[Coping Process in Women with FGM from Ethiopia - The Contribution of Attitude]. / Belastungsbewältigung bei Frauen mit FGM aus Äthiopien ­ Zur Rolle der Einstellung.

The Female Genital Mutilation (FGM) is still practiced in many countries and mainly performed for traditional reasons. In this study, the relationship of the FGM type (type I and type III) with anxiety, depression, and posttraumatic stress disorder as well as the attitude toward FGM was analyzed. For this purpose the data of N=109 of FGM type I and III affected women from Ethiopia were collected. Analyses show moderation effects. It was found that the symptoms of depression and PTSD were less pronounced with a positive attitude towards the FGM in the sample of severely mutilated women (type III). It seems that the attitude toward FGM plays a major role in enhancing social recognition of those affected, thus better coping can take place. As well, this study shows the importance of the attitude of FGM tradition in the population to protect young girls prone for FGM.

Narrative exposure therapy for PTSD increases top-down processing of aversive stimuli--evidence from a randomized controlled treatment trial.

BACKGROUND: Little is known about the neurobiological foundations of psychotherapy for Posttraumatic Stress Disorder (PTSD). Prior studies have shown that PTSD is associated with altered processing of threatening and aversive stimuli. It remains unclear whether this functional abnormality can be changed by psychotherapy. This is the first randomized controlled treatment trial that examines whether narrative exposure therapy (NET) causes changes in affective stimulus processing in patients with chronic PTSD. METHODS: 34 refugees with PTSD were randomly assigned to a NET group or to a waitlist control (WLC) group. At pre-test and at four-months follow-up, the diagnostics included the assessment of clinical variables and measurements of neuromagnetic oscillatory brain activity (steady-state visual evoked fields, ssVEF) resulting from exposure to aversive pictures compared to neutral pictures. RESULTS: PTSD as well as depressive symptom severity scores declined in the NET group, whereas symptoms persisted in the WLC group. Only in the NET group, parietal and occipital activity towards threatening pictures increased significantly after therapy. CONCLUSIONS: Our results indicate that NET causes an increase of activity associated with cortical top-down regulation of attention towards aversive pictures. The increase of attention allocation to potential threat cues might allow treated patients to re-appraise the actual danger of the current situation and, thereby, reducing PTSD symptoms. REGISTRATION OF THE CLINICAL TRIAL: Number: NCT00563888Name: "Change of Neural Network Indicators Through Narrative Treatment of PTSD in Torture Victims" ULR: http://www.clinicaltrials.gov/ct2/show/NCT00563888.

Childhood adversity, mental ill-health and aggressive behavior in an African orphanage: Changes in response to trauma-focused therapy and the implementation of a new instructional system.

BACKGROUND: The number of orphans in Sub-Saharan Africa is constantly rising. While it is known that family or community care is preferable over institutional care of African orphans, little is known about the quality of care in orphanages and possibilities of improvement. STUDY 1: METHODS: Exposure to traumatic stress, experiences of violence in the home, school and orphanage, as well as mental ill-health and aggression of 38 children (mean age of M = 8.64 years) living in an orphanage in rural Tanzania were assessed at two time points. The severity of post-traumatic stress disorder symptoms (PTSD), depressive symptoms, and internalizing and externalizing problems were used as indicators of mental ill-health. RESULTS: Violence experienced in the orphanage correlated more strongly with all indicators of mental ill-health than violence in the former home, school or neighborhood at time point 1. Additionally, violence experienced in the orphanage had a positive relationship with the aggressive behavior of the children at time point 2. STUDY 2: METHODS: With the help of the pre-post assessment of Study 1, the implementation of a new instructional system and psychotherapeutic treatment (KIDNET) for trauma-related illness were evaluated. RESULTS: In response to both, a change in the instructional system and psychotherapeutic treatment of PTSD, a massive decline in experienced violence and in the severity of PTSD-symptoms was found, whereas depressive symptoms and internalizing and externalizing problems exhibited little change. CONCLUSIONS: These studies show that violence, especially in the orphanage, can severely contribute to mental ill-health in orphans and that mental health can be improved by implementing a new instructional system and psychotherapeutic treatment in an orphanage. Moreover, the results indicate that the experience of violence in an orphanage also plays a crucial role in aggressive behavior of the orphans.

Narrative exposure therapy for 7- to 16-year-olds: a randomized controlled trial with traumatized refugee children.

The authors examined the effectiveness of narrative exposure therapy for children (KIDNET) in treating posttraumatic stress disorder (PTSD) in refugee children living in exile. Twenty-six children traumatized by organized violence were randomly assigned to KIDNET or to a waiting list. Significant treatment by time interactions on all PTSD-relevant variables indicated that the KIDNET group, but not the controls, showed a clinically significant improvement in symptoms and functioning. Success of the KIDNET group remained stable at 12-month follow-up. This study confirms previous findings that, if left untreated, PTSD in children may persist for an extended period. However, it also shows that it is possible to effectively treat chronic PTSD and restore functioning in traumatized refugee children in only 8 treatment sessions.

Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study.

Rates of posttraumatic stress disorder (PTSD) are exceptionally high among asylum-seekers. Reportedly, stressors caused by the asylum procedure and psychological consequences of torture contribute to the maintenance of symptoms and interfere with treatment. In a pilot randomized controlled trial, the authors examined the efficacy of trauma-focused treatment in 32 asylum-seekers with PTSD resulting from state-sponsored violence and other traumatic events. Narrative exposure therapy (NET) was compared with treatment as usual (TAU), with a focus on stabilization and psychoactive medication. Six months after treatment, a significant reduction of posttraumatic stress symptoms was found in the NET participants but not in the TAU group. Although treatment gains were moderate, these results indicate that NET is a promising approach for the treatment of PTSD in asylum-seekers living in unstable conditions.

Treating children traumatized by war and Tsunami: a comparison between exposure therapy and meditation-relaxation in North-East Sri Lanka.

BACKGROUND: The North-Eastern part of Sri Lanka had already been affected by civil war when the 2004 Tsunami wave hit the region, leading to high rates of posttraumatic stress disorder (PTSD) in children. In the acute aftermath of the Tsunami we tested the efficacy of two pragmatic short-term interventions when applied by trained local counselors. METHODS: A randomized treatment comparison was implemented in a refugee camp in a severely affected community. 31 children who presented with a preliminary diagnosis of PTSD were randomly assigned either to six sessions Narrative Exposure Therapy for children (KIDNET) or six sessions of meditation-relaxation (MED-RELAX). Outcome measures included severity of PTSD symptoms, level of functioning and physical health. RESULTS: In both treatment conditions, PTSD symptoms and impairment in functioning were significantly reduced at one month post-test and remained stable over time. At 6 months follow-up, recovery rates were 81% for the children in the KIDNET group and 71% for those in the MED-RELAX group. There was no significant difference between the two therapy groups in any outcome measure. CONCLUSION: As recovery rates in the treatment groups exceeded the expected rates of natural recovery, the study provides preliminary evidence for the effectiveness of NET as well as meditation-relaxation techniques when carried out by trained local counselors for the treatment of PTSD in children in the direct aftermath of mass disasters. TRIAL REGISTRATION: ClinicalTrials.gov Identifier:NCT00820391.

Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): from neurocognitive theory to field intervention.

Many children in war-affected and refugee populations have experienced multiple traumatic experiences, and high rates of psychologic disorders, especially posttraumatic stress disorder (PTSD), are found. Intervention strategies require pragmatic and effective approaches to treatment. This article describes the rationale for and the use of narrative exposure therapy in children (KidNET). KidNET is a short-term treatment for PTSD based on a neurocognitive theory of traumatic memory. Early treatment trials, including randomized controlled studies, show promising results for the treatment of children and adolescents who have PTSD living in war-affected countries and refugee communities.

Altered oscillatory brain dynamics after repeated traumatic stress.

BACKGROUND: Repeated traumatic experiences, e.g. torture and war, lead to functional and structural cerebral changes, which should be detectable in cortical dynamics. Abnormal slow waves produced within circumscribed brain regions during a resting state have been associated with lesioned neural circuitry in neurological disorders and more recently also in mental illness. METHODS: Using magnetoencephalographic (MEG-based) source imaging, we mapped abnormal distributions of generators of slow waves in 97 survivors of torture and war with posttraumatic stress disorder (PTSD) in comparison to 97 controls. RESULTS: PTSD patients showed elevated production of focally generated slow waves (1-4 Hz), particularly in left temporal brain regions, with peak activities in the region of the insula. Furthermore, differential slow wave activity in right frontal areas was found in PTSD patients compared to controls. CONCLUSION: The insula, as a site of multimodal convergence, could play a key role in understanding the pathophysiology of PTSD, possibly accounting for what has been called posttraumatic alexithymia, i.e., reduced ability to identify, express and regulate emotional responses to reminders of traumatic events. Differences in activity in right frontal areas may indicate a dysfunctional PFC, which may lead to diminished extinction of conditioned fear and reduced inhibition of the amygdala.

Lack of cortisol response in patients with posttraumatic stress disorder (PTSD) undergoing a diagnostic interview.

BACKGROUND: According to DSM-IV, the diagnosis of posttraumatic stress disorder (PTSD) requires the experience of a traumatic event during which the person's response involved intense fear, helplessness, or horror. In order to diagnose PTSD, clinicians must interview the person in depth about his/her previous experiences and determine whether the individual has been traumatized by a specific event or events. However, asking questions about traumatic experiences can be stressful for the traumatized individual and it has been cautioned that subsequent "re-traumatization" could occur. This study investigated the cortisol response in traumatized refugees with PTSD during a detailed and standardized interview about their personal war and torture experiences. METHODS: Participants were male refugees with severe PTSD who solicited an expert opinion in the Psychological Research Clinic for Refugees of the University of Konstanz. 17 patients were administered the Vivo Checklist of War, Detention, and Torture Events, a standardized interview about traumatic experiences, and 16 subjects were interviewed about absorption behavior. Self-reported measures of affect and arousal, as well as saliva cortisol were collected at four points. Before and after the experimental intervention, subjects performed a Delayed Matching-to-Sample (DMS) task for distraction. They also rated the severity of selected PTSD symptoms, as well as the level of intrusiveness of traumatic memories at that time. RESULTS: Cortisol excretion diminished in the course of the interview and showed the same pattern for both groups. No specific response was detectable after the supposed stressor. Correspondingly, ratings of subjective well-being, memories of the most traumatic event(s) and PTSD symptoms did not show any significant difference between groups. Those in the presumed stress condition did not perform worse than persons in the control condition after the stressor. However, both groups performed poorly in the DMS task, which is consistent with memory and concentration problems demonstrated in patients with PTSD. CONCLUSION: A comprehensive diagnostic interview including questions about traumatic events does not trigger an HPA-axis based alarm response or changes in psychological measures, even for persons with severe PTSD, such as survivors of torture. Thus, addressing traumatic experiences within a safe and empathic environment appears to impose no unacceptable additional load to the patient.

Decoupling neural networks from reality: dissociative experiences in torture victims are reflected in abnormal brain waves in left frontal cortex.

From a neuroscience perspective, little is known about the long-term effect of torture. Dissociative experiences and posttraumatic stress disorder are often the results of this experience. We examined psychological dissociation within a group of 23 torture victims and report its manifestations within neural networks in the human brain. In particular, we observed that dissociative experiences are associated with slow abnormal brain waves generated in left ventrolateral frontal cortex. Given that focal slow waves often result from depriving neural networks of major input, the present results may indicate decoupling of frontal affective processors from left cortical language areas. This interpretation is consistent with the fact that disturbed access to structured verbal memory concerning traumatic events is a core feature of the dissociative experience.

Post-tsunami stress: a study of posttraumatic stress disorder in children living in three severely affected regions in Sri Lanka.

At 3 to 4 weeks after the December 2004 tsunami disaster we assessed symptoms of posttraumatic stress disorder (PTSD) in 264 children who lived in severely affected coastal communities in Manadkadu (northern coast), Kosgoda (western coast), and Galle (southern coast) in Sri Lanka. The prevalence rate of tsunami-related posttraumatic stress disorder (PTSD) (ignoring the time criterion) ranged between 14% and 39% and an additional 5% to 8% had PTSD unrelated to the tsunami. The PTSD symptoms were explained by the severity of the trauma exposure and family loss, as well as previous traumatic events. The results confirm the relevance of the individual history of traumatic events for the genesis of PTSD and indicate a high need of mental health assistance among the tsunami-affected children in Sri Lanka.