Sabina Palic

Psychosocial treatment of posttraumatic stress disorder in adult refugees: A systematic review of prospective treatment outcome studies and a critique

BACKGROUND Refugees with posttraumatic stress disorder (PTSD) often present with complicated traumatic symptoms, prolonged and repeated exposure to traumatic events, acculturation, and social problems. A consensus about suitability of psychosocial treatments for refugees does not exist. Never the less there is a need to review the state of knowledge about effective treatments for traumatized refugees, to help guide the practitioners in their choice of treatment methods. METHODS A systematic review of treatment outcome studies was carried out. RESULTS Twenty-five studies were reviewed. The majority were treatment studies of different forms of cognitive-behavioral therapy (CBT). The rest were reports of outcomes of alternative treatments and a small group of studies of multidisciplinary treatments. LIMITATIONS The amount of grey literature not covered by the review could not be estimated precisely. Included studies are methodologically diverse and consist of different refugee populations. This makes a broad interpretation of the treatment results only tentative. CONCLUSIONS Very large effect sizes were obtained in some of the CBT studies, indicating a broad suitability of CBT in the treatment of core symptoms of PTSD in adult refugees. Empirical evidence also points to the possibility that the maladaptive traumatic reactions in refugees can take shape of more complex reactions than those strictly specified in the diagnostic category of PTSD. Effectiveness of CBT treatments has as yet not been tested on the whole range of symptoms in these complex cases. There are few studies of treatments alternative to CBT and they are less methodologically rigorous than the CBT studies.

PTSD-8 – A short PTSD Inventory

Traumatic events pose great challenges on mental health services in scarcity of specialist trauma clinicians and services. Simple short screening instruments for detecting adverse psychological responses are needed. Several brief screening instruments have been developed. However, some are limited, especially in relation to reflecting the posttraumatic stress disorder (PTSD) diagnosis. Recently, several studies have challenged pre-existing ideas about PTSD’s latent structure. Factor analytic research currently supports two four factor models. One particular model contains a dysphoria factor which has been associated with depression and anxiety. The symptoms in this factor have been hailed as less specific to PTSD. The scope of this article is therefore to present a short screening instrument, based on this research; Posttraumatic Stress Disorder (PTSD) – 8 items. The PTSD-8 is shown to have good psychometric properties in three independent samples of whiplash patients (n=1710), rape victims (n=305), and disaster victims (n=516). Good test-rest reliability is also shown in a pilot study of young adults from families with alcohol problems (n=56).

Personality dysfunction and complex posttraumatic stress disorder among chronically traumatized Bosnian refugees.

Abstract A proposal for the inclusion of complex posttraumatic stress disorder (CPTSD) in the upcoming ICD-11 has been put forward. Using self-report, we investigated the resemblance between disorders of extreme stress not otherwise specified (DESNOS) and both axis I and II syndromes among 116 treatment-seeking Bosnian refugees. In this sample, the prevalence of DESNOS overlapped to a large degree with the prevalence of schizotypal and paranoid personality disorders (PDs). There was, however, also a large prevalence of axis I syndromes in the group. Thus, DESNOS in the refugees can be categorized as an axis I or II disorder depending on the chronicity and the severity of functional impairment. DESNOS and PD-like states were even observed among the refugees with no history of childhood maltreatment. No large differences were observed between DESNOS and PD regarding sex. The symptom constellation of CPTSD in the ICD-11 is partially supported. However, CPTSD might resemble PD to a considerable degree.

Replicability and Generalizability of Posttraumatic Stress Disorder (PTSD) Networks : A Cross-Cultural Multisite Study of PTSD Symptoms in Four Trauma Patient Samples

The growing literature conceptualizing mental disorders like posttraumatic stress disorder (PTSD) as networks of interacting symptoms faces three key challenges. Prior studies predominantly used (a) small samples with low power for precise estimation, (b) nonclinical samples, and (c) single samples. This renders network structures in clinical data, and the extent to which networks replicate across data sets, unknown. To overcome these limitations, the present cross-cultural multisite study estimated regularized partial correlation networks of 16 PTSD symptoms across four data sets of traumatized patients receiving treatment for PTSD (total N = 2,782). Despite differences in culture, trauma type, and severity of the samples, considerable similarities emerged, with moderate to high correlations between symptom profiles (0.43–0.82), network structures (0.62–0.74), and centrality estimates (0.63–0.75). We discuss the importance of future replicability efforts to improve clinical psychological science and provide code, model output, and correlation matrices to make the results of this article fully reproducible.

Assessment of dissociation in Bosnian treatment-seeking refugees in Denmark

Abstract Background: Dissociative experiences are common in traumatized individuals, and can sometimes be mistaken for psychosis. It is difficult to identify pathological dissociation in the treatment of traumatized refugees, because there is a lack of systematic clinical descriptions of dissociative phenomena in refugees. Furthermore, we are currently unaware of how dissociation measures perform in this clinical group. Aims: To describe the phenomenology of dissociative symptoms in Bosnian treatment-seeking refugees in Denmark. Method: As a part of a larger study, dissociation was assessed systematically in 86 Bosnian treatment-seeking refugees using a semi-structured clinical interview (Structured Interview for Disorders of Extreme Stress—dissociation subscale; SIDES-D) and a self-report scale (Dissociative Experiences Scale; DES). Results: The SIDES-D indicated twice as high prevalence of pathological dissociation as the DES. According to the DES, 30% of the refugees had pathological dissociation 15 years after their resettlement. On the SIDES-D, depersonalization and derealization experiences were the most common. Also, questions about depersonalization and derealization at times elicited reporting of visual and perceptual hallucinations, which were unrelated to traumatic re-experiencing. Questions about personality alteration elicited spontaneous reports of a phenomenon of “split” pre- and post-war identity in the refugee group. Whether this in fact is a dissociative phenomenon, characteristic of severe traumatization in adulthood, needs further examination. Conclusions: Knowledge of dissociative symptoms in traumatized refugees is important in clinical settings to prevent misclassification and to better target psychotherapeutic interventions. Much development in the measurement of dissociation in refugees is needed.

Impact of Traumatic Events on Posttraumatic Stress Disorder among Danish Survivors of Sexual Abuse in Childhood

Childhood sexual abuse can be extremely traumatic and lead to lifelong symptomatology. The present study examined the impact of several demographic, abuse, and psychosocial variables on posttraumatic stress disorder severity among a consecutive sample of treatment-seeking, adult child sexual abuse survivors (N = 480). The child sexual abuse sample was characterized by severe trauma exposure, insecure attachment, and significant traumatization, with an estimated 77% suffering from posttraumatic stress disorder, more than twice the level of the comparison group. Regression analyses revealed risk factors associated with the development of posttraumatic stress disorder in which the strongest predictors being additional traumas, negative affectivity, and somatization. The findings add to existing research confirming the stressful nature of child sexual abuse and the variables that contribute to the development and severity of posttraumatic stress disorder.

Predicting Chronic Posttraumatic Stress Disorder in Bereaved Relatives: A 6- Month Follow-Up Study

The objectives of the present study were to examine the prevalence of posttraumatic stress disorder (PTSD) and to identify predicative risk factors for PTSD in bereaved people after a terminal illness. Fifty-four persons (mean age 60 years) participated in the study. Demographic, peritraumatic, and psychosocial factors were assessed in order to identify variables that affected PTSD severity. Six months after the loss, 21.6 % of the subjects had PTSD, an 8.6 % decrease from PTSD measured one month after the loss. Intake of medicine after the loss, place of death, not having a close intimate, negative affectivity, and the A2 criterion predicted 65 % of PTSD severity. A considerable number of the bereaved were still at great risk for developing PTSD six months after loss.

Rasch Validation and Cross-Validation of the Health of Nation Outcome Scales for Monitoring of Psychiatric Disability in Traumatized Refugees in Western Psychiatric Care:

There are no validated measures of psychiatric disability for traumatized refugees in Western psychiatric care. This is a serious shortcoming as it precludes monitoring of global treatment outcomes in this group, as well as appropriate matching of treatment needs to the disability levels. Using Rasch analysis, we evaluated the psychometrics of the Health of Nation Outcome Scales (HoNOS) in pretreatment data of consecutive refugee patients (N = 448) from a Danish psychiatric clinic. Then, we carried out a cross-validation of the pretreatment HoNOS model on posttreatment data from the same group. A revised 10-item HoNOS fit the Rasch model at pretreatment and also showed excellent fit within the cross-validation data. Culture, gender, and need for translation did not exert serious bias on the measure’s performance. The results establish good monitoring properties of the 10-item HoNOS as the first validated measure of psychiatric disability for traumatized refugees in Western psychiatric care.

Childhood Abuse Types and Physical Health at the Age of 24: Testing Health Risk Behaviors and Psychological Distress as Mediators

This study examines whether adult psychological distress and health risk behaviors mediate the relationship between childhood abuse and physical health in adulthood. A randomly selected population-based sample, with oversampling to include a one-third subgroup of former child protection cases, completed a structured interview. Questions pertained to childhood exposure to abuse, adult psychological distress, physical health, and health risk behaviors. Previous research using this sample had identified three abuse typologies: emotional abuse, sexual abuse, and polyvictimization (physical abuse, emotional abuse, and neglect). All three typologies were significantly associated with poorer self-reported physical health. Psychological distress and health risk behaviors partially mediated the relationship between nonabuse, sexual abuse, polyvictimization, and physical health, and fully mediated the relationship between emotional abuse and physical health. The results of this study indicate that health risk behaviors and symptoms of psychological distress could contribute to some of the long-lasting consequences of childhood abuse on adult physical health.

Comparison of psychiatric disability on the health of nation outcome scales (HoNOS) in resettled traumatized refugee outpatients and Danish inpatients

BackgroundCurrently, the mental health issues of traumatized refugees are mainly documented in terms of posttraumatic stress disorder, depression, and anxiety. Importantly, there are no reports of the level of psychiatric disability in treatment seeking traumatized refugees resettled in the West. Insufficient acknowledgment of the collective load of bio-psycho-social problems in this patient group hinders effective psychiatric and social service utilization outside the specialized clinics for traumatized refugees.MethodsThe level of psychiatric disability in traumatized refugees from Danish specialized clinics (N = 448) is documented using routine monitoring data from pre- and post-treatment on the Health of Nation Outcome Scales (HoNOS). Furthermore, the HoNOS ratings are compared with routine monitoring data from Danish inpatients with different diagnoses (N = 10.911).ResultsThe routinely collected data indicated that despite their outpatient status, traumatized refugees had higher levels of psychiatric disability at pre-treatment compared to most inpatients. Moreover, the traumatized refugees had a HoNOS profile characterized by an overall high problem level in various psychiatric and social domains. The rate of pre- to post-treatment improvement on the HoNOS was smaller for the traumatized refugees than it was for the psychiatric inpatients.ConclusionsThe level, and the versatile profile, of psychiatric disability on the HoNOS point to complex bio-psycho-social problems in resettled treatment seeking traumatized refugees. Thus, a broader assessment of symptoms and better cooperation between psychiatric, health care, and social systems is necessary in order to meet the treatment needs of this group.