Long-term effects of psychotherapy in a context of continuous community and gang violence: changes in aggressive attitude in high-risk South African adolescents.

BACKGROUND: Post-traumatic stress but also aggressive attitudes and behaviour can be found in adolescents living in a context of ongoing community and gang violence in the low-income urban areas of Cape Town, South Africa. AIMS: We investigated the long-term effects (15-20 months after therapy) of (a) Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) and (b) the cognitive behavioural intervention 'Thinking for a Change' (CBT) on post-traumatic stress disorder (PTSD) and aggression compared with a waiting list. METHOD: Fifty-four young males participated in the treatment trial, of which 17 completed the FORNET intervention, 11 the CBT intervention, and 26 were on a waiting list. The primary outcome was the change score for the Appetitive Aggression Scale; secondary outcomes were the PTSD Symptom Scale-Interview change scores, and the number of perpetrated violent event types. RESULTS: The reduction in scores for PTSD that had been observed in FORNET completers at the first follow-up were still significant at the second long-term follow-up (Cohen's d = 0.86). In this treatment arm (FORNET), the scores for appetitive aggression were also significantly reduced (Cohen's d = 1.00). There were no significant changes observed for CBT or for the waiting list. CONCLUSIONS: The study indicates that FORNET can successfully reduce post-traumatic stress as well as the attraction to violence even for individuals living under conditions of continuous traumatic stress.

Associations between telomere length and symptoms of posttraumatic stress disorder and appetitive aggression in trauma-exposed men.

Exposure to community violence is common in South Africa and negatively impacts on biopsychosocial health. Posttraumatic stress disorder (PTSD) is characterised by symptoms of intrusion, avoidance, hypervigilance and negative alterations in cognition and mood, and can develop consequent to trauma exposure. Individuals who repeatedly experience and witness violence may also come to view it as appealing and rewarding. This appetitive aggression (AA) increases the likelihood of perpetrating violence. Telomeres are repetitive nucleotide sequences that protect the ends of chromosomes. Telomere length (TL) attrition is a stress-sensitive marker of biological aging that has been associated with a range of psychiatric disorders. This study investigated the cross-sectional relationship between TL and symptoms of PTSD and AA in South African men residing in areas with high community violence. PTSD and AA symptom severity was assessed in 290 men using the Posttraumatic Stress Disorder Symptom Scale - Interview (PSS-I) and Appetitive Aggression Scale (AAS), respectively. Quantitative polymerase chain reaction was performed on DNA extracted from saliva and used to calculate relative TL (rTL). Regression models were used to assess the relationships between rTL and PSS-I and AAS scores. Network analyses using EBIC glasso methods were performed using rTL and items from each of the AAS and PSS-I measures. Both PSS-I (p = 0.023) and AAS (p = 0.016) scores were positively associated with rTL. Network analyses indicated that rTL was weakly related to two PSS-I and five AAS items but performed poorly on indicators of centrality and was not strongly associated with measure items either directly or indirectly. The positive association between rTL and measures of AA and PTSD may be due to the induction of protective homeostatic mechanisms, which reduce TL attrition, following early life trauma exposure.

DNA methylation and psychotherapy response in trauma-exposed men with appetitive aggression.

Exposure to violence can lead to appetitive aggression (AA), the positive feeling and fascination associated with violence, and posttraumatic stress disorder (PTSD), characterised by hyperarousal, reexperience and feelings of ongoing threat. Psychotherapeutic interventions may act via DNA methylation, an environmentally sensitive epigenetic mechanism that can influence gene expression. We investigated epigenetic signatures of psychotherapy for PTSD and AA symptoms in South African men with chronic trauma exposure. Participants were assigned to one of three groups: narrative exposure therapy for forensic offender rehabilitation (FORNET), cognitive behavioural therapy or waiting list control (n = 9-10/group). Participants provided saliva and completed the Appetitive Aggression Scale and PTSD Symptom Severity Index at baseline, 8-month and 16-month follow-up. The relationship, over time, between methylation in 22 gene promoter region sites, symptom scores, and treatment was assessed using linear mixed models. Compared to baseline, PTSD and AA symptom severity were significantly reduced at 8 and 16 months, respectively, in the FORNET group. Increased methylation of genes implicated in dopaminergic neurotransmission (NR4A2) and synaptic plasticity (AUTS2) was associated with reduced PTSD symptom severity in participants receiving FORNET. Analyses across participants revealed a proportional relationship between AA and methylation of TFAM, a gene involved in mitochondrial biosynthesis.

Appetitive and reactive aggression are differentially associated with the STin2 genetic variant in the serotonin transporter gene.

Appetitive aggression is a sub-category of instrumental aggression, characterised by the primary intrinsic enjoyment of aggressive activity. Aggression is heritable, and serotonergic and monoaminergic neurotransmitter systems have been found to contribute to the underlying molecular mechanisms. The aim of this study was to investigate the role that genetic variants in the serotonin transporter (SLC6A4) and monoamine oxidase A (MAOA) genes play in the aetiology of appetitive aggression in South African Xhosa males (n = 290). SLC6A4 5-HTTLPR, rs25531, and STin2 variants, as well as MAOA-uVNTR were investigated for their association with levels of appetitive aggression using Poisson regression analysis. The STin2 VNTR12 allele was found to be associated with increased levels of appetitive aggression (p = 0.003), but with decreased levels of reactive aggression (p = 7 × 10-5). This study is the first to investigate genetic underpinnings of appetitive aggression in a South African population, with preliminary evidence suggesting that SCL6A4 STin2 variants play a role in its aetiology, and may also be important in differentiating between appetitive and reactive aggression. Although the results require replication, they shed some preliminary light on the molecular dichotomy that may underlie the two forms of aggression.

Associations between societal disapproval and changes in symptoms of PTSD and appetitive aggression following treatment among high-risk South African males.

Background: In violent communities, social rejection as a person with victim-offender attributes is associated with more intense symptoms of posttraumatic stress disorder (PTSD) and a higher propensity towards violence, i.e. appetitive aggression. Successful community reintegration encompassing adequate social acknowledgment of individuals with both a history of violence exposure and perpetration may be necessary to enhance the treatment effects of interventions addressing PTSD and aggression. Objective: In this study, the effects of treatment and post-treatment traumatic events, violent offenses, and social acknowledgment (with sub-dimensions of general disapproval, family disapproval, and recognition as a person with both a history of violence exposure and commission) on changes in PTSD symptom severity and appetitive aggression from baseline to 8-month follow-up were investigated. Method: Data were collected from 54 males recruited through a Cape Town offender reintegration programme for an intervention study targeting trauma and aggression (n = 28 treatment; n = 26 wait-list). Changes in PTSD symptom severity after treatment were assessed with the PTSD Symptom Scale-Interview, changes in appetitive aggression with the Appetitive Aggression Scale (AAS), post-treatment traumatic events with an adapted version of the Child's Exposure to Violence Checklist, offenses with an adapted checklist from the AAS, and social acknowledgment with an adapted form of the Social Acknowledgment Questionnaire. Results: Path analyses revealed negative relationships between ongoing societal disapproval and changes in PTSD symptom severity and appetitive aggression at 8-months, controlling for age. All other variables were non-significant, except for treatment, which was associated with PTSD symptom reduction. Conclusions: As a complementary strategy to effective psychotherapeutic treatment, increased social acknowledgment may contribute significantly to the alleviation of PTSD symptoms and appetitive aggression. Psychological interventions should, therefore, not neglect the impact of societal factors on treatment effects.

Planteamiento: En comunidades violentas, el rechazo social como persona con atributos de víctima-agresor se asocia con síntomas más intensos del trastorno por estrés postraumático (TEPT) y una mayor propensión a la violencia, es decir, a la apetencia por la agresión. Puede que sea necesaria una reintegración con éxito en la comunidad ­que incluya un adecuado reconocimiento social de aquellos individuos con una historia tanto de exposición a la violencia como de agresión­ para mejorar los efectos del tratamiento de las intervenciones que abordan el TEPT y la agresión.Objetivo: En este estudio, se investigaron los efectos del tratamiento y los eventos traumáticos post-tratamiento, los delitos violentos y el reconocimiento social (con subdimensiones de desaprobación general, desaprobación familiar y reconocimiento como persona con antecedentes tanto de exposición a la violencia como de perpetración) sobre los cambios en la gravedad de los síntomas del TEPT y la apetencia por la agresión desde el inicio hasta el seguimiento a los 8 meses.Método: Se recogieron datos de 54 varones reclutados a través de un programa de reintegración de delincuentes de Ciudad del Cabo para un estudio de intervención dirigido a trauma y agresión (n = 28 tratamiento, n = 26 lista de espera). Se evaluaron los cambios en la gravedad de los síntomas del TEPT después del tratamiento con la Escala-Entrevista de Síntomas de TEPT (PTSD Symptom Scale-Interview), los cambios en la apetencia por la agresión con la Escala de Apetencia por la Agresión (AAS, siglas en ingles de Appetitive Aggression Scale), los eventos traumáticos posteriores al tratamiento con una versión adaptada de la Lista de verificación de exposición a la violencia para niños (Child's Exposure to Violence Checklist), las agresiones con una lista de verificación adaptada del AAS, y el reconocimiento social con una forma adaptada del Cuestionario de Reconocimiento Social (Social Acknowledgment Questionnaire).Resultados: Los análisis de ruta revelaron relaciones negativas entre la desaprobación social continuada y los cambios en la gravedad de los síntomas del TEPT y la apetencia por la agresión a los 8 meses, controlando la edad. Todas las demás variables no fueron significativas, excepto por el tratamiento, que se asoció con la reducción de los síntomas de TEPT.Conclusiones: Como estrategia complementaria a un tratamiento psicoterapéutico efectivo, el aumento del reconocimiento social puede contribuir significativamente al alivio de los síntomas del TEPT y la apetencia por la agresión. Por lo tanto, las intervenciones psicológicas no deben descuidar el impacto de los factores sociales sobre los efectos del tratamiento.

The interplay between trauma, substance abuse and appetitive aggression and its relation to criminal activity among high-risk males in South Africa.

BACKGROUND: In persistently unsafe environments, the cumulative exposure to violence predicts not only the development of posttraumatic stress disorder (PTSD), but also of increased aggression and violent outbursts. Substance use disorders interact with these developments, as drug consumption may blunt symptoms and also reduce the threshold for violent acts. Investigating the interplay between these variables and the possible cumulative effect of drug abuse on the attraction to cruelty is a crucial step in understanding the cycle of violence and developing intervention programs that address this cycle in violence-troubled communities such as low-income urban areas in South Africa. METHODS: Young males at risk (N=290) were recruited through a reintegration center for offenders in Cape Town. We assessed types of traumatic events experienced, PTSD symptom severity, appetitive aggression, committed offenses and patterns of drug abuse prior to the perpetration of violence. RESULTS: Path-analyses confirmed a positive relationship between exposure to traumatic events and PTSD symptom severity, appetitive aggression, the number of committed offenses and drug abuse prior to violence. PTSD symptoms were positively associated with the propensity toward aggression. Furthermore, more severe drug abuse was related to higher attraction to violence and more committed offenses. CONCLUSIONS: We conclude that like exposure to violence, drug abuse may play a key role in the attraction to aggression and criminal acts. Measures of violence prevention and psychotherapeutic interventions for trauma-related suffering may not be effective without enduring drug abuse rehabilitation.

Feasibility and effectiveness of narrative exposure therapy and cognitive behavioral therapy in a context of ongoing violence in South Africa.

OBJECTIVE: In an observer-blinded intervention trial, we tested the reduction of posttraumatic stress symptoms, aggressive attitude, and behavior in young males living in a context of ongoing community and gang violence by means of (a) forensic offender rehabilitation narrative exposure therapy (FORNET), and (b) the cognitive-behavioral intervention "Thinking for a Change" (TFAC). A waiting list served as the control condition. METHOD: A total of 39 young men were included in the data analysis: 15 completed FORNET, 11 underwent cognitive-behavioral therapy (CBT), and 13 were on a waiting list for later treatment. The primary efficacy endpoints were the PTSD Symptom Scale-Interview (PSS-I) severity score, the Appetitive Aggression Scale (AAS) score, and the number of perpetrated violent event types 8 months (on average) after treatment. RESULTS: Only in the sample receiving FORNET were posttraumatic stress disorder (PTSD) scores significantly reduced at the first follow-up (Cohen's d = -0.97) and significantly different from those of the control group (Cohen's d = -1.03). The changes in scores for appetitive aggression and perpetrated events were not significant for any of the treatment conditions. CONCLUSIONS: The study shows that trauma-focused treatment can reduce the psychological symptoms of posttraumatic stress even for individuals living under unsafe conditions in low-income urban communities. However, achieving changes in violent behavior within a context of ongoing violence may require more than the treatment of trauma-related suffering, confrontation with one's offenses, or cognitive-behavioral interventions. (PsycINFO Database Record

Perpetuating the cycle of violence in South African low-income communities: attraction to violence in young men exposed to continuous threat.

BACKGROUND: Life in the low-income urban communities of South Africa is imprinted by a cycle of violence in which young males predominantly are in the roles of both victim and perpetrator. There is some evidence that adolescents who show an attraction to cruelty can display high levels of psychosocial functioning despite the presence of posttraumatic stress symptoms. However, the role of appetitive aggression in the context of ongoing threats and daily hassles is not yet fully understood. OBJECTIVE: In this study, we examine the role of attraction to violence in areas of continuous traumatic stress exposure and its effect on posttraumatic stress disorder (PTSD) severity and violence perpetration. METHOD: A sample of 290 young males from two low-income Cape Town communities was surveyed. We assessed appetitive aggression with the Appetitive Aggression Scale (AAS), PTSD symptoms with the PTSD Symptom Scale-Interview, the number of witnessed and self-experienced traumatic event types with an adaptation of the Child Exposure to Community Violence questionnaire, and the number of perpetrated violence event types with an adapted offence checklist from the AAS. RESULTS: Appetitive aggression scores were predicted by witnessed as well as self-experienced traumatic events. Higher appetitive aggression scores resulted in higher levels of PTSD severity and perpetrated violence. CONCLUSIONS: Young males living in the low-income areas of South Africa may develop an attraction to cruelty in response to exposure to violence. Their willingness to fight in turn can increase the likelihood of continued violent behaviour. In contrast to previous research from postconflict areas, appetitive aggression and engagement in violence do not prevent the development of PTSD, but are instead associated with higher levels of posttraumatic stress. PTSD symptoms such as avoidance and hyperarousal, as well as an attraction to cruelty and thus the willingness to fight, might support survival in areas of ongoing conflict, but at the same time they could fuel the cycle of violence.