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.

Psychometric evaluation of the Dutch International Trauma Questionnaire for the 11th revision of the International Classification of Diseases posttraumatic stress disorder and complex posttraumatic stress disorder.

BACKGROUND: The International Trauma Questionnaire (ITQ) is a recent self-report measure to assess the severity and probable posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as defined by the 11th revision of the International Classification of Diseases. Few studies have examined the psychometric properties of full and short ITQ versions in depth. Therefore, we aimed to evaluate the psychometric properties of the Dutch-translated 28-item ITQ and the 12-item version. METHOD: Data were used from existing clinical studies and routine clinical assessments for the 28-item (n = 956) and 12-item (N = 4,944) ITQ versions in trauma-exposed treatment-seeking individuals in the Netherlands. Internal consistency and factor validity were assessed, and rates of probable PTSD and CPTSD were estimated. In addition, convergent and discriminant validity were examined by correlations with similar and dissimilar measures. RESULTS: Both versions of the ITQ showed good internal consistency and convergent validity. Confirmatory factor analysis showed that both a first-order correlated six-factor model and a two-factor second-order model were a good representation of the latent structure for the ITQ-12. The ITQ-12 resulted in higher CPTSD rates compared to the ITQ-28 (47% vs. 36.3%), while a similar number of patients met the criteria for either PTSD or CPTSD (70.6% vs. 76.4%). CONCLUSION: Internal consistency and convergent validity for the ITQ-12 and ITQ-28 were supported. The factorial validity was good for the ITQ-12 and acceptable for the ITQ-28. The discrepancy in CPTSD rates between the ITQ-12 and ITQ-28 calls for further testing of scoring methods against diagnostic clinical interviews for CPTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Widening the scope: defining and treating moral injury in diverse populations.

Moral injury is an emerging concept that captures the psychosocial consequences of involvement in and exposure to morally transgressive events. In the past decade, research on moral injury has grown exponentially. In this special collection we review papers on moral injury published in the European Journal of Psychotraumatology from its inception until December 2022, that have a primary focus on moral injury as evidenced by the words 'moral injury' in the title or abstract. We included 19 papers on quantitative (n = 9) and qualitative (n = 5) studies of different populations including (former) military personnel (n = 9), healthcare workers (n = 4) and refugees (n = 2). Most papers (n = 15) focused on the occurrence of potentially morally injurious experiences (PMIEs), moral injury and associated factors, while four papers primarily concerned treatment. Together, the papers offer a fascinating overview of aspects of moral injury in different populations. Research is clearly widening from military personnel to other populations such as healthcare workers and refugees. Focal points included the impact of PMIEs involving children, the association of PMIEs and personal childhood victimisation, the prevalence of betrayal trauma, and the relationship between moral injury and empathy. As for treatment, points of interest included new treatment initiatives as well as findings that PMIE exposure does not impede help-seeking behaviour and response to PTSD treatment. We further discuss the wide range of phenomena that fall under moral injury definitions, the limited diversity of the moral injury literature, and the clinical utility of the moral injury construct. From conceptualisation to clinical utility and treatment, the concept of moral injury matures. Whether or not moral injury becomes a formal diagnosis, the need to examine tailored interventions to alleviate moral injury is clear.

Moral injury is increasingly studied outside military populations, such as in healthcare workers and refugees.Among the most impactful potentially morally injurious experiences (PMIEs) are those involving children, but betrayal trauma may be the most prevalent type of PMIE.There is a need for tailored, evidence-based interventions to alleviate moral injury.

Corrigendum: Initial development of perpetrator confrontation using deepfake technology in victims with sexual violence-related PTSD and moral injury.

[This corrects the article DOI: 10.3389/fpsyt.2022.882957.].

Treatment response and treatment response predictors of a multidisciplinary day clinic for police officers with PTSD.

OBJECTIVE: Police officers typically face multiple potentially traumatic events and consequently have a higher conditional probability of developing PTSD. Although most police officers with PTSD benefit from first-line treatment, it is unknown whether recommended intensification of treatment for low responders is effective and which factors contribute to response. This study aimed to examine the treatment response of a day clinic for police officers with PTSD and identify predictors of treatment response. METHOD: Between 2009 and 2019, routine outcome monitoring measurements consisting of PTSD symptom severity and general psychological distress were administered at two timepoints among 102 patients undergoing a day clinic treatment consisting of trauma-focused therapy, sociotherapy, and psychomotor therapy. Hierarchical regression was used to assess whether change in PTSD symptom severity was associated with baseline PTSD and depression severity, gender, age, and eligibility for a recognition procedure. RESULTS: Significant improvements in PTSD symptom severity were found over the course of the treatment (d = .59), with 47% of patients showing statistically reliable improvement in their symptoms. The only significant predictor of treatment response was eligibility for a recognition procedure, with the total model explaining approximately 10% of the variation in treatment response. CONCLUSIONS: Intensifying treatment for police officers with PTSD who do not respond to previous trauma-focused treatment appears beneficial for a substantial number of patients. However, eligibility for a recognition procedure may negatively impact treatment response. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development of an online supportive treatment module for moral injury in military veterans and police officers.

Background: Military members and police officers often operate in high stakes situations and under high levels of physical and psychological stress. Consequently, they may be confronted with morally injurious experiences and develop moral injury. Most treatments for moral injury are cognitive-behavioral, face-to-face treatments, which may be supported by online interventions. Online interventions have shown promise in the treatment of trauma-related psychopathology, but few such interventions for moral injury yet exist. Objective: To develop and conduct a preliminary evaluation of an online treatment module for moral injury in treatment-seeking military veterans and police officers, to be used in conjunction with regular face-to-face treatment. Method: An online module was developed based on the moral injury literature, using elements from seven existing treatments. A preliminary evaluation was conducted using both quantitative and qualitative methods, and focusing on perceived feasibility, acceptability and engagement of the module, as well as potential benefits and harms. The concept module was evaluated by 15 assessors, including patient representatives, multidisciplinary caregivers and experts. Results: The module was rated favorably, with mean evaluation scores ranging from 7.9 to 8.8 on a 10-point scale. Several suggestions for improvement were made, especially concerning privacy issues, safety instructions, patient-therapist collaborations, and role plays, and the module was adapted accordingly. Conclusion: Using input from literature, patient representatives and experts, we developed an online treatment module for moral injury in military veterans and police officers, to be used in conjunction with face-to-face therapy. Acceptability and feasibility will be further examined in a future pilot study.

Initial development of perpetrator confrontation using deepfake technology in victims with sexual violence-related PTSD and moral injury.

Background: Interventions aimed at easing negative moral (social) emotions and restoring social bonds - such as amend-making and forgiving-have a prominent role in the treatment of moral injury. As real-life contact between persons involved in prior morally injurious situations is not always possible or desirable, virtual reality may offer opportunities for such interventions in a safe and focused way. Objective: To explore the effects of the use of deepfake technology in the treatment of patients suffering from PTSD and moral injury as a result of being forced by persons in authority to undergo and commit sexual violence (so-called betrayal trauma). Methods: Two women who had experienced sexual violence underwent one session of confrontation with the perpetrator using deepfake technology. The women could talk via ZOOM with the perpetrator, whose picture was converted in moving images using deepfake technology. A therapist answered the questions of the women in the role of the perpetrator. Outcome measures were positive and negative emotions, dominance in relation to perpetrator, self-blame, self-forgiveness, and PTSD-symptom severity. Results: Both participants were positive about the intervention. Although they knew it was fake, the deepfaked perpetrator seemed very real to them. They both reported more positive and less negative emotions, dominance in relation to the perpetrator and self-forgiveness, and less self-blame and PTSD-symptoms after the intervention. Conclusion: Victim-perpetrator confrontation using deepfake technology is a promising intervention to influence moral injury-related symptoms in victims of sexual violence. Deepfake technology may also show promise in simulating other interactions between persons involved in morally injurious events.

Moral Injury in Trauma-Exposed, Treatment-Seeking Police Officers and Military Veterans: Latent Class Analysis.

Exposure to morally injurious events may have a severe, prolonged negative impact on psychosocial functioning, known as moral injury (MI). Research into the prevalence of MI has mostly focused on event exposure rather than on psychosocial impact. Also, the relationship between MI and post-traumatic stress disorder (PTSD) remains a matter of interest. The aim of this study was to identify MI and PTSD symptom profiles among trauma-exposed, treatment-seeking police officers and military veterans, and to explore demographic and clinical differences between symptom profiles. Latent class and multinomial regression analyses were conducted in a sample of 1,703 participants, using the Clinician-Administered PTSD Scale for DSM-5 and the Brief Symptom Inventory. Four classes of participants were identified, labeled as a MI class (n = 192; 11.27%), a MI-PTSD class (n = 565; 33.18%), a PTSD class (n = 644; 37.82%), and a Neither MI-nor PTSD class (n = 302; 17.73%), resulting in 44.45% (n = 757) of participants who met an MI symptom profile with or without PTSD. There were significant differences between the classes in terms of gender as well as PTSD and comorbid psychopathology symptom severity, the latter of which was highest in the MI-PTSD class. In conclusion, a substantial subgroup of trauma-exposed, treatment-seeking police officers and military veterans could be classified as suffering from MI. Routinely screening for MI in treatment-seeking police officers and military veterans is recommended, and interventions aimed at relieving MI in these populations may be indicated.

Psychopathology and resilience in older adults with posttraumatic stress disorder: a randomized controlled trial comparing narrative exposure therapy and present-centered therapy.

Objective: Using data from a randomized controlled trial on psychotherapy for posttraumatic stress disorder (PTSD) in older adults (aged >55), this study aimed at analysing the efficacy of two psychological interventions in terms of self-reported symptoms, comorbid psychopathology and resilience outcomes. Method: Thirty-three outpatients (age 55-81) with PTSD were randomly assigned to eleven sessions of narrative exposure therapy or present-centered therapy. Self-reported symptom severity of PTSD, depression and general psychopathology, along with measures of resilience (self-efficacy, quality of life and posttraumatic growth cognitions), were target outcomes. Harvard Trauma Questionnaire, Beck Depression Inventory, Brief Symptom Inventory, General Efficacy Scale, World Health Organization Quality of Life Assessment and Meaning of War Scale (personal growth) were assessed pre-treatment, post-treatment and at four months follow-up. Because of variable inter-assessment intervals, a piecewise mixed effects growth model was used to investigate treatment effects. Results: Neither post-treatment, nor at mean follow-up, between-group effects were found. At follow-up, significant medium to large within-group effect sizes were found in the NET-group for psychopathology (self-reported PTSD: Cohen's d = 0.54, p < .01; depression: Cohen's d = 0.51, p = .03; general psychopathology: Cohen's d = 0.74, p = .001), but not so in the PCT-group. Resilience (self-efficacy, quality of life and personal growth cognitions) did not significantly change in either group. Conclusions: In older adults with PTSD, the efficacy of NET extended beyond PTSD, reducing not only self-reported symptoms of PTSD but also comorbid depression and general psychopathology.

Objetivo: Utilizando datos de un ensayo controlado aleatorizado sobre psicoterapia para pacientes con trastorno de estrés postraumático (TEPT) en adultos mayores (> 55 años), este estudio tuvo como objetivo analizar la eficacia de dos intervenciones psicológicas respecto a síntomas autoinformados, psicopatología comorbida, y resultados de resiliencia.Método: Treinta y tres pacientes ambulatorios (de 55 a 81 años) con TEPT fueron asignados al azar a once sesiones de terapia de exposición narrativa (NET en sus siglas en ingles) o terapia centrada en el presente (TCP). Los resultados que se midieron fueron, el autoreporte de la gravedad de síntomas de estrés postraumático, depresión y psicopatología general, junto con medidas de resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento postraumático). Se evaluaron antes del tratamiento, después del tratamiento y a los cuatro meses de seguimiento con los siguientes cuestionarios: Cuestionario de trauma de Harvard, el Inventario de depresión de Beck, el Inventario breve de síntomas, la Escala de eficacia general, Evaluación de la Calidad de Vida y de Significado de la Guerra de la Organización Mundial de la Salud (crecimiento personal). Debido a los intervalos variables entre evaluaciones, se utilizó un modelo de crecimiento de efectos mixtos por partes para investigar los efectos del tratamiento.Resultados: No se encontraron diferencias entre los grupos ni posteriores al tratamiento ni durante el seguimiento medio. En el seguimiento, se encontraron tamaños de efecto significativos medianos a grandes dentro del grupo NET. para psicopatología (TEPT autoinformado: d de Cohen = 0.54, p < .01; depresión: d de Cohen = 0,51, p = 0,03; psicopatología general: d de Cohen = 0,74, p = 0,001), pero no así en el grupo TCP. La resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento personal) no tuvieron cambios significativos en ninguno de los grupos.Conclusiones: En adultos mayores con TEPT, la eficacia de la NET se extendió más allá del TEPT, reduciendo no sólo síntomas autoinformados de TEPT, sino también depresión comórbida y psicopatología general.

Wellbeing and clinical videoconferencing satisfaction among patients in psychotrauma treatment during the coronavirus pandemic: cross-sectional study.

Background: The coronavirus pandemic appears to put psychiatric patients with pre-existing symptomatology at risk of symptom increase, but evidence is scarce. While the pandemic and stringent governmental measures have accelerated the use of clinical videoconferencing (VCT), patient satisfaction with VCT is unclear. Objective: Aim of the study was to assess the wellbeing of patients in psychotrauma treatment during the coronavirus pandemic and to evaluate their use of and satisfaction with VCT. Method: This study used data from a routine outcome monitoring assessment completed by patients in treatment at a specialized psychotrauma institute and administered before the easing of governmental measures in June 2020. Wellbeing (Brief Symptom Inventory, Cantril Ladder, perceived stress level, and symptom change), VCT use and VCT satisfaction, and their association with demographic variables (gender, age, education level, and refugee status) were analysed. Results: Of the 318 respondents (response rate 64.5%), 139 (43.7%) reported a symptom increase, which was associated with a higher coronavirus-related stress level and general psychopathology as well as lower life satisfaction. There were significant effects of age and education level on wellbeing. VCT was reported to have been used by 228 (71.7%) patients. VCT satisfaction ratings were higher among women and those with lower levels of stress (r = -.20, p < .01) and general psychopathology (r = .21, p < .01). No difference in treatment satisfaction was found between patients who used VCT versus those who did not (mean difference = -.09 95% CI: -.79 to .62, p = .81). Conclusions: The coronavirus pandemic has aggravated mental health complaints according to a substantial percentage of patients in psychotrauma treatment. Although VCT was found to be acceptable, face-to-face treatment may remain necessary for specific target groups with limited access to VCT (such as refugees) and patients with high levels of general psychopathology.

Antecedentes: La pandemia por el coronavirus parece incrementar el riesgo de un aumento de síntomas a los pacientes psiquiátricos con sintomatología preexistente, pero la evidencia es escasa. Si bien la pandemia y las estrictas medidas gubernamentales han acelerado el uso de la videoconferencia clínica (VCT, por sus siglas en inglés), la satisfacción del paciente con la VCT no está clara.Objetivo: El objetivo del estudio fue el de evaluar el bienestar de los pacientes en tratamiento por psicotrauma durante la pandemia por el coronavirus; además, evaluar su uso y su satisfacción con la VCT.Método: Este estudio empleó los datos de las evaluaciones rutinarias de control clínico de un instituto especializado en psicotraumatología completadas por pacientes y realizadas antes de la flexibilización de las medidas gubernamentales en Junio del 2020. Se analizaron el bienestar (Inventario Breve de Síntomas, Escalera de Cantril, nivel de estrés percibido y cambio de síntomas), el uso de la VCT, la satisfacción con la VCT y su asociación con variables demográficas (género, edad, nivel educacional y condición de refugiado).Resultados: De los 318 encuestados (tasa de respuesta del 64,5%), 139 (43,7%) reportaron un aumento de síntomas, lo cual se asoció con niveles de estrés asociado al coronavirus más altos y con psicopatología general, así como con una menor satisfacción con la vida. Hubo efectos significativos entre la edad y el nivel educativo sobre el bienestar. 228 (71,7%) pacientes reportaron haber usado la VCT. Los índices de satisfacción con la VCT fueron más altos entre las mujeres y entre aquellos con menores niveles de estrés (r = −.20, p < .01) y de psicopatología general (r = .21, p < .01). No se encontraron diferencias entre la satisfacción con el tratamiento en pacientes que usaron la VCT en comparación con aquellos que no lo usaron (diferencia media = −.09 IC del 95%: −.79 a .62, p = .81).Conclusiones: La pandemia por el coronavirus ha agravado las quejas de salud mental en un porcentaje importante de pacientes en tratamiento por psicotrauma. A pesar que se halló que la VCT era aceptable, el tratamiento presencial puede seguir siendo necesario para grupos específicos con acceso limitado a la VCT (como los refugiados) y para los pacientes con altos niveles de psicopatología general.

Empathy is key in the development of moral injury.

Background: Moral injury is a relatively new field within psychotraumatology that focuses on understanding and treating psychosocial symptoms after exposure to potentially morally injurious events (PMIE's). There are currently three models of the development of moral injury which centre around the influence of attributions, coping and exposure. While the capacity for empathy is known to underlie moral behaviour, current models for moral injury do not explicitly include empathy-related factors. Objective: This paper aims to make a case for complementing current models of the development of moral injury with the perception-action model of empathy (PAM). Method: In this paper, the perception-action mechanism of empathy and the empathic behaviour that it may initiate, are described. The PAM states that perception of another person's emotional state activates the observer's own representations of that state. This forms the basis for empathic behaviour, such as helping, by which an observer tries to alleviate both another person's and their own, empathic, distress. In this paper it is proposed that in PMIE's, empathic or moral behaviour is expected but not, or not successfully, performed, and consequently distress is not alleviated. Factors known to influence the empathic response, including attention, emotion-regulation, familiarity and similarity, are hypothesized to also influence the development of moral injury. Results: Two cases are discussed which illustrate how factors involved in the PAM may help explain the development of moral injury. Conclusions: As empathy forms the basis for moral behaviour, empathy-related factors are likely to influence the development of moral injury. Research will have to show whether this hypothesis holds true in actual practice.

Antecedentes: El daño moral es un área relativamente nueva dentro de la psicotraumatología que se centra en la comprensión y el tratamiento de los síntomas psicosociales después de la exposición a eventos potenciales de daño moral (PMIE, en sus siglas en inglés). Actualmente hay tres modelos de desarrollo del daño moral que se centran en la influencia de las atribuciones, el afrontamiento y la exposición. Mientras que se sabe que la capacidad de empatía subyace en la conducta moral, los modelos actuales de daño moral no incluyen explícitamente factores relacionados con la empatía.Objetivo: El presente documento tiene por objetivo presentar un caso para complementar los modelos actuales de desarrollo de daño moral con el modelo de percepción-acción de la empatía (PAM, en sus siglas en inglés).Método: En este artículo se describe el mecanismo de percepción-acción de la empatía y la conducta empática que puede iniciar. El PAM establece que la percepción del estado emocional de otra persona activa las propias representaciones del observador de ese estado. Esto forma la base de la conducta empática, como la ayuda, por la cual un observador trata de aliviar empáticamente tanto el sufrimiento de otra persona como el suyo propio. En este artículo se propone que en el PMIE se espera una conducta empática o moral pero no se realiza, o no se realiza con éxito, y por consiguiente no se alivia la angustia. Se formula la hipótesis de que los factores que se sabe que influyen en la respuesta empática, incluyendo la atención, la regulación de las emociones, la familiaridad y la similitud, también influyen en el desarrollo del daño moral.Resultados: Se discuten dos casos que ilustran cómo los factores involucrados en el PAM pueden ayudar a explicar el desarrollo del daño moral.Conclusión: Como la empatía es la base de la conducta moral, es probable que los factores relacionados con la empatía influyan en el desarrollo del daño moral. La investigación tendrá que demostrar si esta hipótesis es válida en la práctica real.

The Dissociative Subtype of PTSD Interview (DSP-I): Development and Psychometric Properties.

The inclusion of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the importance of assessing PTSD-DS. We developed the Dissociative Subtype of PTSD Interview (DSP-I). This clinician-administered instrument assesses the presence and severity of PTSD-DS (i.e., symptoms of depersonalization or derealization) and contains a supplementary checklist that enables assessment and differentiation of other trauma-related dissociative symptoms (i.e., blanking out, emotional numbing, alterations in sensory perception, amnesia, and identity confusion). The psychometric properties were tested in 131 treatment-seeking individuals with PTSD and histories of multiple trauma, 17.6 % of whom met criteria for PTSD-DS in accordance with the DSP-I. The checklist was tested in 275 treatment-seeking individuals. Results showed the DSP-I to have high internal consistency, good convergent validity with PTSD-DS items of the CAPS-5, and good divergent validity with scales of somatization, anxiety and depression. The depersonalization and derealization scales were highly associated. Moreover, the DSP-I accounted for an additional variance in PTSD severity scores of 8% over and above the CAPS-5 and number of traumatic experiences. The dissociative experiences of the checklist were more strongly associated with scales of overall distress, somatization, depression, and anxiety than scales of depersonalization and derealization. In conclusion, the DSP-I appears to be a clinically relevant and psychometrically sound instrument that is valuable for use in clinical and research settings.

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis.

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self-concept, which together are termed "disturbances in self-organization" (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO-only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tept complejo en pacientes expuestos a negligencia emocional y eventos traumáticos: un análisis de clases latentes TEPTC EN PACIENTES EXPUESTOS A NEGLIGENCIA: ACL El diagnóstico de trastorno de estrés postraumático complejo (TEPTC) propuesto en la 11' revisión de la Clasificación Internacional de Enfermedades refleja una evidencia creciente que un subgrupo de individuos con TEPT también sufre de problemas en la regulación emocional, habilidades interpersonales, y auto- concepto (conocido como "problemas en la auto-organización" [DSO], por sus siglas en inglés). Aunque se asume que el TEPTC es el resultado de la exposición a eventos traumáticos complejos, la negligencia emocional puede ser un contribuyente. Este estudio investigó la confirmación del TEPT y síntomas DSO (que juntos calificaban para TEPTC) en una muestra clínica de una generación post guerra. La muestra consistió en 218 pacientes que estuvieron expuestos a negligencia emocional en su infancia, un subgrupo que también había estado expuesto a potenciales eventos traumáticos. Usando los ítems del Cuestionario de Trauma de Harvard y el Inventario de Síntomas Abreviado, un análisis de clases latentes (ACL) reveló dos clases: alta confirmación de casi todos los síntomas de TEPTC (n=83; 38.1%) y baja confirmación de todos los síntomas de TEPTC (n=135; 61.9%). Contrario a nuestra hipótesis, no se encontró ninguna clase de sólo DSO. El método de pasos R3 mostró que el género y el número de eventos traumáticos son predictores significativos para la pertenencia a alguna clase. Comparado con la clase de baja probabilidad, los individuos de la clase TEPTC tenían más probabilidad de ser mujer, p = .013, y reportar un mayor número de experiencias traumáticas, p = .000. Se discute el rol intermediario potencial de la negligencia emocional en el desarrollo de DSO y TEPTC.

Development and Evaluation of the Dutch Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).

Background: In 2013, the Clinician-Administered PTSD Scale, the golden standard to assess PTSD, was adapted to the DSM-5 (CAPS-5). Objective: This project aimed to develop a clinically relevant Dutch translation of the CAPS-5 and to investigate its psychometric properties. Method: We conducted a stepped translation including Delphi rounds with a crowd of 44 Dutch psychotrauma experts and five senior psychotrauma experts. Using partial crowd-translations, two professional translations and the official Dutch translation of the DSM-5, each senior expert aggregated one independent translation. Consensus was reached plenary. After back-translation, comparison with the original CAPS-5 and field testing, a last round with the senior experts resulted in the final version. After implementation clinicians conducted CAPS-5 interviews with 669 trauma-exposed individuals referred for specialized diagnostic assessment. Reliability of the Dutch CAPS-5 was investigated through internal consistency and interrater reliability analyses, and construct validity through confirmatory factor analysis (CFA). Results: CAPS-5 total severity score showed high internal consistency (α = .90) and interrater reliability (ICC = .98, 95% CI: .94-.99). CAPS-5 diagnosis showed modest interrater reliability (kappa = .59, 95% CI: .20-.98). CFA with alternative PTSD models revealed adequate support for the DSM-5 four-factor model, but a six-factor (Anhedonia) model fit the data best. Conclusions: The Dutch CAPS-5 is a carefully translated instrument with adequate psychometric properties. Current results add to the growing support for more refined (six and seven) factor models for DSM-5 PTSD indicating that the validity and clinical implications of these models should be objective of further research.

Antecedentes: En el año 2013 la Escala para el TEPT Aplicada por el Clínico, la prueba estándar para evaluar el TEPT, fue adaptada al DSM-5 (CAPS-5).Objetivo: Este proyecto apuntó a desarrollar una traducción holandesa clínicamente relevante de la Escala para el TEPT Aplicada por el Clínico adaptada al DSM-5 (CAPS-5) e investigar sus propiedades psicométricas.Método: Realizamos una traducción escalonada, incluyendo fases del método Delphi con un grupo de 44 expertos holandeses en psicotrauma y cinco expertos de larga trayectoria en psicotrauma. Utilizando traducciones en grupo parciales, dos traducciones profesionales y la traducción holandesa oficial del DSM-5, cada experto experimentado sumó una traducción independiente. Se alcanzó un conceso pleno. Después de traducciones inversas, comparación con el CAPS-5 original y ensayo de campo, una última fase con los expertos experimentados resultó en la versión definitiva. Tras la implementación, los clínicos realizaron entrevistas aplicando CAPS-5 a 669 individuos expuestos a trauma referidos por evaluación diagnóstica especializada. Se investigó la fiabilidad del CAPS-5 holandés a través de consistencia interna y análisis de confiabilidad, y se estableció su validez a través de análisis factorial de tipo confirmatorio.Resultados: El puntaje de severidad total del CAPS-5 mostró alta consistencia interna (α = .90) y confiabilidad (ICC = .98, 95% IC: .94 - .99). El diagnóstico de CAPS-5 mostró una modesta confiabilidad (kappa = .59, 95% CI: .20 - .98). El análisis factorial de tipo confirmatorio con modelos alternativos de TEPT reveló un respaldo adecuado para el modelo de 4 factores del DSM-5, pero un modelo de 6 factores (Anhedonia) se ajusta mejor a los datos.Conclusiones: El CAPS-5 holandés es un instrumento cuidadosamente traducido con adecuadas propiedades psicométricas. Nuestros resultados se suman al respaldo creciente para modelos de factores (seis y siete) más refinados para el TEPT según el DSM-5, indicando que la validez y las implicaciones clínicas de estos modelos deberían ser objeto de futuras investigaciones.

A five-day inpatient EMDR treatment programme for PTSD: pilot study.

Background: Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) have been demonstrated to be efficacious, but also have considerable non-response and dropout rates. Intensive treatment may lead to faster symptom reduction, which may contribute to treatment motivation and thereby to reduction of dropout. Objective: The aim of the current study was to investigate the feasibility and preliminary effectiveness of an intensive five-day inpatient treatment with Eye Movement Desensitization and Reprocessing (EMDR) and trauma-informed yoga for patients with PTSD. Method: A non-controlled pilot study with 12 adult patients with PTSD was conducted. At baseline the PTSD diagnosis was assessed with the Clinician-Administered PTSD Scale (CAPS-5) and comorbid disorders with the Mini International Neuropsychiatric Interview (MINI). Primary outcome was self-reported PTSD symptom severity (PTSD Check List for DSM-5; PCL-5) measured at the beginning of day 1 (T1), at the end of day 5 (T2) and at follow-up on day 21 (T3). Reliable change indexes (RCI) and clinically significant changes were calculated. Results: From T1 to T3, PTSD symptoms significantly improved with a large effect size (Cohen's d = 0.91). Nine of the 11 patients who completed treatment showed reliable changes in terms of self-reported PTSD. At T3, two of the patients no longer met criteria for PTSD as measured with the PCL-5. One patient dropped out after the first day. No serious adverse events occurred. Conclusions: The majority of patients in our pilot study experienced symptom reduction consistent with reliable changes in this five-day inpatient treatment with EMDR and yoga. Randomized controlled trials - with longer follow up periods - are needed to properly determine efficacy and efficiency of intensive clinical treatments for PTSD compared to regular treatment. This is one of the first studies to show that intensive EMDR treatment is feasible and is indicative of reliable improvement in PTSD symptoms in a very short time frame.

Planteamiento: Se ha demostrado que las psicoterapias centradas en el trauma para el TEPT son eficaces, pero también tienen tasas considerables de falta de respuesta y abandono. El tratamiento intensivo puede llevar a una reducción más rápida de los síntomas, lo que puede contribuir a la motivación para el tratamiento y, por lo tanto, a la reducción del abandono. Objetivo: El objetivo del presente estudio fue investigar la viabilidad y eficacia preliminar de un tratamiento intensivo de 5 días para pacientes hospitalizados con Desensibilización y Reprocesamiento por Movimientos Oculares (EMDR) y yoga basado en el trauma para pacientes con TEPT. Método: Se realizó un estudio piloto no controlado con 12 pacientes adultos con TEPT. Al inicio del estudio, se evaluó el diagnóstico de TEPT con el CAPS-5 y los trastornos comórbidos con el MINI. El resultado principal fue la gravedad de los síntomas de PTSD por medio de autoinforme (PCL-5) medida al comienzo del día 1 (T1), al final del día 5 (T2) y en el seguimiento el día 21 (T3). Se calcularon los índices de cambio fiable (RCI, por sus siglas en inglés) y los cambios clínicamente significativos. Resultados: De T1 a T3, los síntomas de TEPT mejoraron significativamente con un tamaño de efecto grande (d de Cohen = 0,91) y 9 de los 11 pacientes que completaron el tratamiento mostraron cambios fiables en términos de auto-informes de TEPT. En T3, dos de los pacientes ya no cumplían los criterios para el trastorno de estrés postraumático medido con el PCL-5. Un paciente se retiró después del primer día. No se produjeron eventos adversos graves. Conclusiones: la mayoría de los pacientes en nuestro estudio piloto experimentaron una reducción de síntomas consistente con cambios fiables en este tratamiento de 5 días con EMDR y yoga. Se necesitan ensayos controlados aleatorios, con períodos de seguimiento más largos, para determinar adecuadamente la eficacia y la eficiencia de los tratamientos clínicos intensivos para el TEPT en comparación con el tratamiento habitual. Este es uno de los primeros estudios que demuestra que el tratamiento intensivo con EMDR es factible y es indicativo de una mejora fiable en los síntomas de TEPT después de un período de tiempo muy corto.

Posttraumatic world assumptions among treatment-seeking refugees.

The clinical relevance of negative changes in cognitions about oneself, others, and the world is reflected in the diagnostic criteria for posttraumatic stress disorder (PTSD) in the DSM-5 and complex posttraumatic stress disorder in the ICD-11. Although such changes in cognition have been posited to be especially relevant for traumatised refugees, few studies have examined this in refugee populations. The present study used a cross-sectional design to compare negative cognitions among 213 adult treatment-seeking refugees with those in previously published samples from the general population, veterans with combat-related PTSD, and whiplash victims. Measures included the World Assumptions Scale (WAS) and the Events and DSM-IV PTSD subscales of the Harvard Trauma Questionnaire (HTQ). Path models examined the relation of the WAS subscales to five demographic and trauma-related variables. Results showed that world assumptions were especially negative with regard to Benevolence of World, Benevolence of People, and Luck subscales, on which refugees scored lower than all reference samples. Differences between the refugee sample and the reference samples were smallest with regard to self-worth and self-controllability. World assumptions were associated with gender and PTSD symptom severity but not with age, length of residence in the Netherlands, and number of traumatic event types. The DSM-5 criterion of negative changes in belief about oneself, others, and the world appears more applicable to refugees than the more narrowly formulated ICD-11 criterion of diminished and defeated sense of self. Prevention and treatment efforts with refugees may need to be especially aimed at preventing a further decline of trust as well as restoration of trust in others and the world.

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.