Susanne Schaal

Narrative exposure therapy versus interpersonal psychotherapy. A pilot randomized controlled trial with Rwandan genocide orphans.

Background: The aim of the present study was to evaluate the efficacy of treatment modules for trauma spectrum disorders in a sample of Rwandan genocide orphans. Methods: Twenty-six orphans (originally 27) who presented with posttraumatic stress disorder (PTSD) at first assessment continued to meet a PTSD DSM-IV diagnosis 6 months after their initial assessment. They were offered participation in a controlled treatment trial. A group adaptation of interpersonal psychotherapy (IPT, n = 14) was compared to individual narrative exposure therapy (NET, n = 12). The last NET session involved guided mourning. Each treatment program consisted of 4 weekly sessions. Main outcome measures were diagnostic status and symptoms of PTSD and depression assessed before treatment, at 3 months post-test and at 6 months follow-up using the Clinician-Administered PTSD Scale, Mini-International Neuropsychiatric Interview, and Hamilton Rating Scale. Results: At post-test, there were no significant group differences between NET and IPT on any of the examined outcome measures. At 6-month follow-up, only 25% of NET, but 71% of IPT participants still fulfilled PTSD criteria. There was a significant time × treatment interaction in the severity of PTSD [Wilks’ Λ = 0.75, F(2,23) = 3.93; p < 0.05] and depression symptoms [Wilks’ Λ = 0.23, F(2,23) = 3.40; p = 0.05]. At follow-up, NET participants were significantly more improved than IPT participants with respect to both the severity of symptoms of PTSD and depression. Conclusions: Individual NET in combination with group-based mourning comprises an effective treatment for traumatized survivors who have to bear the loss of loved ones and have been suffering from symptoms of PTSD and depression.

Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors

BackgroundThe concept of Prolonged Grief Disorder (PGD) has been defined in recent years by Prigerson and co-workers, who have developed and empirically tested consensus and diagnostic criteria for PGD. Using these most recent criteria defining PGD, the aim of this study was to determine rates of and risks for PGD in survivors of the 1994 Rwandan genocide who had lost a parent and/or the husband before, during or after the 1994 events.MethodsThe PG-13 was administered to 206 orphans or half orphans and to 194 widows. A regression analysis was carried out to examine risk factors of PGD.Results8.0% (n = 32) of the sample met criteria for PGD with an average of 12 years post-loss. All but one person had faced multiple losses and the majority indicated that their grief-related loss was due to violent death (70%). Grief was predicted mainly by time since the loss, by the violent nature of the loss, the severity of symptoms of posttraumatic stress disorder (PTSD) and the importance given to religious/spiritual beliefs. By contrast, gender, age at the time of bereavement, bereavement status (widow versus orphan), the number of different types of losses reported and participation in the funeral ceremony did not impact the severity of prolonged grief reactions.ConclusionsA significant portion of the interviewed sample continues to experience grief over interpersonal losses and unresolved grief may endure over time if not addressed by clinical intervention. Severity of grief reactions may be associated with a set of distinct risk factors. Subjects who lose someone through violent death seem to be at special risk as they have to deal with the loss experience as such and the traumatic aspects of the loss. Symptoms of PTSD may hinder the completion of the mourning process. Religious beliefs may facilitate the mourning process and help to find meaning in the loss. These aspects need to be considered in the treatment of PGD.

The thrill of being violent as an antidote to posttraumatic stress disorder in Rwandese genocide perpetrators

Background The cumulative exposure to life-threatening events increases the risk for posttraumatic stress disorder (PTSD). However, over the course of evolutionary adaptation, intra-species killing may have also evolved as an inborn strategy leading to greater reproductive success. Assuming that homicide has evolved as a profitable strategy in humans, a protective mechanism must prevent the perpetrator from getting traumatised by self-initiated violent acts. Objective We thus postulate an inverse relation between a persons propensity toward violence and PTSD. Method We surveyed a sample of 269 Rwandan prisoners who were accused or convicted for crimes related to the 1994 genocide. In structured interviews we assessed traumatic event types, types of crimes committed, the persons appetitive violence experience with the Appetitive Aggression Scale (AAS) and PTSD symptom severity with the PSS-I. Results Using path-analysis, we found a dose-response effect between the exposure to traumatic events and the PTSD symptom severity (PSS-I). Moreover, participants who had reported that they committed more types of crimes demonstrated a higher AAS score. In turn, higher AAS scores predicted lower PTSD symptom severity scores. Conclusions This study provides first empirical support that the victims struggling can be an essential rewarding cue for perpetrators. The results also suggest that an appetitive aggression can inhibit PTSD and trauma-related symptoms in perpetrators and prevent perpetrators from getting traumatised by their own atrocities.

Prolonged grief disorder and depression in widows due to the Rwandan genocide.

Should pathological grief be viewed as a nosological category, separate from other forms of mental diseases? Diagnostic criteria for “Prolonged Grief Disorder” (PGD) have recently been specified by Prigerson and her coworkers. We interviewed a total of 40 widows who had lost their husbands during the Rwandan genocide in 1994. We assessed Major Depression using the Mini-International Neuropsychiatric Interview (M.I.N.I.) and prolonged grief reactions with the PG-13. In order to examine the distinctiveness of the two syndromes we performed a multitrait correlational matrix analysis using modified versions of Generalized Proximity Functions (GPFs). 12.5% (n = 5) of the sample fulfilled the criteria for a diagnosis of PGD; 40% (n = 16) met criteria for Major Depressive Episode. The two syndromes were strongly associated. No discriminant validity was found between the two constructs suggesting that PGD may rather be an appearance of depression than a separate nosological entity.

Addressing Post-traumatic Stress and Aggression by Means of Narrative Exposure: A Randomized Controlled Trial with Ex-Combatants in the Eastern DRC

Former child soldiers and ex-combatants are at high risk of developing trauma-related disorders and appetitive aggression, which reduce successful integration into peaceful societies. In a randomized controlled clinical trial, we offered Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) to 15 ex-combatants with the goal of reducing traumatic stress and appetitive aggression compared to “treatment as usual.” Measures included the PTSD Symptom Scale-Interview and the Appetitive Aggression Scale assessed prior to treatment and 2 weeks and 6 months after the treatment. We also assessed closeness to combatants as an index of reintegration. The treatment group reported reduced PTSD symptoms and less contact with combatants. Appetitive aggression decreased substantially in both groups. The results indicate that it is feasible to add psychological treatment to facilitate the reintegration process. We wish to thank the former combatants and former child soldiers who participated in this study and the Congolese translators. We also want to thank the very motivated and reliable staff of the reintegration center, especially Pascal Badibanga Zagabe, Leonce Kyakimwa, Lydie Mirimo Ajua, David Ngufu, and Matata Banyene. Furthermore, we want to thank Charlotte Salmen for conducting the follow-up interviews and James Moran for conducting the follow-up interviews as well as proofreading the manuscript. Sources of support: Deutsche Forschungsgemeinschaft (DFG), vivo international. Trial registration clinicaltrials.gov Identifier: NCT01625117

Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: a randomized controlled trial in Rwanda

Background: Dissemination of psychotherapeutic modules to local counselors seems a key requirement for coping with mental health disasters in conflict regions. We tested a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD). Methods: We randomly assigned widowed or orphaned survivors of the 1994 Rwandan genocide with a PTSD diagnosis to narrative exposure therapy (NET) treatment (NET-1, n = 38) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2, n = 38). Expert therapists trained a first dissemination generation of local Rwandan psychologists in NET complemented by 2 sessions of interpersonal psychotherapy modules. Under the supervision of the experts, these Rwandan psychologists (a) provided NET to the NET-1 participants and (b) subsequently trained and supervised a second generation of local psychologists. This second dissemination generation provided treatment to the WL/NET-2 group. The primary outcome measure was the Clinician-Administered PTSD Scale total score before therapy and at 3- and 12-month follow-ups. Results: At the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL group. The treatment gains of NET-1 were maintained and increased at follow-up, with a within-group effect size of Cohens d = 1.47 at the 12-month follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups, with an effect size of Cohens d = 1.37 at the 12-month follow-up. Conclusions: A TTT model of PTSD treatment dissemination can be effective in resource-poor postconflict societies.

Mental health 15 years after the killings in Rwanda : Imprisoned perpetrators of the genocide against the Tutsi versus a community sample of survivors

Objectives of this study were to compare rates of mental health disorders in Rwandan genocide perpetrators with those of genocide survivors and to investigate potential predictors of symptoms of posttraumatic stress disorder (PTSD) and depression for both groups. We expected high rates of mental disorders in both study groups and hypothesized that symptom severity would be predicted by female gender, older age, lower level of education, higher level of trauma exposure, lower level of agreement to reconciliation, and the participation in killing. Structured clinical interviews were carried out with 269 imprisoned perpetrators (66% men) and 114 survivors (64% women). Significantly more survivors than perpetrators met symptom criteria for PTSD (46% vs. 14%) and suffered from anxiety symptoms (59% vs. 36%). A substantial proportion of both groups suffered from clinically significant depression (46% vs. 41%). PTSD severity in perpetrators was associated with trauma exposure, high levels of agreement to reconciliation, and no participation in killing; the severity of depression was associated with trauma exposure and no participation in killing. In the survivor sample, the severity of PTSD and depression were both correlated with female gender, trauma exposure, and low levels of agreement to reconciliation. Results suggest that both groups exhibit considerable psychiatric morbidity.

Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors

Background During the Rwandan genocide of 1994, nearly one million people were killed within a period of 3 months. Objective The objectives of this study were to investigate the levels of trauma exposure and the rates of mental health disorders and to describe risk factors of posttraumatic stress reactions in Rwandan widows and orphans who had been exposed to the genocide. Design Trained local psychologists interviewed orphans (n=206) and widows (n=194). We used the PSS-I to assess posttraumatic stress disorder (PTSD), the Hopkins Symptom Checklist to assess depression and anxiety symptoms, and the M.I.N.I. to assess risk of suicidality. Results Subjects reported having been exposed to a high number of different types of traumatic events with a mean of 11 for both groups. Widows displayed more severe mental health problems than orphans: 41% of the widows (compared to 29% of the orphans) met symptom criteria for PTSD and a substantial proportion of widows suffered from clinically significant depression (48% versus 34%) and anxiety symptoms (59% versus 42%) even 13 years after the genocide. Over one-third of respondents of both groups were classified as suicidal (38% versus 39%). Regression analysis indicated that PTSD severity was predicted mainly by cumulative exposure to traumatic stressors and by poor physical health status. In contrast, the importance given to religious/spiritual beliefs and economic variables did not correlate with symptoms of PTSD. Conclusions While a significant portion of widows and orphans continues to display severe posttraumatic stress reactions, widows seem to constitute a particularly vulnerable survivor group. Our results point to the chronicity of mental health problems in this population and show that PTSD may endure over time if not addressed by clinical intervention. Possible implications of poor mental health and the need for psychological intervention are discussed.

Associations Between Prolonged Grief Disorder, Depression, Posttraumatic Stress Disorder, and Anxiety in Rwandan Genocide Survivors

A number of studies have demonstrated that symptoms of prolonged grief disorder (PGD) represent a symptom cluster distinct from bereavement-related depression, anxiety, and posttraumatic stress disorder (PTSD). The aim of the present study was to confirm and extend these findings using the most recent criteria defining PGD. The authors interviewed a total of 400 orphaned or widowed survivors of the Rwandan genocide. The syndromes were strongly linked to each other with a high comorbidity. Principal axis factoring resulted in the emergence of 4 different factors. The symptoms of depression, along with the cognitive, emotional, and behavioral symptoms of PGD, loaded on the first factor, symptoms of anxiety on the second factor, symptoms of PTSD on the third factor, and the separation distress symptoms of PGD on the fourth factor. This indicates that the concept of PGD includes symptoms that are conceptually related to depression. However, the symptom cluster of separation distress presents a grief-specific dimension that may surface unrelated to depressive symptoms.

Rates and predictors of mental stress in Rwanda: investigating the impact of gender, persecution, readiness to reconcile and religiosity via a structural equation model

BackgroundAs a consequence of the 1994 Rwandan genocide, prevalences of mental disorders are elevated in Rwanda. More knowledge about determinants of mental stress can help to improve mental health services and treatment in the east-central African country. The present study aimed to investigate actual rates of mental stress (posttraumatic stress disorder, syndromal depression and syndromal anxiety) in Rwanda and to examine if gender, persecution during the genocide, readiness to reconcile as well as importance given to religiosity and quality of religiosity are predictors of mental stress.MethodsThe study comprised a community sample of N = 200 Rwandans from Rwanda’s capital Kigali, who experienced the Rwandan genocide. By conducting structured interviews, ten local Master level psychologists examined types of potentially lifetime traumatic events, symptoms of posttraumatic stress disorder (PTSD), depression and anxiety, readiness to reconcile and religiosity. Applying non-recursive structural equation modeling (SEM), the associations between gender, persecution, readiness to reconcile, religiosity and mental stress were investigated.ResultsRespondents had experienced an average number of 11.38 types of potentially lifetime traumatic events. Of the total sample, 11% met diagnostic criteria for PTSD, 19% presented with syndromal depression and 23% with syndromal anxiety. Female sex, persecution and readiness to reconcile were significant predictors of mental stress. Twofold association was found between centrality of religion (which captures the importance given to religiosity) and mental stress, showing, that higher mental stress provokes a higher centrality and that higher centrality reduces mental stress. The variables positive and negative religious functioning (which determine the quality of religiosity) respectively had an indirect negative and positive effect on mental stress.ConclusionsStudy results provide evidence that rates of mental stress are still elevated in Rwanda and that female sex, persecution, readiness to reconcile, centrality and religious functioning are predictors of mental stress. Seventeen years after the genocide, there remains a large gap between the need for and provision of mental health services in Rwanda. Results underline the importance of improving the respective infrastructure, with a focus on the requirements of women and persons, who were persecuted during the genocide. They further highlight that the consideration of readiness to reconcile, centrality and religious functioning in therapeutic interventions can aid mental health in Rwanda.