Esmina Avdibegovic

Depression, Anxiety and Somatization in Women with War Missing Family Members

Introduction: During the war circumstances, women and children are exposed to multiple traumatic experiences, one of which is an violent disappearance of a family member. Goal: The aim of this research was to establish the presence of symptoms of depression, anxiety and somatization in women in Bosnia and Herzegovina who have sought their war missing family members for 15 to 18 years. Subjects and Methods: The research was based on a sample of 120 women with war missing family member and 40 women without a war missing family member as a control group. For assessment of depression, anxiety and symptoms of somatization the self-rating Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HAM-A), Somatic Symptoms Index (SSI) questionnaire and a general questionnaire on the sociodemographic data and data on war missing family members were used. Results: A significantly higher intensity of symptoms of depression (p<0.001), anxiety (p<0.001) and somatization (p = 0.013) was present in women with, in comparison to women without a missing family member. In comparison of the kinship with the missing family members, statistically significantly higher intensity of symptoms of depression, anxiety and somatization was in women with a missing child (p<0.001) in comparison to other missing family members. Conclusion: A prolonged period of seeking, waiting and uncertainty of what happened in the war with the missing family member presents for those women a prolonged suffering manifested through depression, anxiety and symptoms of somatization.

Monoamine Oxidase A Gene Methylation and Its Role in Posttraumatic Stress Disorder: First Evidence from the South Eastern Europe (SEE)- PTSD Study

Abstract Background Posttraumatic stress disorder is characterized by an overactive noradrenergic system conferring core posttraumatic stress disorder symptoms such as hyperarousal and reexperiencing. Monoamine oxidase A is one of the key enzymes mediating the turnover of noradrenaline. Here, DNA methylation of the monoamine oxidase A gene exonI/intronI region was investigated for the first time regarding its role in posttraumatic stress disorder risk and severity. Methods Monoamine oxidase A methylation was analyzed via direct sequencing of sodium bisulfite-treated DNA extracted from blood cells in a total sample of N=652 (441 male) patients with current posttraumatic stress disorder, patients with remitted posttraumatic stress disorder, and healthy probands (comparison group) recruited at 5 centers in Bosnia-Herzegovina, Croatia, and the Republic of Kosovo. Posttraumatic stress disorder severity was measured by means of the Clinician-Administered Posttraumatic Stress Disorder Scale and its respective subscores representing distinct symptom clusters. Results In the male, but not the female sample, patients with current posttraumatic stress disorder displayed hypermethylation of 3 CpGs (CpG3=43656362; CpG12=43656514; CpG13=43656553, GRCh38.p2 Assembly) as compared with remitted Posttraumatic Stress Disorder patients and healthy probands. Symptom severity (Clinician-Administered Posttraumatic Stress Disorder Scale scores) in male patients with current posttraumatic stress disorder significantly correlated with monoamine oxidase A methylation. This applied particularly to symptom clusters related to reexperiencing of trauma (cluster B) and hyperarousal (cluster D). Conclusions The present findings suggest monoamine oxidase A gene hypermethylation, potentially resulting in enhanced noradrenergic signalling, as a disease status and severity marker of current posttraumatic stress disorder in males. If replicated, monoamine oxidase A hypermethylation might serve as a surrogate marker of a hyperadrenergic subtype of posttraumatic stress disorder guiding personalized treatment decisions on the use of antiadrenergic agents.

Emotional Profile of Women Victims of Domestic Violence

Introduction: Research indicates that women victims of domestic violence show significant cognitive changes, emotional numbing, and avoidance of interpersonal relationships. Aim: The aim of this research was to analyze emotional profile of women victims of domestic violence, and to determine the relationship between dimensions of emotions and frequency of women exposure to domestic violence. Methods: The research was conducted on the sample of 169 women, 111 were victims of domestic violence and 58 were women who did not experience domestic violence. Plutchik’s Emotions Profile Index (EPI) was used for measuring of the emotion profile, and the Modified Inventory of Domestic Violence for measuring experiences of different types of violence. Basic socio-demographic data were also collected. Results: Significant differences between women victims of domestic violence and women who did not experience domestic violence were found in a few dimensions of emotional profile. Women victims of domestic violence had higher results in the dimensions of deprivation/depression and aggression/destruction, while women who did not experience domestic violence had higher results in dimensions of reproduction and incorporation. Aggression was in significant negative correlation with reproduction, incorporation and self protection, whereas it was significant positive correlation with deprivation and opposition. There were significant and positive correlation between the dimensions of aggression and deprivation and frequency of all three forms of domestic violence and age of women. Conclusion: According to results obtained in this research, it can be concluded that women victims of domestic violence have significantly more intensive negative emotional dimensions in comparison to women who were not abused. Women victims of domestic violence with higher frequency of abuse describe themselves as more sad, apathetic, lonely, angry, quarrelsome and less sociable. Prominence of negative emotions, deprivation and aggression, can be factor of risk for mental health disorders and for re-victimisation of women victims of domestic violence.

Hypermethylation of the monoamine oxidase A gene – a new epigenetic marker for posttraumatic stress disorder?

Posttraumatic Stress Disorder (PTSD) can develop after experiencing or witnessing any severe traumatic event such as combat. Point prevalence rates in war-affected regions, e.g. Bosnia-Herzegovina and Kosovo, range from 18% to 35%. Noradrenergic dysfunction as represented by e.g. elevated noradrenaline concentrations in the cerebrospinal fluid of PTSD patients is known to play a substantial role in the pathogenesis of PTSD symptoms [1]. Epigenetic regulation (i.e. DNA methylation) is strongly suggested to moderate the interaction between environmental influences and a genetic predisposition. Therefore, differential methylation of genes involved in the noradrenergic system such as the monoamine oxidase A (MAOA) gene might be part of the complex biological underpinnings of a dysregulated noradrenergic system and thereby contribute to PTSD risk. The present study aimed at investigating MAOA gene methylation as a possible epigenetic marker of PTSD status and severity in a sample comprising patients with PTSD and healthy controls recruited from war-affected regions in Bosnia-Herzegovina, Croatia and Kosovo. DNA methylation levels of MAOA (exonI/intronI region) were analyzed in PTSD patients [N=216; m=157, age (mean±s.d.): 50.08±6.74 years], remitted PTSD patients [N=151; m=98, age (mean±s.d.): 49.48±8.20 years] and healthy controls [N=349, m=232, age (mean±s.d.): 48.81±8.50 years] by direct sequencing of sodium bisulfite-treated DNA followed by semi-quantitative analysis of the sequencing results via the Epigenetic Sequencing Methylation software. Severity of PTSD symptoms was assessed by the Clinician-Administered PTSD Scale (CAPS). All participants were assessed for potential confounders of methylation (sex, age, or smoking status). Possible categorical differences were analyzed by (M)ANCOVAs with age and smoking status as covariates. Post-hoc tests (Bonferroni) were performed to test individual differences in methylation across groups. Associations between dimensional measures were analyzed performing partial correlation analyses controlled for age and smoking status. In the male subsample, analyses revealed significant methylation differences at three out of 13 CpG sites between patients with current PTSD, remitted PTSD patients, and healthy controls. Post-hoc tests showed trend-wise significant (padjusted In the female subsample, we failed to observe association of MAOA methylation with either current or remitted PTSD, while there was a positive correlation between MAOA methylation and symptom severity (r=0.294, p=0.033). The results of the present study for the first time suggest MAOA hypermethylation – possibly resulting in an increased noradrenergic tonus – as a disease status and severity marker of PTSD particularly in male patients. Given robust replication, MAOA hypermethylation might thus serve as an epigenetic marker within the complex risk factor constellation of PTSD. Furthermore, applying a personalized pharmaco-therapeutic approach, anti-adrenergic agents might prove to be beneficial in counterbalancing increased noradrenergic signalling specifically in male PTSD patients displaying MAOA hypermethylation.

Predictors of insight in patients with schizophrenia

Aim To establish predictors of insight in patients with schizophrenia with regard to symptoms severity, executive functioning, level of education, marital status, age, and number of hospitalizations. Subjects and methods A cross-sectional study was conducted on 60 consecutive outpatients with schizophrenia. Positive symptoms were established with 4-item Positive Symptom Ranking Scale (PSRS), and negative symptoms with Brief Negative Symptoms Assessment (BNSA). The level of insight was established with Self-Appraisal of Illness Questionnaire (SAIQ). Executive functions were established with Wisconsin card sorting test, and three verbal subtests from Wechlers Intelligence Test: information, similarities, and calculating. All neuropsychological tests were administered by psychologist educated in administration of these and other neuropsychological tools. Results Predictive statistical model identifies age and illness duration as negative, and higher level of education, and being married as a positive predictors of insight with 38.5% variance explained. Scores on subscales “Similarities” and “Calculating” had positive association with insight score. Model explains 24.7% of variance. When model was adjusted on alpha 5% level of concluding only three significant positive predictors appears: higher level of education, higher score on “Similarities” subscale, and being married. Model explains 38.5% of variance. Conclusion Level of education and marital status, among all other factors, have important impact on level of insight in patients with schizophrenia.

Opiate addiction recovery: New treatment with buprenorphine and naloxone (suboxone) helps bring families together in Bosnia and Herzegovina

Background The centre for medical prevention of opiate addiction established, as a part of the Tuzla University Clinical Centres Department of Psychiatry, is a result of several years of cooperation between the Tuzla department of psychiatry and the centre for addiction of the University Hospital in Orebro, Sweden. By working together, the scientists have developed the Tuzla model for opiate addiction in 2009, a first ever project of such kind in Bosnia and Herzegovina. Objectives To describe principles of organization and results of six years working period with buprenorphine+naloxone program. Method Authors described principles of organization and results of six years working period of the centre for medical prevention of opiate addiction in Tuzla. Results Once a patient is admitted to the center, a family member or a close friend signs a statement, committing to ensure that the patient will take the prescribed medicine regularly and always sticks around, from the very first psychiatric interview until the treatment finalization. This program helps create a bond between the addict and another person, which makes it different from other treatment programs which usually tend to isolate addicts in institutions. Another difference is that instead of methadone, patients receive another drug that has shown much better results–buprenorphine+naloxone (Suboxone ® ). Currently, the centre has about 160 patients who come for regular treatment and check-ups. Since the centre was established, over 260 patients were successfully treated. Conclusion The program helps families to rebuild their homes and relationships torn-apart by addictions, through rehabilitation, re-socialization and reintegration.

EPA-0908 – Successful treatment with interferon therapy of hepatitis c positive opiate addicts who are in substitution maintenance therapy with buprenorphine/naloxone (suboxone®)

Hepatitis C is highly infected disease with long period of failure to recognize it, what leads to chronic liver damage and lower chances for complete cure if detected late. Intravenous (IV) opiate users are not aware when be infected from virus carriers using the same non-sterile equipment so they pass the infection to other IV drug users. By implementation of substitution treatment of opiate addicts with Buprenorphine/Naloxone (Suboxone) at the Department of Psychiatry in Tuzla on 27 July 2009 year, we made the obligatory serological tests for hepatitis B and C and HIV, as well as laboratory findings with liver function parameter analysis as a condition for starting substitution therapy. In this way we discovered 50/195 opiate addicts hepatitis C positive. Although faced with danger of the final result if not treated in time, addicts when became aware that they were hepatitis C positive, they avoid further needed procedures leading to the inclusion of specific therapy with pegylated interferon. In this paper, the authors presented the procedure of multidisciplinary approach of treatment of hepatitis C positive opiate addicts despite their resistances they do not occur on the continuation of the procedure detecting HCV genotypes, and the inclusion of specific therapy for the treatment of hepatitis C in the clinics for infectious or internal diseases. At the end, the authors present eleven clinical vignettes of successful treatment of hepatitis C in opiate addicts realized with multidisciplinary team. All of the treated individuals, after finished interferon treatment appeared hepatitis C negative.

EPA-1059 – Metabolic syndrome in patients with schizophrenia: polypharmacy with first generation antipsychotics vs. clozapine alone

Background To establish the prevalence of metabolic syndrome and its parameters in group of patients with schizophrenia in polypharmacy – receiving first generation antipsychotics versus clozapine alone treated group. Subjects and methods 48 outpatients with schizophrenia divided into two groups: the first group of 21 patients in polypharmacy with first generation antipsychotics, and the second group of 27 patients treated with clozapine alone were assessed for the presence of metabolic syndrome. We used logistic regression models to assess the relationship between metabolic syndrome and antipsychotic therapy, gender and age. Results metabolic syndrome was found in 52.1% of all subjects. Compared to first generation antipsychotics polypharmacy, the monopharmacy with clozapine was associated with elevated rates of metabolic syndrome (28.6% vs. 70.4%, p= 0.004). With regard to particular parameters of metabolic syndrome, the elevated plasma triglycerides were significantly more present in subjects within Clozapine group (p=0.03). Logistic regression analysis showed that female gender (p= 0.004), older age (p=0.56), and clozapine treatment (p= 0.005) were significantly associated with metabolic syndrome. Discussion Results of this study are consistent with other studies, which showed that patients receiving Clozapine are at higher risk for metabolic abnormalities. Conclusion Compared to polypharmacy with first generation antipsychotics, the higher prevalence of metabolic syndrome is found in patients treated with Clozapine alone. The most prevalent metabolic disorder is dyslipidemia. Female gender, older age, clozapine treatment are significantly associated with metabolic syndrome.

1519 – Significance of support of world psychiatric association and european psychiatric association to congresses of national psychiatric associations - case of bosnia-herzegovina

Bosnia-Herzegovina (BH) appeared as very complex geopolitical and demographical country after tragic 1992-1995 war and Daytona Peace Agreement. Besides all national professional medical associations, the Psychiatric Association of Bosnia- Herzegovina (PABH) is only one which is successfully established on the whole geopolitical space of BH. This Association organized the first national Congress which is the third Congress of psychiatrists after BH established trough Daytona Peace Agreement. In very humble financial occasions with world economic crisis it was very difficult to organize professional and scientific meeting with high level of realization. After communication with the leaders of World Psychiatric Association (WPA) and European Psychiatric Association (EPA) considering mutual collaboration, realization of this Congress was possible on very high level of scientific and professional achievements and performances. The Third Congress was Co-sponsored by WPA and under the patronage of EPA. WPA helped in engagement of ten distinguished university professors and researchers from USA, Australia, UK, South Africa, Pakistan, Germany, Italy and Austria but also with the workshop: “Partnership for mental health improvement in world: WPA recommendations for good practice in work with users of mental health services and their families”. EPA helped with two EPA academia CME courses: “Complexity of posttraumatic reactions” and “Psychoses-proneness: Clinical assessments of vulnerability”. All 30 university professors of psychiatry from Slovenia, Croatia, Serbia and Bosnia-Herzegovina (region of former Yugoslavia) together with about 260 participants had opportunity to be informed about the most novel achievements in theory and practice of psychiatry and mental health care in the World.

1285 – Training of bosnia-herzegovina mental health professionals in group analysis as the factor of development of culture of dialogue in the aftermath ofthe 1992–1995 war

Aim The primary objective will focus the first of all on Group Analysis (GA) as the psychotherapy method and theory of group analysis applied particularly in post-war environments. It outlines in particular a Zagreb Institute for GA Training Programme that took place in Tuzla University Clinical Centre, Department of Psychiatry, in Bosnia-Herzegovina (BH) in response to 1992–1995 war, in helping to train mental health workers in GA to enable them to treat psychological trauma symptoms of war survivors. Method In the GA education in the period of 16 years mental health professionals employed in mental health services were involved as well as other care employees as General Practitioners, Family physicians, pediatricians, gynecologists and neurosurgeons, psychologists and special educators. Results Trainees in education were from greater part of BH, and from several towns from neighborhoods countries. In this way a new room for mutual exchanges of experiences and establishing of cooperation was created. Idea of group analytic treatment of persons with mental health problems spread out on the whole region of BH through this model of education. The future of GA application as a psychotherapy model in BH confirmed through established models of education which are employed inowadays in Tuzla, Sarajevo and Mostar. The future of GA is provided in activities focused on foundations of the Institute for Analysis in Tuzla. Conclusion Training of Bosnia-Herzegovina mental health workers to effectively use GA with enthusiastic help of GA trainers from Institute for GA Zagreb will develop dialogue culture in postwar BH.