Potentially morally injurious experiences and associated factors among Dutch UN peacekeepers: a latent class analysis.

Background: During peacekeeping missions, military personnel may be involved in or exposed to potentially morally injurious experiences (PMIEs), such as an inability to intervene due to a limited mandate. While exposure to such morally transgressive events has been shown to lead to moral injury in combat veterans, research on moral injury in peacekeepers is limited.Objective: We aimed to determine patterns of exposure to PMIEs and associated outcome- and exposure-related factors among Dutch peacekeepers stationed in the former Yugoslavia during the Srebrenica genocide.Method: Self-report data were collected among Dutchbat III veterans (N = 431). We used Latent Class Analysis to identify subgroups of PMIE exposure as assessed by the Moral Injury Scale-Military version. We investigated whether deployment location, posttraumatic stress disorder (PTSD), posttraumatic growth, resilience, and quality of life differentiated between latent classes.Results: The analysis identified a three-class solution: a high exposure class (n = 79), a moderate exposure class (n = 261), and a betrayal and powerlessness-only class (n = 135). More PMIE exposure was associated with deployment location and higher odds of having probable PTSD. PMIE exposure was not associated with posttraumatic growth. Resilience and quality of life were excluded from analyses due to high correlations with PTSD.Conclusions: Peacekeepers may experience varying levels of PMIE exposure, with more exposure being associated with worse outcomes 25 years later. Although no causal relationship may be assumed, the results emphasize the importance of better understanding PMIEs within peacekeeping.

Peacekeeping veterans reported different patterns of exposure to potentially morally injurious experiences: high exposure, moderate exposure, or experiences of betrayal and powerlessness only.Deployment location predicted the pattern of exposure.More exposure was associated with worse psychological outcomes 25 years later.

Intrusions related to indirectly experienced events in clinical offspring of World War Two survivors.

Negative events may not only linger on in the form of intrusive memories in the minds of those directly exposed but also in those who are only indirectly confronted with these events. The aim of the present study was to investigate if intrusions referring to indirectly experienced traumatic events do indeed occur, and to compare their frequency and characteristics to intrusions about directly experienced negative events. Participants (N = 98) were adult postwar offspring of World War Two survivors currently in treatment in one of two clinics specialized in the treatment of war victims. We examined the frequency and characteristics of intrusions about indirectly experienced (i.e., parent war-related) events and two types of directly (self-) experienced events: Self-experienced traumatic events and negative events related to participants' upbringing. Intrusions referring to indirectly experienced traumatic events did indeed occur. The frequency as well as other characteristics of these intrusions did not differ from those of both types of intrusions about directly experienced events. The similarities between intrusions related to different types of events emphasize the (re)constructive nature of memory. Our findings indicate that traumatic events not only affect those directly involved but may also continue to plague the next generation.

Intergenerational consequences of the Holocaust on offspring mental health: a systematic review of associated factors and mechanisms.

Exposure to war and violence has major consequences for society at large, detrimental impact on people's individual lives, and may also have intergenerational consequences. To gain more insight into these intergenerational consequences, research addressing the impact of the Holocaust on offspring is an important source of information. The aim of the current study was to systematically review the mechanisms of intergenerational consequences by summarizing characteristics in Holocaust survivors and their offspring suggested to impact the offspring's mental health. We focused on: 1) parental mental health problems, 2) (perceived) parenting and attachment quality, 3) family structure, especially parental Holocaust history, 4) additional stress and life events, and 5) psychophysiological processes of transmission. We identified 23 eligible studies published between 2000 and 2018. Only Holocaust survivor studies met the inclusion criteria. Various parent and child characteristics and their interaction were found to contribute to the development of psychological symptoms and biological and epigenetic variations. Parental mental health problems, perceived parenting, attachment quality, and parental gender appeared to be influential for the mental well-being of their offspring. In addition, having two survivor parents resulted in higher mental health problems compared to having one survivor parent. Also, there was evidence suggesting that Holocaust survivor offspring show a heightened vulnerability for stress, although this was only evident in the face of actual danger. Finally, the results also indicate intergenerational effects on offspring cortisol levels. Clinical and treatment implications are discussed.

La exposición a la guerra y la violencia tiene consecuencias importantes para la sociedad en general, un impacto perjudicial en la vida individual de las personas, y también puede tener consecuencias intergeneracionales. Para obtener más información sobre estas consecuencias intergeneracionales, la investigación que aborda el impacto del Holocausto en la descendencia es una fuente importante de información. El objetivo del presente estudio fue revisar sistemáticamente los mecanismos de las consecuencias intergeneracionales resumiendo las características de los sobrevivientes del Holocausto y sus descendientes, que podrían impactar la salud mental de la descendencia. Nos centramos en: 1) los problemas de salud mental de los padres, 2) la calidad (percibida) de la crianza y el apego, 3) la estructura familiar, especialmente antecedentes del Holocausto de los padres, 4) el estrés y los eventos de la vida adicionales, y 5) los procesos psicofisiológicos de la transmisión. Identificamos 23 estudios elegibles publicados entre 2000 y 2018. Solo los estudios de sobrevivientes del Holocausto cumplieron con los criterios de inclusión. Se descubrió que diversas características de los padres y de los hijos y su interacción contribuyen al desarrollo de los síntomas psicológicos y las variaciones biológicas y epigenéticas. Los problemas de salud mental de los padres, la crianza percibida, la calidad del apego, y el género parental parecieron influir en el bienestar mental de sus hijos. Además, tener dos padres sobrevivientes resultó en mayores problemas de salud mental en comparación con tener uno de los padres sobrevivientes. Además, hubo evidencia que sugiere que los descendientes de los sobrevivientes del Holocausto muestran una mayor vulnerabilidad al estrés, aunque esto fue solo evidente ante el peligro real. Finalmente, los resultados también indican los efectos intergeneracionales en los niveles de cortisol de la descendencia. Se discuten las implicaciones clínicas y de tratamiento.

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.

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.

Complex PTSD and phased treatment in refugees: a debate piece.

BACKGROUND: Asylum seekers and refugees have been claimed to be at increased risk of developing complex posttraumatic stress disorder (complex PTSD). Consequently, it has been recommended that refugees be treated with present-centred or phased treatment rather than stand-alone trauma-focused treatment. This recommendation has contributed to a clinical practice of delaying or waiving trauma-focused treatment in refugees with PTSD. OBJECTIVE: The aim of this debate piece is to defend two theses: (1) that complex trauma leads to complex PTSD in a minority of refugees only and (2) that trauma-focused treatment should be offered to all refugees who seek treatment for PTSD. METHODS: The first thesis is defended by comparing data on the prevalence of complex PTSD in refugees to those in other trauma-exposed populations, using studies derived from a systematic review. The second thesis is defended using conclusions of systematic reviews and a meta-analysis of the efficacy of psychotherapeutic treatment in refugees. RESULTS: Research shows that refugees are more likely to meet a regular PTSD diagnosis or no diagnosis than a complex PTSD diagnosis and that prevalence of complex PTSD in refugees is relatively low compared to that in survivors of childhood trauma. Effect sizes for trauma-focused treatment in refugees, especially narrative exposure therapy (NET) and culturally adapted cognitive-behaviour therapy (CA-CBT), have consistently been found to be high. CONCLUSIONS: Complex PTSD in refugees should not be assumed to be present on the basis of complex traumatic experiences but should be carefully diagnosed using a validated interview. In line with treatment guidelines for PTSD, a course of trauma-focused treatment should be offered to all refugees seeking treatment for PTSD, including asylum seekers.

Attentional bias modification in Dutch veterans with posttraumatic stress disorder--a case series with a personalized treatment version.

Beneficial effects of attentional bias modification have been claimed for a number of anxiety disorders, but study results are variable. A recent trial in patients with posttraumatic stress disorder (PTSD) showed no therapeutic effects. The use of personally relevant and verbal stimuli might increase the efficacy of attentional bias modification. In an A-B case series design, we hypothesized that individualized attentional bias modification would lead to reduction of attentional bias and a decrease in PTSD symptoms. Six Dutch male war veterans (mean age 39.33 years) who had developed PTSD after peacekeeping missions underwent the treatment. No therapeutic effects were observed. Inter- and intraindividual attentional bias scores varied widely and did not respond to attentional bias modification as hypothesized. This study provides no evidence that individualized attentional bias modification is an effective treatment for PTSD.

EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study.

BACKGROUND: Traumatised asylum seekers and refugees are clinically considered a complex population. Discussion exists on whether with this population treatment guidelines for post-traumatic stress disorder (PTSD) should be followed and Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) should be applied, or whether a phased model starting with stabilisation is preferable. Some clinicians fear that trauma-focused interventions may lead to unmanageable distress or may be ineffective. While cognitive-behavioural interventions have been found to be effective with traumatised refugees, no studies concerning the efficacy of EMDR with this population have been conducted as yet. OBJECTIVE: In preparation for a randomised trial comparing EMDR and stabilisation with traumatised refugees, a pilot study with 20 participants was conducted. The objective was to examine feasibility of participation in a randomised trial for this complex population and to examine acceptability and preliminary efficacy of EMDR. DESIGN: Participants were randomly allocated to 11 sessions of either EMDR or stabilisation. Symptoms of PTSD (SCID-I, HTQ), depression and anxiety (HSCL-25), and quality of life (WHOQOL-BREF) were assessed at pre- and post-treatment and 3-month follow-up. RESULTS: Participation of traumatised refugees in the study was found feasible, although issues associated with complex traumatisation led to a high pre-treatment attrition and challenges in assessments. Acceptability of EMDR was found equal to that of stabilisation with a high drop-out for both conditions. No participants dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilisation. Different symptom courses between the two conditions, with EMDR showing some improvement and stabilisation showing some deterioration between pre-treatment and post-treatment, justify the conduct of a full trial. CONCLUSION: With some adaptations in study design, inclusion of a greater sample is justifiable to determine which treatment is more suitable for this complex population.