Nadine Stammel

Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia

BACKGROUND During the Khmer Rouge (KR) regime from 1975 to 1979 millions of Cambodians were confronted with the death or murder of family members. The long-term psychological consequences of these traumatic losses have not yet been investigated. The purpose of this study was to determine the rate and potential predictors of prolonged grief disorder (PGD) in survivors of the KR regime. METHOD The Inventory of Complicated Grief-Revised (ICG-R) was administered in a sample of N=775 Cambodians in face-to-face interviews who had lost at least one family member during the KR regime. Symptoms of PTSD were assessed with the PTSD Checklist-Civilian Version and symptoms of depression and anxiety with the Hopkins Symptom Checklist-25. RESULTS The prevalence of PGD in the sample was 14.3%. PGD was moderately associated with symptoms of depression, anxiety and PTSD. The loss of a spouse, a child, or a parent was associated with higher symptom severity of PGD than was the loss of a sibling or distant relatives. PGD was predicted by the relationship to the deceased and symptoms of depression and PTSD. LIMITATIONS Limitations of the study include the non-random sampling recruitment. The ICG-R has not been validated for use in Cambodia. CONCLUSIONS The vast majority of Cambodians lost family members during the KR regime. Even three decades later, PGD was prevalent in a substantial proportion of the present sample and related to other psychiatric disorders. The results underline the importance of examining PGD in studies of war-related psychological impairment.

When hope and grief intersect: Rates and risks of prolonged grief disorder among bereaved individuals and relatives of disappeared persons in Colombia

BACKGROUND Forced disappearance is a frequent phenomenon in violent conflicts and regimes, yet little is known about unresolved grief processes as a possible outcome of the disappearance of a loved one. This study investigates prolonged grief disorder (PGD) and its risk factors in a sample of persons who lost a significant other to disappearance as compared with a sample of bereaved individuals, both groups having experienced displacement due to the armed conflict in Colombia. METHOD In a cross-sectional study conducted in four Colombian provinces, 73 persons who lost a significant other to disappearance and 222 bereaved individuals completed measures of PGD (PG-13), depression (HSCL-25), and PTSD (PCL-C) via face-to-face interviews. Trauma- and loss-related variables, including the extent to which significant others of disappeared persons hoped that their loved one was still alive, were assessed. RESULTS Results indicated that 23% of participants who lost a significant other to disappearance met criteria for PGD as compared to 31.5% in bereaved participants. No differences were found between the two groups in terms of symptom severity of PGD, depression, posttraumatic stress disorder, or traumatic exposure. Regression analysis indicated that, among relatives and friends of disappeared persons, the extent of hope predicted PGD above and beyond depression severity whereas among bereaved persons, PGD was predicted by time since the loss, the number of traumatic events and symptom severity of PTSD and depression. LIMITATIONS The instruments were not validated for use in Colombia; generalizability of findings is limited. CONCLUSION Forced disappearance is related to prolonged grief reactions, particularly when those left behind maintain hope that the disappeared person is still alive.

Posttraumatische Belastungsstörungen bei Folter- und Kriegsopfern

ZusammenfassungDie posttraumatische Belastungsstörung ist eine häufige Folge von Folter- und Kriegserfahrungen. Zusätzlich zu der traumatischen Exposition wird das Erkrankungsrisiko durch Migrationsstressoren wie den Migrationsakt selbst und spezifische Postmigrationsstressoren erhöht. Die besonderen strukturellen Merkmale (Sprachbarrieren, interkulturell divergierende Krankheits- und Behandlungskonzepte, aufenthaltsrechtliche Unsicherheiten) bedürfen bei der Diagnostik und der psychotherapeutischen Behandlung expliziter Aufmerksamkeit. In diesem Beitrag wird das Störungsbild der (komplexen) posttraumatischen Belastungsstörung bei Kriegs- und Folteropfern beschrieben, übersetzte und validierte diagnostische Verfahren werden vorgestellt und auf besondere Aspekte psychotherapeutischer Behandlungsmöglichkeiten wird eingegangen.AbstractPosttraumatic stress disorder (PTSD) is a frequent psychological consequence of torture and war. In addition to the traumatic exposure, migration and post-migration stressors increase the risk for mental health consequences. Specific aspects, such as language barriers, intercultural divergent concepts of illness and treatment and unstable residential circumstances require explicit attention in the course of the diagnostic and psychotherapeutic process. Based on the current state of knowledge this article offers a description of clinical symptoms of (complex) PTSD, reviews diagnostic options and points out specific aspects in the principles of cognitive-behavioural treatment of PTSD in victims of torture and war.

Applicability of the ICD-11 proposal for PTSD: a comparison of prevalence and comorbidity rates with the DSM-IV PTSD classification in two post-conflict samples

Background The World Health Organization recently proposed significant changes to the posttraumatic stress disorder (PTSD) diagnostic criteria in the 11th edition of the International Classification of Diseases (ICD-11). Objective The present study investigated the impact of these changes in two different post-conflict samples. Method Prevalence and rates of concurrent depression and anxiety, socio-demographic characteristics, and indicators of clinical severity according to ICD-11 in 1,075 Cambodian and 453 Colombian civilians exposed to civil war and genocide were compared to those according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Results Results indicated significantly lower prevalence rates under the ICD-11 proposal (8.1% Cambodian sample and 44.4% Colombian sample) compared to the DSM-IV (11.2% Cambodian sample and 55.0% Colombian sample). Participants meeting a PTSD diagnosis only under the ICD-11 proposal had significantly lower rates of concurrent depression and a lower concurrent total score (depression and anxiety) compared to participants meeting only DSM-IV diagnostic criteria. There were no significant differences in socio-demographic characteristics and indicators of clinical severity between these two groups. Conclusions The lower prevalence of PTSD according to the ICD-11 proposal in our samples of persons exposed to a high number of traumatic events may counter criticism of previous PTSD classifications to overuse the PTSD diagnosis in populations exposed to extreme stressors. Also another goal, to better distinguish PTSD from comorbid disorders could be supported with our data.

Construction of a questionnaire for readiness to reconcile in victims of human rights violations

Background Post-conflict reconciliation is supposed to have a positive impact on survivors of war and conflict. However, knowledge is limited as validated questionnaires to assess individual readiness to reconcile in the context of human rights violations are still missing. Objectives This study aimed to develop and pilot-test a questionnaire to assess individual readiness to reconcile in victims of human rights violations. Methods The questionnaire was developed and pilot-tested in a sample of 60 adult Kurdish refugees from Turkey. In addition to the questionnaire, trauma exposure, Posttraumatic Stress Disorder (PTSD), depression, anxiety, perceived emotional closeness to the Kurdish people as well as the participants’ ability to differentiate between perpetrators and the people in general were assessed in structured interviews, and their associations with readiness to reconcile were analyzed. Results Factor and item analysis resulted in an 18-item questionnaire with three subscales (openness to interactions; absence of feelings of revenge; openness to conflict resolution). Cronbachs α for the subscales ranged from 0.74 to 0.90, explaining 61% of the total variance. The ability to differentiate between perpetrators and people in general and perceived emotional closeness were the best predictors for readiness to reconcile. The level of trauma exposure was not linked to readiness to reconcile. Although readiness to reconcile was negatively related to PTSD, depression and anxiety, none of these associations reached statistical significance. Conclusions The questionnaire appears to be a reliable measure with good psychometric properties. Further validations in different samples are needed.

Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder

BackgroundExposure to trauma and bereavement is common in conflict-affected regions. Previous research suggests considerable heterogeneity in responses to trauma and loss with varying symptom representations. The purpose of the current study was to (1) identify classes of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptom profiles among individuals who were exposed to both trauma and loss due to the Colombian armed conflict and (2) to examine whether sociodemographic, loss and trauma-related characteristics could predict class membership.MethodsThree hundred eight victims of internal displacement who had experienced trauma and loss were assessed through measures of PGD (PG-13), PTSD (PCL-C), and social support (DUKE-UNC). Latent class analysis (LCA) was performed to analyze differential profiles by symptoms of PGD and PTSD and multinomial logistic regression was used to analyze predictors of class membership.ResultsLCA revealed a four-class solution: a resilient class (23.6%), a PTSD-class (23.3%), a predominately PGD class (25.3%) and a high distress-class with overall high values of PGD and PTSD (27.8%). Relative to the resilient class, membership to the PGD class was predicted by the loss of a close family member and the exposure to a higher number of assaultive traumatic events, whereas membership to the PTSD class was predicted by the perception of less social support. Compared to the resilient class, participants in the high distress-class were more likely to be female, to have lost a close relative, experienced more accidental and assaultive traumatic events, and perceived less social support.DiscussionSpecific symptom profiles emerged following exposure to trauma and loss within the context of the Colombian armed conflict. Profiles were associated with distinct types of traumatic experiences, the degree of closeness to the person lost, the amount of social support perceived, and gender. The results have implications for identifying distressed subgroups and informing interventions in accordance with the patient’s symptom profile.

Traumatized refugees: identifying needs and facing challenges for mental health care

ABSTRACT In the past few years the number of refugees worldwide has increased dramatically. Many of them were traumatized in their homelands due to violent conflict or persecution, as well as during their flight, and are confronted with ongoing stressors in the exile countries. In order to contribute to enhancing the clinical knowledge, this special issue of the European Journal of Psychotraumatology focuses on traumatized refugees. It includes three review articles as well as four original articles on the mental health burden, screening instruments and interventions in different groups of refugees. The articles published in this special issue focus on important aspects of better understanding the needs of traumatized refugees, as well as on identifying and offering appropriate mental health care for this population. Future research recommendations are provided in the hope to contribute to improving mental health care strategies of this still underserved population.

Multidisciplinary treatment for traumatized refugees in a naturalistic setting: symptom courses and predictors

ABSTRACT Background: Multidisciplinary treatment approaches are commonly used in specialized psychosocial centres for the treatment of traumatized refugees, but empirical evidence for their efficacy is inconsistent. Objective: In order to obtain more evidence on the development of mental health and well-being of traumatized refugees who receive multidisciplinary treatment, symptom courses of posttraumatic stress disorder (PTSD), anxiety, depression and somatoform symptoms as well as in the subjective quality of life were investigated in the course of a multidisciplinary treatment. In addition, it was analysed if sociodemographic variables were predictors for possible changes in symptomatology and quality of life. Method: N = 76 patients of the outpatient clinic of a psychosocial centre for traumatized refugees receiving regular multidisciplinary treatment were surveyed using standardized questionnaires at three measurement points (at the beginning of treatment, and after an average of 7 and 14 months of treatment) in a single-group design. Results: Multilevel analysis showed significant improvements of symptoms of PTSD (p < .001), depression (p < .001), anxiety (p < .001), and somatoform symptoms (p = .002) as well as of the subjective quality of life (p < .001) over time. Among the tested predictors (gender, age, country of origin), age was a significant predictor for the course of somatoform symptoms (p < .05). Younger patients showed greater improvements in symptomatology over time than older ones. Conclusions: The results suggest that the received multidisciplinary treatment had a positive effect on trauma-related symptoms as well as on quality of life of traumatized refugees. There was no indication that sociodemographic characteristics predicted the symptom courses of the patients, except for somatoform symptoms. Younger patients benefitted more from multidisciplinary treatment than older ones.

Transgenerational trauma in a post-conflict setting: Effects on offspring PTSS/PTSD and offspring vulnerability in Cambodian families

We assessed transgenerational effects of maternal traumatic exposure, posttraumatic stress symptoms and posttraumatic stress disorder on trauma-related symptoms in Cambodian offspring born after the genocidal Khmer Rouge Regime. We conducted a randomized cross-sectional study. N=378 mothers from 4 provinces of the country and one of each of their grown-up children were interviewed. Lifetime traumatic exposure was determined using a context-adapted event list. Present posttraumatic stress symptoms and a potential posttraumatic stress disorder were assessed using the civilian version of the Posttraumatic Stress Disorder Checklist. We found no indication of transgenerational effects that were directly related to maternal traumatic exposure, posttraumatic stress symptoms or posttraumatic stress disorder. Instead, a gender-specific moderating effect was found. Individual traumatic exposure had a stronger effect on posttraumatic stress symptoms in daughters, the higher the mothers lifetime traumatic exposure. There is evidence of an interaction between lifetime traumatic exposure of mothers and their offspring that can be interpreted as an increased vulnerability to symptoms of posttraumatic stress in daughters. The mechanisms of transgenerational trauma in the Cambodian context require further research, as learning from previous conflicts will be instructive when addressing the pressing humanitarian needs of todays world.

The Readiness to Reconcile Inventory

Although awareness of the importance of reconciliation in post-conflict societies has grown in recent decades, validated measures assessing victims’ attitudes toward reconciliation are lacking. To fill this gap, the Readiness to Reconcile Inventory (RRI) was developed and its factor structure and aspects of construct validity were psychometrically tested in two independent samples of survivors of the Khmer Rouge regime in Cambodia. Exploratory factor analysis in a sample of N = 247 survivors identified a 13-item, three-factor internal structure of the RRI that was confirmed by confirmatory factor analysis in an independent sample of N = 830 survivors of the Khmer Rouge regime. All RRI subscales showed good internal consistency (Cronbach’s &agr;s from .80 to .83). Multiple-group analysis established configural, metric, and scalar invariance across sex. The RRI thus demonstrated good reliability and fulfilled some aspects of construct validity. It is a time-effective and easy-to-administer instrument for assessing readiness to reconcile in victims of war and conflict.