Hans Peter Söndergaard

Elevated Blood Levels of Dehydroepiandrosterone Sulphate Vary with Symptom Load in Posttraumatic Stress Disorder: Findings from a Longitudinal Study of Refugees in Sweden

Background: The present study is part of a longitudinal study of recently resettled refugees with the aim of learning which factors in their daily life influence health as measured by self-report and stress-responsive hormones. Methods: In a group of recently resettled refugees with a high incidence of posttraumatic stress disorder (PTSD), diagnosed by structured interview, self-rated symptoms of PTSD were followed three times over a period of 9 months after inclusion in the study. Eighty-six individuals were included in the study and 58 subjects (67.4%) completed it. Blood samples were drawn at each examination for assessment of hormone levels. Results: After adjustment for age, dehydroepiandrosterone sulphate (DHEA-s) was observed to be higher in non-depressed PTSD cases than in non-PTSD without depression. There was an interaction between PTSD and depression regarding DHEA-s levels. DHEA-s correlated significantly with changes in self-rated symptoms of PTSD at last follow-up; the greater the increase in PTSD symptoms, the greater the increase in plasma DHEA-s. The variation of DHEA-s levels in relation to changes in self-rated health in non-PTSD showed the opposite pattern, although not reaching significance. Conclusions: The finding of changes in DHEA-s should encourage further studies of the role of altered steroid metabolism in PTSD.

Alexithymia, emotions and PTSD; findings from a longitudinal study of refugees.

The objective of the present study was to assess alexithymia by means of the Toronto Alexithymia Scale (TAS-20) and The Emotion Protocol (EP) in a group of refugees. Eighty-six subjects were willing to participate. At last follow-up, 33 non-PTSD and 22 PTSD subjects had complete data. Subjects with PTSD had higher scores on the TAS-20 (F=4.314, df=77, p=0.041), but on the subscale level, this was significant only with regard to Factor I, difficulties identifying feelings (F=5.316, df=77, p=0.024). TAS Factor I and to a lower extent TAS Factor II (difficulties naming feelings) were significantly associated with the self-rated presence of dysphoric affects. At follow-up, an increase in TAS Factor I score was associated with increased prevalence of self-rated symptoms of PTSD, but not depression. Decrease in prolactin was associated with significant increase of TAS Factor I (rho=−0.396, n=54, p=0.003). The present study indicates that alexithymia as measured by TAS-20 is indeed associated with symptoms of PTSD. This association is almost exclusively explained by the TAS Factor I subscale and is in turn associated with a high level of self-reported dysphoric affect. The longitudinal inverse correlation with prolactin points to the possibility of an underlying disturbance in serotonergic and/or dopaminergic systems. The results thus indicate that secondary, or post-traumatic, alexithymia is a measure of suppressed or warded-off negative affects.

Self-reported life event patterns and their relation to health among recently resettled Iraqi and Kurdish refugees in Sweden.

This paper presents the findings of a longitudinal study of life events in refugees belonging to different language groups from Iraq. Eighty-six individuals were included in the study. Data regarding life events and self-reported health measurements were collected after baseline assessment with 3-monthly intervals on three occasions. Posttraumatic stress disorder was diagnosed by means of a structured interview at baseline. The results indicate that the subjects were influenced to a great extent by political events and the situation of significant others in the home country. Further, the number of negative life events in the host country showed a significant association with self-rated deteriorated health. In subjects with posttraumatic stress disorder, the effects of certain life events were more pronounced.

Morphometric and Psychometric Comparisons between Non-Substance-Abusing Patients with Posttraumatic Stress Disorder and Normal Controls

Background: Hippocampal decrease in size in response to posttraumatic stress disorder (PTSD) is still a subject of controversy. The aims of this study were to: (1) confirm previous hippocampus findings in PTSD patients compared to controls, using ethnically similar study groups where alcohol and drug abuse were non-existent; (2) test influence of disease duration as well as depression scores on possible morphological changes; (3) test whether the voxel-based morphometry (VBM) data confirm the group differences seen in the region of interest (ROI) analysis, and (4) test the associations between the cognitive test scores and the morphological changes. Methods: VBM and ROI-based analysis were applied in 23 patients and 17 healthy controls. Culture-neutral cognitive tests were used. Results: The ROI-based method showed significantly decreased gray matter volumes for global hippocampal volume, as in a separate analysis of left and right sides in the PTSD group. Total volume of the hippocampus was significantly decreased on the left side, as in the global assessment. A multiple regression VBM model showed significant voxel clusters for group affiliation in the right hippocampus, modelling lowering of gray matter associated with the PTSD group. Disease duration was shown to be negatively correlated to bilateral hippocampal volume and high depression score to bilateral gray matter parahippocampal volume. No significant correlations were found between hippocampal or parahippocampal volumes and cognitive functions. Conclusion: The present and previous studies showed that morphologic differences do not appear to be due to drug or alcohol abuse. The VBM data partially confirm the group differences seen in the ROI-based method in the medial temporal lobe. The fact that the significantly lower score on the short-term memory test in the PTSD group is not correlated to hippocampal volume may suggest a more general basis for such memory impairment.

Screening for post-traumatic stress disorder among refugees in Stockholm

A screening procedure (The Health Leaflet; HL) to assist social workers in finding subjects with possible post-traumatic stress disorder (PTSD) in recently resettled refugees is presented. It is compared with two established self-rating instruments, the Harvard Trauma Questionnaire (HTQ) and Impact of Event Scale-22 (IES-22), as well as structured clinical interview. Aim: To validate the screening interview and the rating scales in comparison to a clinical assessment for PTSD, and examine the feasibility of lay screening for PTSD. Findings: The Health Screening Interview with a cut-off value of 10 points identified cases with fully developed PTSD with both sensitivity and specificity about 0.7. Only two items--difficulties concentrating and having been exposed to torture--contributed to the discriminatory performance of the HL interview. In the HTQ symptom subscale, emotional detachment and a feeling of going mad contributed to the discriminatory performance. In the IES-22, recurring strong affects about the events, as well as intrusive memories, were the items with the highest canonical correlation coefficients. In the HL, the single screening question about difficulties concentrating identified 31/32 individuals diagnosed with PTSD in this group, with a relative risk of 24. Conclusions: A mental health screening procedure during refugee reception performed by lay persons is clearly feasible and can assist in identifying subjects with trauma-related healthcare needs, thus leading to more realistic demands in refugee reception.

A longitudinal study of hormonal reactions accompanying Life events in recently resettled Refugees

Background: Refugees constitute a growing section of the general population in many countries. It is therefore important to study which factors in everyday life are important to recently resettled refugees after they have been granted residence. Methods: Life events from a checklist, as well as categories derived from written responses to open-ended questions were analysed (repeated-measures ANOVA). Changes over time in mean serum/plasma concentrations of cortisol, thyroxine, prolactin, and dehydroepiandrosterone sulphate (DHEA-S) were compared in subjects with and without the reported events. Results: Distress in significant others (close friends or first-degree relatives) and a perception of excessive demands in everyday life were associated with increases in serum cortisol. Events associated with decreased levels of prolactin were typically situations of strain in relation to authorities or individuals to which the subjects were in a position of dependency. DHEA-S changed in opposite directions in post-traumatic stress disorder (PTSD) and non-PTSD subjects. DHEA-S also changed with positive events. Conclusions: Distress in significant others and a too demanding everyday life lead to significant changes in the stress-responsive hormones cortisol, prolactin and DHEA-S. Since DHEA-S behaves differently in PTSD, this condition is a potential confounder in studies of DHEA-S with an unknown proportion of PTSD among participants.

Language Acquisition in Relation to Cumulative Posttraumatic Stress Disorder Symptom Load over Time in a Sample of Resettled Refugees

Objective: To study the effects of symptoms of posttraumatic stress disorder (PTSD), depression and dissociation as well as cumulative symptom load on language learning during the introduction phase in resettled refugees. Method: Participants were resettled refugees of Iraqi origin. They were assessed by means of a structured interview for PTSD at baseline as well as self-rating questionnaires. Language acquisition was studied by means of register data from the school system. Five levels of language proficiency were recorded. Self-reported symptom scores for PTSD, depression and dissociation (Impact of Events Scale-22, Hopkins Symptom Checklist-25, Dissociative Experiences Scale) were measured at four time points during 9 months immediately after resettlement. In 49 participants in a longitudinal study, data regarding progress in language studies were accessible. Results: The results of the study indicate that the speed of language acquisition – the number of levels taken during the study, adjusted to hours of school presence – is related to the cumulative PTSD symptom load over time (Events Scale-22), but is not related neither to the symptom load of depression and dissociation, nor to the number of previous school years. Conclusion: The study shows that the symptom load of PTSD during the follow-up period is significantly inversely related to the speed of language acquisition in refugees. This implies that treatment as well as preventive measures against worsening of PTSD symptoms are important in order to minimise harmful post-migration stress for the facilitation of integration.

Patterns of Injury and Reported Violence Depending on Relationship to Assailant in Female Swedish Sexual Assault Victims

Earlier studies have explored the differences between known-assailant sexual assaults and stranger assaults and reported the stranger assaults as being more violent. Only a few studies have discriminated between sexual assaults by intimate partners from assaults by other known assailants when comparing with assaults by strangers. In this study, we explored differences in the extent of violence and physical injury in sexual assaults committed by intimate partners compared with assaults by strangers and acquaintances. Medical and forensic records of 690 consecutive women attending a sexual assault center in Stockholm, Sweden were reviewed. The final sample included in the analysis consisted of 503 patients. Our results showed that women sexually assaulted by their intimate partners more frequently reported physical violence (OR = 4.1) than women assaulted by strangers (OR = 2.0) and acquaintances (OR = 1.0). Genital injuries were not found to be related to the victim–assailant relationship in this study. Extragenital injuries showed a tendency toward being more frequently found after intimate partner assaults compared with stranger and acquaintance assaults; however, this was not found to be significant in adjusted analyses. Previous history of sexual assault was more common, and seeking medical care within 72 hr as well as being under the influence of alcohol during the assault was less frequent among intimate partner victims. These results support the conclusion that sexual assaults committed by intimate partners, contradictory to earlier studies, are likely to involve more physical violence and result in injuries just as often as assaults committed by strangers.

Identifying risk factors for PTSD in women seeking medical help after rape

Objectives Rape has been found to be the trauma most commonly associated with Posttraumatic Stress Disorder (PTSD) among women. It is therefore important to be able to identify those women at greatest risk of developing PTSD. The aims of the present study were to analyze the PTSD prevalence six months after sexual assaults and identify the major risk factors for developing PTSD. Methods Participants were 317 female victims of rape who sought help at the Emergency Clinic for Raped Women at Stockholm South Hospital, Sweden. Baseline assessments of mental health were carried out and followed up after six months. Results Thirty-nine percent of the women had developed PTSD at the six month assessment, and 47% suffered from moderate or severe depression. The major risk factors for PTSD were having been sexually assaulted by more than one person, suffering from acute stress disorder (ASD) shortly after the assault, having been exposed to several acts during the assault, having been injured, having co-morbid depression, and having a history of more than two earlier traumas. Further, ASD on its own was found to be a poor predictor of PTSD because of the substantial ceiling effect after sexual assaults. Conclusions Development of PTSD is common in the aftermath of sexual assaults. Increased risk of developing PTSD is caused by a combination of victim vulnerability and the extent of the dramatic nature of the current assault. By identifying those women at greatest risk of developing PTSD appropriate therapeutic resources can be directed.

Psychophysiological Studies of EMDR

Eye movement desensitization and reprocessing (EMDR) has been established as an efficacious therapy for posttraumatic stress disorder (PTSD). The working mechanism of the procedure is, however, still partly unknown. It is therefore important to explore the physiological effects of eye movements and alternative bilateral stimulation. This article describes our research on the effects of eye movements during authentic EMDR sessions of chronic PTSD in refugees with war and torture experiences and places this research in the context of other findings. The findings point to defi nite physiological effects of eye movements; namely a dearousal with increased fi nger temperature and changes in the balance between the parasympathetic and sympathetic autonomous nervous systems.