An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors.

INTRODUCTION: Torture is associated with adverse health consequences, with especially high rates of PTSD, depression and chronic pain. Despite increased awareness of the relationship between pain and posttraumaticsymptoms, and the accompanying need for effective treatment strategies, few studies have examined an integrated treatment of comorbid PTSD and pain. METHODS: In this study, using an A-B case series design with three and six month follow-up, six refugee torture survivors with comorbid PTSD, depression and chronic pain received 20 sessions of Narrative Exposure Therapy (NET) and 10 sessions of physiotherapy. Outcome variables included symptoms of PTSD and depression, pain intensity, physical functioning and quality of life. Symptoms of PTSD and pain were also rated after each treatment session. RESULTS: Two patients achieved clinically significant reduction in symptoms of PTSD. Only one patient achieved clinically significant change in depressive symptoms, and two experienced clinically significant reduction in pain intensity. Clinical descriptions of the course of treatment for all patients are provided. DISCUSSION AND CONCLUSIONS: Despite its limitations, the study suggests that some torture survivors who suffer high symptom loads may benefit from a combined treatment of NET and physiotherapy. Appreciating individual differences and how they affect treatment can provide valuable insight and inform clinicians working with torture survivors. Directions for future researchregarding the improvement of rehabilitation strategies of torture survivors are discussed, and highlighted through descriptions from the six therapy cases.

Pathological spirit possession as a cultural interpretation of trauma-related symptoms.

OBJECTIVE: Spirit possession is a phenomenon frequently occurring in war-torn countries. It has been shown to be an idiom of distress entailing dissociative symptoms. However, its association with trauma exposure and trauma-related disorders remains unclear. This study aimed to explore subjective disease models and the relationship between pathological spirit possession and trauma-related disorders in the Eastern Democratic Republic of the Congo. METHOD: Seventy-three (formerly) possessed persons (74% female, mean age = 34 years), referred by traditional and spiritual healers, were interviewed about their experiences of pathological spirit possession, trauma exposure, posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, shame and guilt, psychotic symptoms, somatic complaints, and the impairment of psychosocial functioning. RESULTS: The most common disease model for pathological spirit possession was another person having sent the spirit, mostly a family member or a neighbor, out of jealousy or conflict over resources. Significant correlations were found between spirit possession over lifetime and PTSD symptom severity, feelings of shame and guilt, depressive symptoms, somatic complaints, and psychotic symptoms. Spirit possession during the preceding 4 weeks was associated with PTSD symptom severity, impairment of psychosocial functioning, and psychotic symptom severity. CONCLUSIONS: The results of this study indicate that pathological spirit possession is a broad explanatory framework for various subjectively unexplainable mental and physical health problems, including but not limited to trauma-related disorders. Understanding pathological spirit possession as a subjective disease model for various mental and physical health problems may help researchers and clinicians to develop culturally sensitive treatment approaches for affected individuals. (PsycINFO Database Record

Does dissociation moderate treatment outcomes of narrative exposure therapy for PTSD? A secondary analysis from a randomized controlled clinical trial.

Dissociative symptoms, especially depersonalisation and derealisation, are often perceived as a contraindication for exposure-based treatments of posttraumatic stress disorder (PTSD) despite limited empirical evidence. The present paper examines whether derealisation and depersonalisation influence the treatment outcomes of narrative exposure therapy (NET) and treatment as usual (TaU) among severely traumatised asylum seekers and refugees. We performed a secondary analysis of a recently published randomized controlled multicentre trial comparing NET and TaU for the treatment of PTSD in asylum seekers and refugees. In order to investigate whether depersonalisation and derealisation moderate treatment outcomes, a number of moderated multiple, blockwise regression analyses were conducted. Missing data were handled with multiple imputation. The main finding from intention-to-treat analyses is that derealisation and depersonalisation overall do not moderate the treatment outcomes of either NET or TaU. The treatment condition was the most stable predictor of residual gain scores across outcome measures, with NET being associated with lower residual gain scores indicating better treatment outcomes. The present study substantiates and extends previous research indicating that dissociative symptoms such as derealisation and depersonalisation do not moderate the treatment outcome of exposure-based treatments for PTSD. CLINICALTRIALSGOV IDENTIFIER: NCT00218959.

Gender and offender status predicting treatment success in refugees and asylum seekers with PTSD.

BACKGROUND: Current knowledge is limited regarding patient characteristics related to treatment outcome of posttraumatic stress disorders (PTSD) in refugees and asylum seekers. OBJECTIVE: Gender, torture status, offender status, level of anger, and level of depression were investigated for possible effects on the treatment outcome. METHOD: Patient characteristics were explored in 54 refugees and asylum seekers who had completed a treatment program for PTSD. Non-responders (10), those who had the same or higher levels of symptom severity after treatment, were compared with responders, those who had lower symptom severity after treatment (44). Symptom severity was measured by Clinician-Administered PTSD Scale. The non-responders and responders constituted the dichotomous, dependent variable. The independent variables were gender, torture status, offender status, level of anger, and level of depression. T-tests and Exact Unconditional Homogeneity/Independence Tests for 2×2 Tables were used to study the relationship to treatment outcome. RESULTS: Being male and reporting to have been a violent offender were significantly more frequent characteristics among the non-responders compared to the responders. The levels of pretreatment anger, depression and torture status did not affect the treatment outcome. CONCLUSIONS: The study adds support to findings that females benefit more from treatment of PTSD than males and that violent offenders are difficult to treat within the standard treatment programs.

Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study.

OBJECTIVE: There has been uncertainty about whether refugees and asylum seekers with PTSD can be treated effectively in standard psychiatric settings in industrialized countries. In this study, Narrative Exposure Therapy (NET) was compared to Treatment As Usual (TAU) in 11 general psychiatric health care units in Norway. The focus was on changes in symptom severity and in the diagnostic status for PTSD and depression. METHOD: Refugees and asylum seekers fulfilling the DSM-IV criteria for PTSD (N = 81) were randomized with an a-priori probability of 2:1 to either NET (N = 51) or TAU (N = 30). The patients were assessed with Clinician Administered PTSD Scale, Hamilton rating scale for depression and the MINI Neuropsychiatric Interview before treatment, and again at one and six months after the completion. RESULTS: Both NET and TAU gave clinically relevant symptom reduction both in PTSD and in depression. NET gave significantly more symptom reduction compared to TAU as well as significantly more reduction in participants with PTSD diagnoses. No difference in treatment efficacy was found between refugees and asylum seekers. CONCLUSIONS: The study indicated that refugees and asylum seekers can be treated successfully for PTSD and depression in the general psychiatric health care system; NET appeared to be a promising treatment for both groups.

Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: a preliminary uncontrolled trial.

Torture has severe mental health effects, especially in terms of posttraumatic stress disorder (PTSD) and depression. However, there is still a lack of empirical treatment studies. The present paper presents data on 16 torture survivors receiving 10 sessions of narrative exposure therapy (NET). Symptoms of PTSD and depression, assessed by Clinician-Administered PTSD Scale (CAPS) and Hamilton Rating Scale for Depression (HRSD), decreased significantly from pre-treatment to 6-month follow-up, with Cohen's d effect sizes of 1.16 and 0.84, respectively. Although treatment gains were moderate, further research on evidence-based treatments for PTSD and depression in refugee torture survivors is warranted.