Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training

BACKGROUND

The aim of the present randomized controlled trial was to compare the outcome of 2 active treatments for posttraumatic stress disorder (PTSD) as a consequence of war and torture: narrative exposure therapy (NET) and stress inoculation training (SIT).

METHODS

Twenty-eight PTSD patients who had experienced war and torture, most of them asylum seekers, received 10 treatment sessions of either NET or SIT at the Outpatient Clinic for Refugees, University of Konstanz, Germany. Posttests were carried out 4 weeks after treatment, and follow-up tests were performed 6 months and 1 year after treatment. The main outcome measure was the PTSD severity score according to the Clinician-Administered PTSD Scale (CAPS) at each time point.

RESULTS

A significant reduction in PTSD severity was found for NET, but not for SIT. A symptom reduction in the NET group occurred between pretest and the 6-month follow-up examination, the effect size being d = 1.42 (for SIT: d = 0.12), and between pretest and the 1-year follow-up, the effect size being d = 1.59 (for SIT: d = 0.19). The rates and scores of major depression and other comorbid disorders did not decrease significantly over time in either of the 2 treatment groups.

CONCLUSIONS

The results indicate that exposure treatments like NET lead to a significant PTSD symptom reduction even in severely traumatized refugees and asylum seekers.

Narrative exposure therapy for PTSD increases top-down processing of aversive stimuli--evidence from a randomized controlled treatment trial

Abstract

Registration of the clinical trial

Number: NCT00563888

Name: "Change of Neural Network Indicators Through Narrative Treatment of PTSD in Torture Victims" ULR: http://www.clinicaltrials.gov/ct2/show/NCT00563888

Do insulin-like growth factor associated proteins qualify as a tumor marker? Results of a prospective study in 163 cancer patients

OBJECTIVE

Insulin-like growth factor (IGF)-1, -2 and Insulin like growth factor binding proteins (IGFBP) are involved in the proliferation and differentiation of cells. It has never been evaluated, if the IGF-system can serve as a tumor marker in neoplasms.

METHODS

In our prospective study 163 patients with colorectal cancer (22), prostate cancer (21), head and neck tumors (17), lymphomas (20), lung cancer (34) and other entities (49) were analysed for their IGF and IGFBP serum levels at the beginning and the end of radiotherapy and compared to 13 healthy people. Subgroups of patients with local tumor disease versus metastatic disease, primary and recurrent therapy and curative versus palliative therapy were compared.

RESULTS

The serum levels of IGF-2 were significantly elevated in patients with prostate and colorectal cancer. However, sensitivity and specificity were only 70%. IGFBP-2 serum levels were elevated in patients with head and neck tumors. Again sensitivity and specificity were only 73%. A difference between local disease and metastatic disease could not be found. A difference between IGF serum levels before and after radiotherapy could not be detected.

CONCLUSION

The IGF-system cannot serve as a new tumor marker. The detected differences are very small, sensitivity and specificity are too low. IGF measurement is not useful for the evaluation of the success of radiotherapy in malignancies.

Trimodal therapy in squamous cell carcinoma of the esophagus

Patients with ESCC (squamous cell carcinoma of the esophagus) are most commonly diagnosed with locally advanced tumor stages. Early metastatic disease and late diagnosis are common reasons responsible for this tumor's poor clinical outcome. The prognosis of esophageal cancer is very poor because patients usually do not have symptoms in early disease stages. Squamous cell carcinoma of the esophagus frequently complicates patients with multiple co-morbidities and these patients often require interdisciplinary diagnosis and treatment procedures. At present time, neoadjuvant radiation therapy and chemotherapy followed by surgery are regarded as the international standard of care. Meta-analyses have confirmed that this approach provides the patient with better local tumor control and an increased overall survival rate. It is recommended that patients with positive tumor response to neoadjuvant therapy and who are poor surgical candidates should consider definitive radiochemotherapy without surgery as a treatment option. In future, EGFR antibodies may also be administered to patients during therapy to improve the current treatment effectiveness. Positron-emission tomography proves to be an early response-imaging tool used to evaluate the effect of the neoadjuvant therapy and could be used as a predictive factor for the survival rate in ESCC. The percentage proportions of residual tumor cells in the histopathological analyses represent a gold standard for evaluating the response rate to radiochemotherapy. In the future, early response evaluation and molecular biological tests could be important diagnostic tools in influencing the treatment decisions of ESCC patients.

[Multimodal therapy in locally advanced gastric cancer]

Locally advanced gastric cancers are characterized by poor prognosis. Clinical outcome can be improved if surgery becomes part of a multimodal treatment approach. The purpose of neoadjuvant treatment includes downsizing of the primary tumor, improvement of the T- and N- categories, and early therapy of micrometastasis. Several controlled clinical trials showed that neoadjuvant chemotherapy as well as neoadjuvant combined radio-chemotherapy, especially for tumors of the gastroesophageal junction, can improve the rate of primary R0 resections, relapse-free survival, and overall survival. While patients with locally advanced tumors clearly benefit from this strategy, the approach is still controversial in patients with early stage disease. Nonresponders do not benefit from neoadjuvant therapy. Therefore, response evaluation and response prediction are of great importance. After successful neoadjuvant chemotherapy, patients should undergo gastrectomy with D(2)-lymphadenectomy because of a high probability of lymph node metastasis. This article summarizes current developments in this field.

Childhood adversity, mental ill-health and aggressive behavior in an African orphanage: Changes in response to trauma-focused therapy and the implementation of a new instructional system

BACKGROUND

The number of orphans in Sub-Saharan Africa is constantly rising. While it is known that family or community care is preferable over institutional care of African orphans, little is known about the quality of care in orphanages and possibilities of improvement. STUDY 1:

METHODS

Exposure to traumatic stress, experiences of violence in the home, school and orphanage, as well as mental ill-health and aggression of 38 children (mean age of M = 8.64 years) living in an orphanage in rural Tanzania were assessed at two time points. The severity of post-traumatic stress disorder symptoms (PTSD), depressive symptoms, and internalizing and externalizing problems were used as indicators of mental ill-health.

RESULTS

Violence experienced in the orphanage correlated more strongly with all indicators of mental ill-health than violence in the former home, school or neighborhood at time point 1. Additionally, violence experienced in the orphanage had a positive relationship with the aggressive behavior of the children at time point 2. STUDY 2:

METHODS

With the help of the pre-post assessment of Study 1, the implementation of a new instructional system and psychotherapeutic treatment (KIDNET) for trauma-related illness were evaluated.

RESULTS

In response to both, a change in the instructional system and psychotherapeutic treatment of PTSD, a massive decline in experienced violence and in the severity of PTSD-symptoms was found, whereas depressive symptoms and internalizing and externalizing problems exhibited little change.

CONCLUSIONS

These studies show that violence, especially in the orphanage, can severely contribute to mental ill-health in orphans and that mental health can be improved by implementing a new instructional system and psychotherapeutic treatment in an orphanage. Moreover, the results indicate that the experience of violence in an orphanage also plays a crucial role in aggressive behavior of the orphans.

Transgenerational impact of intimate partner violence on methylation in the promoter of the glucocorticoid receptor

Prenatal exposure to maternal stress can have lifelong implications for psychological function, such as behavioral problems and even the development of mental illness. Previous research suggests that this is due to transgenerational epigenetic programming of genes operating in the hypothalamic-pituitary-adrenal axis, such as the glucocorticoid receptor (GR). However, it is not known whether intrauterine exposure to maternal stress affects the epigenetic state of these genes beyond infancy. Here, we analyze the methylation status of the GR gene in mothers and their children, at 10-19 years after birth. We combine these data with a retrospective evaluation of maternal exposure to intimate partner violence (IPV). Methylation of the mother's GR gene was not affected by IPV. For the first time, we show that methylation status of the GR gene of adolescent children is influenced by their mother's experience of IPV during pregnancy. As these sustained epigenetic modifications are established in utero, we consider this to be a plausible mechanism by which prenatal stress may program adult psychosocial function.

Female dissociative responding to extreme sexual violence in a chronic crisis setting: the case of Eastern Congo

This cross-sectional study aimed to examine relationships between the number of traumatizing events, degree of shutdown dissociation, posttraumatic stress disorder (PTSD), and depression. Fifty-three female survivors of the ongoing war in Congo who sought medical treatment were interviewed. A path-analytic model was created with paths to PTSD via dissociation, and both the number of self-experienced and witnessed traumatizing events. Cumulative exposure and dissociation were associated with increased PTSD severity. Posttraumatic stress disorder and witnessing predicted depression when depression was modeled as a consequence of PTSD. Moreover, PTSD mediated the correlation between dissociation and depression. The findings suggest that shutdown dissociation may have value in predicting PTSD, and there is evidence of differential effects of threat to oneself as opposed to witnessing trauma.

Prognostic factors in patients with diffuse type gastric cancer (linitis plastica) after operative treatment

Objective

Treatment options for patients with diffuse type gastric cancer (linitis plastica) are discussed controversial. It is sometimes discussed that these patients should be treated primarily in palliative intention conservative without resection.

Methods

In a single-center analysis, we investigated 120 patients with diffuse type gastric cancer. All patients underwent a total gastrectomy, 45 patients even a multivisceral resection because of infiltrating growth, or metastases. Serum tumor marker CEA, CA 72-4, and CA 19-9 were recorded in all patients before surgery. An immunocytochemical detection of free peritoneal tumor cells (FPTC) using Ber-EP4 antibody was correlated with tumor stage and survival. Median follow-up time was 38 months.

Results

Complete resection rate was 31% (n = 37). 61% (n = 73) of all patients had already distant metastases at the time of surgery, 80% of them peritoneal carcinomatosis. Median survival for the whole group was 8 months, after complete resection 17 months. Lavage cytology, distant metastases, resection rate, and CA19-9 levels had significant influence on survival.

Conclusion

A significant survival advantage for patients with diffuse type gastric cancer can only be achived after complete resection. We could define a subset of patients with an extremely poor prognosis even after surgical resection. Meticulous preoperative staging, including a diagnostic laparoscopy to exclude peritoneal carcinomatosis and free peritoneal tumor cells before resection should be mandatory in these patients.

The Tortured Brain

Traumatic stressors such as water boarding, electric shock, or false execution all activate similar bodily, affective, and cognitive responses even when they are quite different from one another. As a result, the memory traces merge into a “trauma network” that includes sensory memories but becomes detached from the particular episodic memory; that is, the trauma network has no time or place. As, with increasing traumatic experiences, more and more cues become integrated in the network, the threshold for excitation is continually lowered and the individual is likely to show frequent alarm and other defense responses to reminders of the trauma. Neuroplastic mechanisms determine subsequent reorganization of brain circuitry in order to adapt to a presumed permanent need for defense.

We hypothesized that aversive pictorial material is differentially processed in visual as well as frontal and limbic areas of the traumatized brain. We used Rapid Serial Visual Presentation (three pictures per second) to present aversive, neutral, and appetitive pictorial stimuli. Event-related magnetic fields were recorded in 41 survivors of torture and organized violence who suffered from posttraumatic stress disorder (PTSD) as well as 43 controls with a comparable ethnic background. Traumatized individuals showed an early shift in the processing of aversive pictures from sensory visual areas to fronto-temporal areas and the amygdala compared to controls without trauma-related symptoms. For survivors, as opposed to controls, these stimuli automatically activate aspects of the defense cascade and thus lead to an excitation of action-related neural activity. We conclude that an enlarged fear network in survivors of organized violence has a low excitation threshold, thus leading to prominent PTSD symptoms. A disintegration of the fear network by reconnecting its elements to the respective episodic memory or by some form of inhibition of the network may bring relief.

Fascination violence: on mind and brain of man hunters

Why are savagery and violence so omnipresent among humans? We suggest that hunting behaviour is fascinating and attractive, a desire that makes temporary deprivation from physical needs, pain, sweat, blood and, ultimately, the willingness to kill tolerable and even appetitive. Evolutionary development into the "perversion" of the urge to hunt humans, that is to say the transfer of this hunt to members of one's own species, has been nurtured by the resultant advantage of personal and social power and dominance. While a breakdown of the inhibition towards intra-specific killing would endanger any animal species, controlled inhibition was enabled in humans in that higher regulatory systems, such as frontal lobe-based executive functions, prevent the involuntary derailment of hunting behaviour. If this control--such as in child soldiers for example--is not learnt, then brutality towards humans remains fascinating and appealing. Blood must flow in order to kill. It is hence an appetitive cue as is the struggling of the victim. Hunting for men, more rarely for women, is fascinating and emotionally arousing with the parallel release of testosterone, serotonin and endorphins, which can produce feelings of euphoria and alleviate pain. Bonding and social rites (e.g. initiation) set up the constraints for both hunting and violent disputes. Children learn which conditions legitimate aggressive behaviour and which not. Big game hunting as well as attack of other communities is more successful in groups--men also perceive it as more pleasurable. This may explain the fascination with gladiatorial combat, violent computer games but as well ritualized forms like football.

[Individualised and differentiated treatment of rectovaginal fistula]

Rectovaginal fistuale (RVF) are a serious and disabling problem for the patients and a surgical challenge for the treating physicians. The most common causes of RVF are postoperative complications, inflammatory bowel disease, complications of radiotherapy, obstetric complications, and neoplasia. Therapeutic options are diverse and results often unsatisfactory. This article presents the treatment of patients with rectovaginal fistulae in the general surgery department of University Hospital in Duesseldorf, Germany. The therapeutic strategy for treatment of RVF is divided according to aetiology, localisation, and comorbidity. A diverting ileostomy is particularly useful if acute inflammation exists. Secondary repair may then be a better option. An initial approach with a local repair by preanal repair is justified in low RVF. For failures muscle flaps are promising.

Narrative exposure therapy for 7- to 16-year-olds: a randomized controlled trial with traumatized refugee children

The authors examined the effectiveness of narrative exposure therapy for children (KIDNET) in treating posttraumatic stress disorder (PTSD) in refugee children living in exile. Twenty-six children traumatized by organized violence were randomly assigned to KIDNET or to a waiting list. Significant treatment by time interactions on all PTSD-relevant variables indicated that the KIDNET group, but not the controls, showed a clinically significant improvement in symptoms and functioning. Success of the KIDNET group remained stable at 12-month follow-up. This study confirms previous findings that, if left untreated, PTSD in children may persist for an extended period. However, it also shows that it is possible to effectively treat chronic PTSD and restore functioning in traumatized refugee children in only 8 treatment sessions.

Prävalenz von traumatischen Stresserfahrungen und seelischen Erkrankungen bei in Deutschland lebenden Kindern von Asylbewerbern

Zusammenfassung. Theoretischer Hintergrund: Während Untersuchungen in Krisenregionen gezeigt haben, dass Flüchtlingskinder häufig unter psychischen Erkrankungen leiden und behandlungsbedürftig sind, liegen bis zum jetzigen Zeitpunkt noch kaum Kenntnisse über die Situation in Deutschland bei Kindern von Asylbewerbern vor. Fragestellung: Wie hoch ist die Prävalenz von psychischen Erkrankungen und damit der Behandlungsbedarf bei Flüchtlingskindern in Deutschland? Methode: 104 Kinder von Asylbewerbern wurden in staatlichen Gemeinschaftsunterkünften im Rahmen von standardisierten psychodiagnostischen Interviews im Hinblick auf psychische Erkrankungen untersucht. Ergebnisse: 19% der Kinder litten unter einer Posttraumatischen Belastungsstörung, weitere Störungen traten eher selten auf. In psychotherapeutischer Behandlung befanden sich nur 4,8% der Kinder. Schlussfolgerungen: Flüchtlingskinder besitzen ein hohes Risiko für chronische Traumafolgeerkrankungen, wodurch eine normale und gesunde Entwicklung in sozialen, schulischen und beruflichen Bereichen behindert wird. Entsprechende psychotherapeutische Hilfe sollte daher weiter entwickelt und breiter angeboten werden.

Dissociation Following Traumatic Stress

We postulate that the cascade “Freeze-Flight-Fight-Fright-Flag-Faint” is a coherent sequence of six fear responses that escalate as a function of defense possibilities and proximity to danger during life-threat. The actual sequence of trauma-related response dispositions acted out in an extremely dangerous situation therefore depends on the appraisal of the threat by the organism in relation to her/his own power to act (e.g., age and gender) as well as the perceived characteristics of threat and perpetrator. These reaction patterns provide optimal adaption for particular stages of imminence. Subsequent to the traumatic threats, portions of the experience may be replayed. The actual individual cascade of defense stages a survivor has gone through during the traumatic event will repeat itself every time the fear network, which has evolved peritraumatically, is activated again (i.e., through internal or external triggers or, e.g., during exposure therapy).When a parasympathetically dominated ‘‘shut-down’’ was the prominent peri-traumatic response during the traumatic incident, comparable dissociative responses may dominate responding to subsequently experienced threat and may also reappear when the traumatic memory is reactivated. Repeated experience of traumatic stress forms a fear network that can become pathologically detached from contextual cues such as time and location of the danger, a condition which manifests itself as posttraumatic stress disorder (PTSD). Intrusions, for example, can therefore be understood as repetitive displays of fragments of the event, which would then, depending on the dominant physiological response during the threat, elicit a corresponding combination of hyperarousal and dissociation. We suggest that trauma treatment must therefore differentiate between patients on two dimensions: those with peritraumatic sympathetic activation versus those who went down the whole defense cascade, which leads to parasympathetic dominance during the trauma and a corresponding replay of physiological and dissociative responding, when reminded. The differential management of dissociative stages (“fright” and “faint”) has important treatment implications.

Trauma-related impairment in children--a survey in Sri Lankan provinces affected by armed conflict

OBJECTIVES

The present study examined traumatic experiences, PTSD, and co-morbid symptoms in relation to neuropsychological and school performance in school children affected by two decades of civil war and unrest.

METHOD

The epidemiological survey of children's mental health included a representative sample of 420 school children. Local teachers were trained to administer a translation of the UCLA-PTSD Index Form. The instrument and the epidemiological findings were validated by assessment through clinical expert interview, school grades, and neuropsychological testing in a subsample (N=67).

RESULTS

Ninety-two percent of the children surveyed had experienced severely traumatizing events such as combat, bombing, shelling, or witnessing the death of a loved one. Twenty-five percent met the criteria for a diagnosis of PTSD. Traumatized children reported lasting interference of experiences with their daily life, which was corroborated by memory testing, scores in school performance and ratings of social withdrawal. Depressive symptoms and poor physical health were frequent in these children. The majority of trained teachers achieved valid results in the structured interviews.

CONCLUSION

Performance and functioning in children are related to the total load of traumatic events experienced. An important component of psychosocial programs in post-conflict areas should include increasing community-based awareness of the consequences of traumatic stress, both as a preventative measure and as a way of decreasing stigmatization of affected individuals.

Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): from neurocognitive theory to field intervention

Many children in war-affected and refugee populations have experienced multiple traumatic experiences, and high rates of psychologic disorders, especially posttraumatic stress disorder (PTSD), are found. Intervention strategies require pragmatic and effective approaches to treatment. This article describes the rationale for and the use of narrative exposure therapy in children (KidNET). KidNET is a short-term treatment for PTSD based on a neurocognitive theory of traumatic memory. Early treatment trials, including randomized controlled studies, show promising results for the treatment of children and adolescents who have PTSD living in war-affected countries and refugee communities.

Altered oscillatory brain dynamics after repeated traumatic stress

BACKGROUND

Repeated traumatic experiences, e.g. torture and war, lead to functional and structural cerebral changes, which should be detectable in cortical dynamics. Abnormal slow waves produced within circumscribed brain regions during a resting state have been associated with lesioned neural circuitry in neurological disorders and more recently also in mental illness.

METHODS

Using magnetoencephalographic (MEG-based) source imaging, we mapped abnormal distributions of generators of slow waves in 97 survivors of torture and war with posttraumatic stress disorder (PTSD) in comparison to 97 controls.

RESULTS

PTSD patients showed elevated production of focally generated slow waves (1-4 Hz), particularly in left temporal brain regions, with peak activities in the region of the insula. Furthermore, differential slow wave activity in right frontal areas was found in PTSD patients compared to controls.

CONCLUSION

The insula, as a site of multimodal convergence, could play a key role in understanding the pathophysiology of PTSD, possibly accounting for what has been called posttraumatic alexithymia, i.e., reduced ability to identify, express and regulate emotional responses to reminders of traumatic events. Differences in activity in right frontal areas may indicate a dysfunctional PFC, which may lead to diminished extinction of conditioned fear and reduced inhibition of the amygdala.

Screening for posttraumatic stress disorder among Somali ex-combatants: a validation study

Background

In Somalia, a large number of active and former combatants are affected by psychological problems such as Posttraumatic Stress Disorder (PTSD). This disorder impairs their ability to re-integrate into civilian life. However, many screening instruments for Posttraumatic Stress Disorder used in post-conflict settings have limited validity. Here we report on development and validation of a screening tool for PTSD in Somali language with a sample of ex-combatants.

Methods

We adapted the Posttraumatic Diagnostic Scale (PDS) to reflect linguistic and cultural differences within the Somali community so that local interviewers could be trained to administer the scale. For validation purposes, a randomly selected group of 135 Somali ex-combatants was screened by trained local interviewers; 64 of them were then re-assessed by trained clinical psychologists using the Composite International Diagnostic Interview (CIDI) and the Self-Report Questionnaire (SRQ-20).

Results

The screening instrument showed good internal consistency (Cronbach's α = .86), convergent validity with the CIDI (sensitivity = .90; specificity = .90) as well as concurrent validity: positive cases showed higher SRQ-20 scores, higher prevalence of psychotic symptoms, and higher levels of intake of the local stimulant drug khat. Compared to a single cut-off score, the multi-criteria scoring, in keeping with the DSM-IV, produced more diagnostic specificity.

Conclusion

The results provide evidence that our screening instrument is a reliable and valid method to detect PTSD among Somali ex-combatants. A future Disarmament, Demobilization and Reintegration Program in Somalia is recommended to screen for PTSD in order to identify ex-combatants with special psycho-social needs.

Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression

The psychological consequences of traumatic stress may last even into old age. In persons in their 60s and 70s who had been victims of political detention and torture four decades ago, we compared the outcome of narrative exposure therapy (NET) to that of psychoeducation (PED) only. From a group of 59 former political detainees, 18 who fulfilled the full PTSD criteria according to the Composite International Diagnostic Interview (CIDI) were offered and accepted participation in the treatment study. The participants were randomly assigned to either one session of PED (n=9) or five sessions of NET (n=9). Symptoms of PTSD (CIDI) and depression (Beck Depression Inventory, BDI) were assessed prior to treatment and after a 6-month follow-up. NET but not PED produced a significant reduction in post-traumatic symptoms and depression scores. Four out of 9 of those who completed NET, compared to 8/9 of those within the PED group, still had PTSD 6 months after the treatment had ended. These results indicate that NET may lead to the alleviation of post-traumatic and depression symptoms even when the conditions persist for excessive time periods.

Decoupling neural networks from reality: dissociative experiences in torture victims are reflected in abnormal brain waves in left frontal cortex

From a neuroscience perspective, little is known about the long-term effect of torture. Dissociative experiences and posttraumatic stress disorder are often the results of this experience. We examined psychological dissociation within a group of 23 torture victims and report its manifestations within neural networks in the human brain. In particular, we observed that dissociative experiences are associated with slow abnormal brain waves generated in left ventrolateral frontal cortex. Given that focal slow waves often result from depriving neural networks of major input, the present results may indicate decoupling of frontal affective processors from left cortical language areas. This interpretation is consistent with the fact that disturbed access to structured verbal memory concerning traumatic events is a core feature of the dissociative experience.