort of soldiers (N = 814), symptoms of post-traumatic stress disorder (PTSD) were assessed before deployment as well as 2, 7, 14, and 26 months (N = 433; 53 %) after their return. Data were analyzed using latent growth modeling. Using multiple group analysis, we examined whether high combat stress exposure during deployment moderated the relation between post-deployment stressors and linear change in post-traumatic distress after deployment. RESULTS: A higher baseline level of post-traumatic distress was associated with more early life stressors (standardized regression coefficient = 0.30, p < 0.001). In addition, a stronger increase in posttraumatic distress during deployment was associated with more deployment stressors (standardized coefficient = 0.21, p < 0.001). A steeper linear increase in posttraumatic distress post-deployment (from 2 to 26 months) was predicted by more post-deployment stressors (standardized coefficient = 0.29, p < 0.001) in high combat stress exposed soldiers, but not in a less combat stress exposed group. The group difference in the predictive effect of post-deployment stressors on progression of post-traumatic distress was significant (χ²(1) = 7.85, p = 0.005). CONCLUSIONS: Progression of post-traumatic distress following combat exposure may be related to sensitization to the effects of post-deployment stressors during the first year following return from deployment.