Naser Morina

A Comparison of DSM‐5 and DSM‐IV Diagnostic Criteria for Posttraumatic Stress Disorder in Traumatized Refugees

The aim of this study was to compare the prevalence rate and factor structure of posttraumatic stress disorder (PTSD) based on the diagnostic criteria of the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; DSM-5; American Psychiatric Association, , ) in traumatized refugees. There were 134 adult treatment-seeking, severely and multiply traumatized patients from various refugee backgrounds were assessed in their mother tongue using a computerized set of questionnaires consisting of a trauma list, the Posttraumatic Diagnostic Scale, and the new PTSD items that had been suggested by the DSM-5 Task Force of the American Psychiatric Association. Using DSM-IV, 60.4% of participants met diagnostic criteria for PTSD; using DSM-5, only 49.3% fulfilled all criteria (p < .001). Confirmatory factor analysis of DSM-IV and DSM-5 items showed good and comparable model fits. Furthermore, classification functions in the DSM-5 were satisfactory. The new Cluster D symptoms showed relatively high sensitivity, specificity, positive predictive power, and negative predictive power. The DSM-5 symptom structure appears to be applicable to traumatized refugees. Negative alterations in cognitions and mood may be especially useful for clinicians, not only to determine the extent to which an individual refugee is likely to meet criteria for PTSD, but also in providing targets for clinical intervention.

Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees

BACKGROUND While emotion dysregulation represents an important mechanism underpinning psychological responses to trauma, little research has investigated this in refugees. In the current study, we examined the mediating role of emotion dysregulation in the relationship between refugee experiences (trauma and living difficulties) and psychological outcomes. METHODS Participants were 134 traumatized treatment-seeking refugees who completed measures indexing trauma exposure, post-migration living difficulties, difficulties in emotion regulation, posttraumatic stress disorder, depression, and explosive anger. RESULTS Findings revealed distinctive patterns of emotion dysregulation associated with each of these psychological disorders. Results also indicated that emotion regulation difficulties mediated the association between both trauma and psychological symptoms, and living difficulties and psychological symptoms. LIMITATIONS Limitations include a cross-sectional design and the use of measures that had not been validated across all cultural groups in this study. CONCLUSIONS These findings underscore the key role of emotion dysregulation in psychological responses of refugees, and highlight potential directions for treatment interventions for traumatized refugees.

Lost in Translation? – Psychotherapie unter Einsatz von Dolmetschern

Language is the most essential tool in psychotherapies. Treatment is not possible if there is no common language between therapist and patient. To enable communication between therapists and patients not speaking a common language, the use of professional trained interpreters is inevitable. With the presence of a third person--the interpreter--a triad is established, which bears difficulties, but also chances. In the present paper, these problems and chances are discussed. Recommendations to optimize the work of interpreters in the psychotherapeutic setting are presented. Interpreters should familiarize themselves with the principles of psychotherapeutic methods and clear role concepts for therapists and interpreters should be defined.

The factor structure of complex posttraumatic stress disorder in traumatized refugees

Background The construct of complex posttraumatic stress disorder (CPTSD) has attracted much research attention in previous years, however it has not been systematically evaluated in individuals exposed to persecution and displacement. Given that CPTSD has been proposed as a diagnostic category in the ICD-11, it is important that it be examined in refugee groups. Objective In the current study, we proposed to test, for the first time, the factor structure of CPTSD proposed for the ICD-11 in a sample of resettled treatment-seeking refugees. Method The study sample consisted of 134 traumatized refugees from a variety of countries of origin, with approximately 93% of the sample having been exposed to torture. We used confirmatory factor analysis to examine the factor structure of CPTSD in this sample and examined the sensitivity, specificity, positive predictive power and negative predictive power of individual items in relation to the CPTSD diagnosis. Results Findings revealed that a two-factor higher-order model of CPTSD comprising PTSD and Difficulties in Self-Organization (χ2 (47)=57.322, p=0.144, RMSEA=0.041, CFI=0.981, TLI=0.974) evidenced superior fit compared to a one-factor higher-order model of CPTSD (χ2 (48)=65.745, p=0.045, RMSEA=0.053, CFI=0.968, TLI=0.956). Overall, items evidenced strong sensitivity and negative predictive power, moderate positive predictive power, and poor specificity. Conclusions Findings provide preliminary evidence for the validity of the CPTSD construct with highly traumatized treatment-seeking refugees. Highlights of the article Complex PTSD (CPTSD), proposed as a sibling diagnosis to posttraumatic stress disorder (PTSD) in ICD-11, has not been previously evaluated with treatment-seeking refugees. This study compared higher-order one and two-factor models of CPTSD using confirmatory factor analysis in a sample of traumatized refugees. Findings indicated that a higher-order two-factor model comprising PTSD and Disturbances in Self-Organization best fit the data. These findings provide preliminary evidence that the CPTSD construct is relevant to individuals exposed to persecution and displacement.

Challenging future, challenging past: the relationship of social integration and psychological impairment in traumatized refugees

Background Refugees have been shown to present high prevalence rates of trauma-related mental disorders. Despite their psychological impairment, they are expected to meet high functional requirements in terms of social integration into, and financial independence from, the host society. Methods This cross-sectional study examined the relationship of mental health problems, post-migration living difficulties (PMLD), and social integration in a sample of 104 refugees seeking treatment for severe posttraumatic stress and comorbid symptoms in two outpatient clinics in Switzerland. Results Despite an average time of residence in Switzerland of over 10 years, participants showed poor integration and a high number of PMLD. Integration difficulties were closely associated with psychological symptoms, but not with socio-demographic parameters such as education or visa status. Conclusions Psychological impairment in treatment-seeking traumatized refugees is associated with poor integration. To foster social integration, it is crucial to better understand and address the specific needs of this highly vulnerable population.

Trauma, mental health, and intergenerational associations in Kosovar Families 11 years after the war

Background While there is a considerable amount of literature addressing consequences of trauma in veterans and holocaust survivors, war and postwar civilian populations, particularly children, are still understudied. Evidence regarding intergenerational effects of trauma in families is inconsistent. Objective To shed light on intergenerational aspects of trauma-related mental health problems among families 11 years after the Kosovo war. Method In a cross-sectional study, a paired sample of 51 randomly selected triplets (school-aged child, mother, father, N=153) of Kosovar families was investigated with regard to trauma exposure, posttraumatic stress (UCLA Posttraumatic Diagnostic Scale), anxiety (Spence Childrens Anxiety Scale, Hopkins Symptom Checklist-25), and depressive symptoms (Depressionsinventar für Kinder und Jugendliche [DIKJ; depression inventory for children and adolescents], Hopkins Symptom Checklist-25). Results Considerable trauma exposure and high prevalence rates of clinically relevant posttraumatic stress, anxiety, and depressive symptoms were found in both parents and children. While strong correlations were found between childrens depressive symptoms and paternal posttraumatic stress, anxiety and depressive symptoms, maternal symptoms did not correlate with their childrens. In multiple regression analyses, only posttraumatic stress symptoms of fathers were significantly related with childrens depressive symptoms. Conclusion Eleven years after the Kosovo war, the presence of posttraumatic stress, anxiety, and depressive symptoms in civilian adults and their children is still substantial. As symptoms of parents and children are associated, mental health problems of close ones should be actively screened and accounted for in comprehensive treatment plans, using a systemic approach. Future research should include longitudinal studies conducting multivariate analyses with larger sample sizes in order to investigate indicators, causal and resilience factors.

The Role of the Health Care Interpreter in a Clinical Setting—A Narrative Review

Objective: To examine published models of health care interpretation and associated roles, expectations, and outcomes. Methods: A literature search was conducted using the key words interpreter/translator, communication, and role and their combinations in PubMed, CINAHL, PsycINFO, and PSYNDEXPlus. References mentioned in articles identified with these search terms were then checked by hand in corresponding publications and books. We excluded articles if they were dealing with concepts of interpretation, role definitions, etc., without presenting any empirical evidence to support their recommendations. Thirty-four of 1,121 references that investigated the role of professional interpreters in health care were found to meet inclusion criteria. Results: Out of 34 articles, only 2 recommend strict adherence to the conduit model in which interpreters are faithfully and exclusively transmitting information; the interpreter’s role is in 32 studies defined in broader terms as the role of a cultural broker (n = 18), a manager or clarifier (n = 22), a patient advocate (n = 13), or a mediator (n = 6). Conclusion: There are no commonly accepted understandings of the interpreters’ role; empirical data are lacking. Practice Implications: The interpreter’s function must be explicitly clarified before a health care encounter is conducted. There should be an agreement of some basic rules.

Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in 8 countries

ABSTRACT The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria’s neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.

Symptoms of posttraumatic stress disorder in a clinical sample of refugees: a network analysis

ABSTRACT Background: Network analysis is an emerging methodology for investigating psychopathological symptoms. Given the unprecedented number of refugees and the increased prevalence of mental disorders such as posttraumatic stress disorder (PTSD) in this population, new methodologies that help us better to understand psychopathology in refugees are crucial. Objective: The objective of this study was to explore the network structure and centrality indices of DSM-5 PTSD symptoms in a cross-sectional clinical sample of 151 severely traumatized refugees with and without a formal PTSD diagnosis. Method: The R-packages qgraph and bootnet were used to estimate the structure of a PTSD symptom network and its centrality indices. In addition, robustness and significance analyses for the edges weights and the order of centrality were performed. Results: Three pairs of symptoms showed significantly stronger connections than at least half of the other connections: hypervigilance and exaggerated startle response, intrusion and difficulties falling asleep, and irritability or outbursts of anger and self-destructive or reckless behaviour. Emotional cue reactivity had the highest centrality and trauma-related amnesia the lowest. Conclusion: Although only 51.0% of participants fulfilled criteria for a probable PTSD diagnosis, emotional cue reactivity showed the highest centrality, emphasizing the importance of emotional trauma reminders in severely traumatized refugees attending an outpatient clinic. However, due to the small sample size, the results should be interpreted with care.

Combining biofeedback and Narrative Exposure Therapy for persistent pain and PTSD in refugees: a pilot study

Objective Many traumatised refugees suffer from both persistent pain and posttraumatic stress disorder (PTSD). To date, no specific guidelines exist for treatment of this group of patients. This paper presents data on a pilot treatment study conducted with 15 traumatised refugees with persistent pain and PTSD. Methods Participants received 10 sessions of pain-focused treatment with biofeedback (BF) followed by 10 sessions of Narrative Exposure Therapy (NET). Structured interviews and standardised questionnaires were used to assess symptoms of pain intensity, pain disability, PTSD and quality of life directly before and after treatment and at 3 months follow-up. Results Following the combined intervention, participants showed a significant reduction in both pain and PTSD symptoms, as well as improved quality of life. Additionally, biofeedback increased motivation for subsequent trauma-focused therapy, which in turn was related to larger PTSD treatment gains. Conclusion This pilot study provides initial evidence that combining BF and NET is safe, acceptable, and feasible in patients with co-morbid persistent pain and PTSD.