Does the Human Right to Healthcare Apply Universally? A Contribution from a Trauma Therapeutic Perspective.

Access to the best possible healthcare is a fundamental human right. However, the provision of medical treatment is not only dependent on the actual treatment options available and the type of illness to be treated but is significantly influenced and restricted by structural and legal conditions. This is particularly evident in the case of refugees and other groups such as the so-called "paperless", whose access to medical treatment is de facto seriously impeded or denied altogether. At the same time, these individuals are particularly vulnerable to the development of mental illness for a variety of reasons. Refugees in particular often suffer from trauma sequelae, resulting in a broad range of impairments. Based on a case study of a refugee woman living in her host country, the interactions between mental illness and limited psychiatric/psychotherapeutic treatment options due to legal restrictions are analyzed from a medical perspective. Her initially only medically oriented treatment was insufficient to mitigate the consequences of these restrictions. As it was a protracted treatment process, the legal aspects of her case therefore also had to be decisively considered. This case study shows that the human right to the best possible healthcare can be considerably restricted by structural requirements, which, in the case of sequential traumatization and severe illnesses with suicidal tendencies, can be labelled as structural violence.

[Traumatic childbirth and trauma-sensitive obstetric support]. / Traumatische Geburt und traumasensible Geburtsbegleitung.

Childbirth can be a very happy and empowering experience for women but also one of suffering and despair. Biographical traumatic experiences, especially sexual, physical and emotional violence, are risk factors for a traumatic childbirth experience with the danger of subsequent trauma sequelae and impaired mother-child bonding; however, obstetrically indicated interventions or poor communication in the delivery room can also primarily be experienced as traumatic.In recent years, policies affecting traumatic childbirth experience have been controversially and sometimes emotionally discussed. In the clinical obstetric routine there is often a fine line between medically necessary rapid interventions and emotionally supportive trauma-sensitive and preventive obstetric care. The following article addresses the causes and prevention strategies of traumatic childbirth experiences from obstetric, midwifery and psychotherapeutic perspectives.

Non-oncologic indication for elbow megaprothesis replacement: 2 cases report.

INTRODUCTION: Treatment of elbow bone defects is still a huge challenge in orthopaedic in order to restore the shape and function of the elbow joint. Bone defect reconstruction is very difficult due to biomechanical complexity of the elbow joint and the poor coverage tissue of this area, so mega-prothesis can be considered the most optimal solution in these cases. CASE REPORT: We present two clinical cases of megaprosthesis elbow replacement for treatment of bone defects caused by sequelae of trauma. There is one case of 3 cm bone defect at proximal ulna and one case of 3 cm bone defect at distal humerus. In the 1st case, the elbow joint is fusioned and the second case, the elbow joint is degenerated totally after 3 previous surgery. We performed total elbow replacement with a customized megaprosthesis for them. The Mayo elbow function assessment scale [1] pre-surgery was poor at 50 points. The average age is 35 years old. The mean post-operative follow-up time was 14 months. Range of elbow flexed motion was 135 degrees, both patients were maximally extension, the forearm pronation and supination were 90 and 75 degrees, respectively. The Mayo score is very good with 97,5 points. Both patients were completely satisfied with the postoperative results. CONCLUSION: Our results show that megaprosthesis elbow replacement is a very effective option for cases large elbow bone defects due to trauma sequelae. However, careful preoperative preparation is required for the best outcome.

[New AWMF guidelines for medicolegal assessment of mental and psychosomatic disorders]. / Neue AWMF-Leitlinie zur Begutachtung psychischer und psychosomatischer Störungen.

The guidelines, which were first published in 2012, were fundamentally revised by a panel of experts from 9 medical and psychological societies and published on the website of the Association of the Scientific Medical Societies in Germany in December 2019 (AWMF registration number 051-029). The guidelines contribute to interdisciplinary quality assurance when assessing applicants for insurance or other compensation benefits who claim psychological or psychosomatic illnesses with resulting functional disorders. The guidelines are divided into 3 separate parts: part I describes specific aspects of the expert examination, part II describes the criteria for assessing occupational performance capacity in terms of different legal fields and part III deals with questions of causality in cases of claimed posttraumatic mental disorders.

Hair cortisol predicts avoidance behavior and depressiveness after first-time and single-event trauma exposure in motor vehicle crash victims.

The role of cortisol as a premorbid vulnerability factor for trauma sequelae remains unclear. Furthermore, the onset of long-term endocrine changes in response to first-time trauma as a function of later psychopathology is not clarified yet. Thus the predictive value of pre- and post-traumatic hair cortisol concentrations (HCCs) for psychological trauma sequelae was investigated in response to motor vehicle crash (MVC). A total of N= 62 MVC survivors participated in this study (46 females, mean age (SD): 43.94(12.95)). Subsequent trauma sequelae were measured with a structured clinical interview and self-report questionnaires to evaluate psychological symptoms (pre-MVC and three months post-MVC). Hair strands were taken immediately after MVC and three months post-MVC, reflecting cumulative cortisol secretion over the three-month period before and after the MVC. A total of 22.6% of the participants developed a trauma sequela with an affective disorder (14.5%) and/or anxiety disorder (16.1%). We observed a significant main effect of group and diagnosis × time interaction with an increase of HCC in those individuals who presented a subsequent psychiatric disorder. Regression analyses revealed that post-MVC increased HCC were significantly predictive of higher levels of subsequent depressiveness, and that pre-MVC increased HCC were predictive of higher levels of subsequent avoidance behavior. Our findings demonstrate that individual differences in long-term cortisol secretion in response to a first-time traumatic event (MVC) contribute to subsequent psychopathology. Specifically, higher long-term cortisol secretion before and after first-time MVC was a risk factor for subsequent development of avoidance behavior and depressiveness, respectively.Lay summaryHigher cortisol secretion and stress experience before a motor vehicle crash was a risk factor for subsequent development of psychological symptoms.

The Temporal Relationship Between Coping Self-Efficacy and Dissociation in Undergraduate Students.

Dissociation is a lack of information integration resulting from a process that ranges on a continuum from normative experiences (e.g., daydreaming) to a pervasive traumatic response involving alterations and/or fragmentation in mental processes such as memory, emotion, and perception. Perceived coping self-efficacy (CSE) is a cognitive appraisal ability utilized to regulate internal and external stressors that arise from traumatic events, and is crucial for effective adaptation after extreme stress or trauma. Thus, CSE may be a critical component in decreasing dissociative experiences following a traumatic event. In the present study, 136 undergraduate students (M age = 22.36 years, SD = 6.27; 81% female, 69.1% Caucasian, 77.2% attended some college) completed self-report measures of trauma, dissociation, and coping self-efficacy. All measures were completed by the same participants at two different time points (Time 1 and Time 2) two months apart; all participants reported a history of exposure to at least one Criterion A traumatic event (according to the DSM-5) at Time 1. We hypothesized that CSE for posttraumatic coping demands at Time 2 would mediate the relationship between dissociation at Time 1 and dissociation at Time 2, and subsequently found evidence of significant mediation, 95% CI [.02, .18]. These findings suggest that initial levels of persistent dissociation negatively predict CSE, which in turn directly and negatively influence persistent dissociation at a later time point. This highlights how CSE may serve as a protective factor against persistent dissociation.

Changes in attachment organization, emotion dysregulation, and interpersonal problems among women in treatment for abuse.

OBJECTIVE: Women who have experienced childhood abuse often have interpersonal difficulties. The current study examines whether changes in emotion dysregulation mediate the relationship between changes in attachment patterns and changes in interpersonal problems among women who completed treatment for the sequelae of childhood abuse. METHOD: Participants were 36 women who completed a program targeting the psychological consequences of childhood maltreatment. At pre-and posttreatment, participants completed a projective assessment of adult attachment, and self-report measures of emotion dysregulation and interpersonal problems. RESULTS: Changes in emotion dysregulation mediated the relationship between shifts toward resolved attachment and changes in interpersonal problems. Compared to participants who maintained their pretreatment attachment patterns, those who shifted toward a resolved pattern became significantly more able to clarify and describe their emotions. Improvements in these abilities were associated with decreased problems with being nonassertive, overly accommodating, self-sacrificing, and socially inhibited. Additionally, improvements in emotional clarity uniquely mediated the relationship between shifts to resolved attachment and reductions in problems with being domineering and intrusive. Moreover, decreased difficulty describing feelings uniquely mediated the relationship between shifts to resolved attachment and decreases in problems with being cold. CONCLUSIONS: Among women who complete treatment for the sequelae of childhood abuse, shifts to resolved attachment were indirectly related to decreases in interpersonal problems through improved emotional processing.

Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: The Vienna Institutional Abuse Study.

Child maltreatment (CM) in foster care settings (i.e., institutional abuse, IA) is known to have negative effects on adult survivor's mental health. This study examines and compares the extent of CM (physical, emotional, and sexual abuse; physical and emotional neglect) and lifetime traumatization with regard to current adult mental health in a group of survivors of IA and a comparison group from the community. Participants in the foster care group (n = 220) were adult survivors of IA in Viennese foster care institutions, the comparison group (n = 234) consisted of persons from the Viennese population. The comparison group included persons who were exposed to CM within their families. Participants completed the Childhood Trauma Questionnaire, the Life Events Checklist for DSM-5, the PTSD Checklist for DSM-5, the International Trauma Questionnaire for ICD-11, and the Brief Symptom Inventory-18 and completed a structured clinical interview. Participants in the foster care group showed higher scores in all types of CM than the comparison group and 57.7% reported exposure to all types of CM. The foster care group had significantly higher prevalence rates in almost all mental disorders including personality disorders and suffered from higher symptom distress in all dimensional measures of psychopathology including depression, anxiety, somatization, dissociation, and the symptom dimensions of PTSD. In both groups, adult life events and some but not all forms of CM predicted PTSD and adult life events partly mediated the association of PTSD and CM. Explanations for the severe consequences of CM and IA are discussed.

Rates of traumatization and psychopathology in criminal justice-involved women.

Prior research has consistently found disproportionate rates of traumatization and psychopathology in criminal justice-involved women. The current study aimed to characterize rates of traumatization, psychopathology, and diagnostic comorbidity in women involved with the justice system. Furthermore, this study examined the role of posttraumatic stress symptoms in the association between traumatic events and levels of self-esteem. Participants were 185 women from the Chicagoland area with current or previous (past 2 years) involvement with the criminal justice system. Results confirmed disproportionate rates of trauma experiences and psychopathology in this population, and logistic regression analyses indicated that rates of traumatization predicted diagnostic comorbidity. Analyses indicated an indirect effect of posttraumatic stress in the association between traumatic experiences and self-esteem. Findings highlight the importance of assessing and targeting both trauma experiences and posttraumatic stress in justice-involved women to optimize prevention and intervention efforts.

[Cervical spine trauma]. / HWS-Traumata.

CLINICAL/METHODICAL ISSUE: In the emergency department 65 % of spinal injuries and 2-5 % of blunt force injuries involve the cervical spine. Of these injuries approximately 50 % involve C5 and/or C6 and 30 % involve C2. Older patients tend to have higher spinal injuries and younger patients tend to have lower injuries. The anatomical and development-related characteristics of the pediatric spine as well as degenerative and comorbid pathological changes of the spine in the elderly can make the radiological evaluation of spinal injuries difficult with respect to possible trauma sequelae in young and old patients. METHODICAL INNOVATIONS: Two different North American studies have investigated clinical criteria to rule out cervical spine injuries with sufficient certainty and without using imaging. PRACTICAL RECOMMENDATIONS: Imaging of cervical trauma should be performed when injuries cannot be clinically excluded according to evidence-based criteria. Degenerative changes and anatomical differences have to be taken into account in the evaluation of imaging of elderly and pediatric patients.