How is trauma-focused therapy experienced by adults with PTSD? A systematic review of qualitative studies.

BACKGROUND: Trauma-focused therapies (TFTs) are first-line treatments for posttraumatic stress disorder (PTSD). However, TFTs are under-utilised, partly due to clinicians' and patients' fear that TFT is too challenging or harmful. We review the qualitative studies on how adults with PTSD experience TFTs to enhance the understanding of user perspectives, therapeutic processes, and outcomes. METHODS: PubMed, PsychINFO and PTSDPubs were searched between October 1st and November 30th, 2021. Study quality assessments were undertaken, and studies were analysed using a descriptive-interpretative approach. Nine studies were included. RESULTS: The analysis resulted in the identification of four key domains, representing a temporal sequence of TFT stages: Overcoming ambivalence towards TFT, Experience of treatment elements, Motivation for dropout/retention, and Perceived changes post-treatment. CONCLUSION: Although many participants reported high levels of distress and considered dropping out, only a minority did eventually drop out and most patients expressed that the hardships in therapy were necessary for PTSD improvement. Establishing a safe therapeutic environment and working with the ambivalence towards treatment was essential for retention. This review serves a dual purpose, to shed light on diverse TFT experiences found to be important for treatment satisfaction, and to elucidate common treatment patterns. The results can be used in preparing patients for therapy and in training TFT therapists. Studies had moderate to high quality, and more studies of experiences of TFT non-responders and dropouts in a non-veteran population are needed to further our understanding of the utility and limitations of TFTs.

Internet-based acceptance and commitment therapy for transdiagnostic treatment of comorbid posttraumatic stress disorder and chronic pain: A development pilot study.

OBJECTIVE: Acceptance and commitment therapy (ACT) is a transdiagnostic, behavioral treatment focusing on common processes behind different diagnoses. Internet-based treatment programs can improve access to treatment and easily be integrated into the individual's life. METHOD: This single-arm, pre-post-follow-up pilot study examined the acceptability, safety, and effectiveness of internet-based ACT (iACT) for participants with comorbid posttraumatic stress disorder (PTSD) and chronic pain treated at a tertiary pain clinic. All participants (N = 10) received the iACT program over a period of 10 weeks and were assessed pre- and postintervention and at a 3-month follow-up. RESULTS: This study provides preliminary evidence for the acceptability, safety, and effectiveness of iACT for comorbid PTSD and chronic pain. The program showed clinically significant improvement in relation to the primary outcomes PTSD symptom severity and pain interference for this patient group with complex, comorbid symptoms, with sustained effects at the 3-month follow-up. CONCLUSIONS: These results add to previous research where face-to-face ACT has been shown to be of benefit to individuals with either chronic pain or PTSD. The findings also suggest that iACT can be delivered to individuals with comorbid PTSD and chronic pain with an effectiveness that is comparable to other cognitive behavioral therapy-based treatments for somatic and psychiatric disorders. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees.

Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.

Relations between PTSD symptom clusters and pain in three trauma-exposed samples with pain.

OBJECTIVES: Little is known about how the individual PTSD symptom clusters relate to intensity and interference of pain and whether these relationships differ across clinical groups. The present study examines relations between PTSD symptom clusters and pain in three trauma-exposed, unique clinical groups: 1) adults seeking treatment for chronic pain with current symptoms of PTSD, 2) trauma affected refugees seeking treatment for PTSD and chronic pain; and 3) individuals identified at admission to the emergency ward after whiplash injury. METHODS: Network analysis was used to assess unique relations between pain intensity, pain interference, re-experiencing, avoidance, numbing, hyperarousal, depression, and anxiety separately in each sample. Links between PTSD clusters and pain were then compared within and between samples. RESULTS: No within-group differences were identified for the links between pain and any of PTSD clusters in the chronic pain and refugee groups. In the whiplash group, hyperarousal was more strongly related to pain than re-experiencing, avoidance, and numbing. Between group comparisons revealed a more pronounced relationship between hyperarousal and pain in the whiplash group, with no between-group differences between the chronic pain and refugee groups. CONCLUSIONS: The findings suggest that when depression and anxiety are accounted for, few unique associations are found between pain and the PTSD symptom clusters in trauma-exposed samples with pain, with the exception of a link between pain and hyperarousal in individuals with whiplash-related PTSD symptoms.

Adverse childhood experiences among children of parents who are refugees affected by trauma in Denmark: a register-based cohort study.

BACKGROUND: Children in families who are refugees might experience more adversities than their peers. Adverse childhood experiences (ACEs) are well known risk factors for poorer adulthood health and adjustment. The risk of ACEs for children with a parent who is a refugee affected by trauma is unknown. We aimed to estimate the hazard of individual and cumulative ACEs using a unique sample of children with parents who are refugees affected by and seeking treatment for trauma and population level data. METHODS: This was a register-based cohort study carried out in Denmark. All children aged 0-15 years, residing in Denmark between Jan 1, 1990, and Dec 31, 2016, were followed up from birth or migration into the country to their 15th birthday. We linked data from the Danish Civil Registration System, the Danish National Patient Register, the Danish Psychiatric Central Research Register, the Employment Classification Module, the Register of Causes of Death, and the Income Statistics Register to investigate ten ACE categories (parental: natural and unnatural death, serious mental illness, substance use disorder, somatic illness, and disability; child: residential instability, family disruption, poverty, and stressors) and the cumulative number of ACE categories for children with a parent from a refugee-sending country and children with a parent who is a refugee in treatment for trauma. The main outcome was the hazard ratio (HR) of the individual and cumulative ACEs among children with a parent from a refugee-sending country and children with a parent who is a refugee affected by trauma, compared with the general population of children in Denmark, both adjusted and unadjusted for parental country of origin. FINDINGS: 2 688 794 children were included in the study, 252 310 of whom had parents from refugee-sending countries. 11 603 children had parents affected by trauma and seeking treatment, of whom 1163 (10%) migrated to Denmark before their second birthday and 10 440 (90%) were born in Denmark. Compared with the general population of children in Denmark, the hazard for most ACEs was significantly higher for both children with parents from a refugee-sending country and children with parents who are refugees affected by trauma. For children with a parent from a refugee-sending country, the highest HR was related to the child living in relative poverty for 3 years (3·62 [95% CI 3·52-3·73]). After adjusting for parental country of origin, the hazards for five ACEs were significantly greater for children of parents who are refugees affected by trauma compared with the remaining children of parents from the same countries. The highest HR for this child group was for parental serious mental illness (1·98 [1·85-2·12]). The hazard for experiencing multiple ACEs was significantly higher for both child groups compared with the general population. INTERPRETATION: Our findings suggest that children with parents from refugee-sending countries have a higher rate of several ACEs compared with the general population. Furthermore, having a parent who is a refugee affected by trauma and seeking treatment seems to be an independent risk factor for poorer health and adjustment in adulthood. This study informs decision makers and caregivers that there might be much added value in addressing needs within the whole family, as opposed to only attending to the parent who is seeking treatment. FUNDING: The Lundbeck Foundation.

Pre-treatment pain predicts outcomes in multimodal treatment for tortured and traumatized refugees: a pilot investigation.

Background: Chronic pain is a common comorbid complaint in traumatized refugees seeking treatment for posttraumatic stress disorder (PTSD) and depression. However, the effect of comorbid pain on treatment remains under investigated. Objective: To investigate whether pre-treatment pain (severity/interference) predicts outcomes in a multimodal treatment targeting PTSD, depression, anxiety, somatic complaints, and health-related disability in refugees exposed to torture and organized violence. Additional predictors were gender, age, and number of treatment sessions. Method: Participants were active cases at a specialist outpatient clinic for tortured refugees (n = 276; 170 men, 106 women) who were either on a treatment waitlist (mean length = 7.4 months, SD = 4.5), in treatment (mean length = 12.2 months, SD = 6.5), or who completed treatment and had (or were waiting for) a follow-up assessment. Participants completed symptom measures at referral, pre- and post-treatment, and 9-month follow-up. Multi-level mixed modelling was used to assess whether outcomes at post-treatment and 9-months were predicted by pain, gender, age, or the number of treatment sessions. Results: Treatment yielded significant pre-to-post-treatment reductions in PTSD, depression, anxiety, and number of pain locations, but no reductions in pain severity/interference, or health-related disability, except for societal participation. Gains for PTSD, depression, and societal participation were maintained at the 9-month follow-up. Higher levels of pain interference (but not severity) predicted poorer outcomes (PTSD, depression, and anxiety). Age, gender and number of treatment sessions did not predict outcomes, except for a small negative effect of (older) age on PTSD. Conclusions: A growing body of literature suggests that pain and PTSD symptoms interact in ways to increase the severity and impact of both disorders in refugee and non-refugee populations alike. The present study suggests interference from pain can lessen the effectiveness of standard multi-modal treatments for refugees.

Antecedentes: el dolor crónico es una queja comórbida común en refugiados traumatizados que buscan tratamiento para el trastorno de estrés postraumático (TEPT) y depresión. Sin embargo, el efecto del dolor comórbido en el tratamiento sigue siendo investigado.Objetivo: investigar si el dolor previo al tratamiento (severidad/interferencia) predice los resultados en un tratamiento multimodal para el TEPT, depresión, ansiedad, quejas somáticas y discapacidad relacionada con la salud en refugiados expuestos a tortura y violencia organizada. Predictores adicionales fueron el sexo, edad y número de sesiones de tratamiento.Método: los participantes fueron casos activos en una clínica ambulatoria especializada para refugiados torturados (n = 276; 170 hombres, 106 mujeres) que estaban en una lista de espera de tratamiento (duración media = 7,4 meses, DE = 4,5), en tratamiento (duración media = 12.2 meses, DE = 6.5), o quienes completaron tratamiento y tuvieron (o estaban esperando) una evaluación de seguimiento. Los participantes completaron las mediciones de síntomas en la derivación, antes y después del tratamiento, y en un Seguimiento a los 9 meses. Se utilizó un modelo mixto multinivel para evaluar si los resultados en el postratamiento y a los 9 meses eran predichos por dolor, sexo, edad o el número de sesiones de tratamiento.Resultados: el tratamiento produjo reducciones significativas desde el pre al postratamiento en TEPT, depresión, ansiedad y número de localizaciones de dolor, pero no hubo reducciones en la severidad/interferencia del dolor o discapacidad relacionada con la salud, excepto por la participación social. Las ganancias para el TEPT, depresión y participación social se mantuvieron a los 9 meses de seguimiento. Los niveles más altos de interferencia del dolor (pero no la gravedad) predijeron resultados más pobres (TEPT, depresión y ansiedad). La edad, sexo y número de sesiones de tratamiento no predijeron los resultados, excepto por un pequeño efecto negativo de la edad (mayor) en TEPT.Conclusiones: un creciente cuerpo de literatura sugiere que el dolor y los síntomas de TEPT interactúan de manera que aumentan la gravedad y el impacto de ambos trastornos en las poblaciones de refugiados y no refugiados por igual. El estudio presente sugiere que la interferencia del dolor puede disminuir la efectividad de los tratamientos multimodales estándar para refugiados.

Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs.

BACKGROUND: Traumatized refugees with comorbid pain report more severe posttraumatic stress disorder (PTSD), respond less well to PTSD-focused treatments and exhibit greater disability. A mutually maintaining relationship may exist between pain and PTSD, that may be partly accounted for by depression, but no prior studies have tested this assumption in traumatized refugees. METHOD: Self-report measures of pain, PTSD, depression, disability, pain catastrophizing (PC) and trauma-related beliefs (TRBs) were administered to 197 refugees referred to the Danish Institute Against Torture (DIGNITY) prior to treatment. The contribution of pain, depression, PC, and TRBs to the overall variance in PTSD severity was examined. We also examined whether the relationship between pain and PTSD was mediated by PC and TRBs, after controlling for depression. RESULTS: Depression, pain severity, PC and TRBs together accounted for 66% of the overall variance in PTSD, with depression being the primary contributor (57%). In univariate tests, both PC and TRBs significantly mediated the relationship between pain interference/severity and PTSD. However, after controlling for depression only PC mediated this relationship. CONCLUSIONS: Negative beliefs about pain and the trauma made small, but additive contributions to the relationship between pain and PTSD severity, after controlling for depression. Longitudinal studies with refugees, involving tests of more complex mutual maintenance models, are warranted. SIGNIFICANCE: After controlling for symptoms of depression, pain catastrophizing and negative trauma-related beliefs partly mediated the relationship between pain and PTSD in tortured refugees. The results suggest that all three variables are important in a mutual mediation model of pain and PTSD, and as targets for treatment, in traumatized refugees.

Torture survivors' symptom load compared to chronic pain and psychiatric in-patients.

Before their entry into the rehabilitation program at the Rehabilitation and Research Centre for Torture Victims ('RCT') in Copenhagen, the degree of symptoms of a group of resettled traumatized refugees was assessed by means of two rating scales: the Disability Rating Index (DRI) (n=197), measuring pain-related functional disability, and the Hospital Anxiety and Depression Scale (HADS) (n=147). The results obtained were compared with other patient populations, which included (1) a large Swedish mixed pain group and (2) various groups of pain patients previously investigated in the validation study of the DRI scale. The DRI scores of the refugee group were comparable to, or higher than, those of the pain groups, except for patients suffering from multiple sclerosis. The degree of anxiety and depression was found to be considerably greater in the refugee group than in the pain groups. Another recently published Danish study comparing traumatized refugees with psychiatric in-patients in terms of Health of Nation Outcome Scores (HoNOS) documented a higher degree of psychiatric disability for refugees. Based on the hypothesis that the observed differences in this study were underestimated due to the exclusion of refugees with psychotic symptoms and substance abuse, a partial re-analysis of the data was carried out by calculating effect sizes with and without the items measuring these symptoms. Controlling for the exclusion of the critical items resulted in a more pronounced difference between the refugees and psychiatric inpatients. Based on the data compared in this study, traumatized refugees are shown to suffer from multiple problems, including chronic pain, at a high symptom-level. This challenges prior clinical assumptions that single factors like PTSD can explain all symptoms.

Cognitive behavioural therapy in multiple sclerosis: a randomized controlled pilot study of acceptance and commitment therapy.

OBJECTIVE: The aim of this study was to design a trial that could evaluate the effect of acceptance and commitment therapy as a group-intervention for multiple sclerosis patients with psychological distress. DESIGN: Randomized controlled trial with assessment at pretreatment, end of treatment, and at 3-month follow-up. SUBJECTS: Multiple sclerosis outpatients with elevated symptoms of anxiety and/or depression (n = 21). METHODS: Patients were randomly assigned to acceptance and commitment therapy or relaxation training. Both treatments consisted of 5 sessions over 15 weeks containing didactic sessions, group discussions, and exercises. Outcome was assessed by self-rated symptoms of anxiety, depression, and a measure of acceptance. RESULTS: At 3-month follow-up, the relaxation training group had a significant decline in anxiety symptoms whereas the acceptance and commitment therapy group showed a maintained improvement in rated acceptance at follow-up. CONCLUSION: The results reflect the different emphases of the therapies. Acceptance and commitment therapy is aimed at living an active, valued life and increasing acceptance, while relaxation training focuses directly on coping strategies to handle emotional symptoms. The results are preliminary, but supportive of further study of brief group interventions for reducing psychological distress in patients with multiple sclerosis.