Chronic pain in refugees with posttraumatic stress disorder (PTSD): A systematic review on patients' characteristics and specific interventions

The role of mind-body interventions in traumatised refugees' primary care: A qualitative exploration of professionals' experiences in a dedicated programme in Geneva

Post-traumatic physical and psychological symptoms are pervasive among refugees. Primary care staff face numerous challenges and often seek innovative ways of addressing their refugee patients' physical and mental health needs. A nascent body of literature suggests that mind-body interventions (MBIs1) have a positive effect on post-traumatic symptoms in this population. But the quality of evidence is still poor, and little is known about the role MBI could play in the primary care of refugees. Following the implementation of two different kinds of MBI in a dedicated primary care unit, this study aimed to explore staff members' perceptions and prescribing habits for MBI. Given the paucity of information about this topic, we used a qualitative design combining ethnography and discourse analysis providing in-depth insight into professionals' experiences of MBI. Data collected over five-months of non-participative observation and the transcription of twelve interviews were analysed following the Interpretative Phenomenological Analysis method (IPA) yielding four main results: (1) Generally poor initial understanding of MBI; (2) A variety of conditions and situations where MBIs appeared acceptable and helpful; (3) A persistent lack of experience and knowledge about the indications for MBI, hindering prescription; (4) The importance of articulating MBIs with mental health services. These results, in the light of the existing literature, suggest that stronger evidence for MBI efficacy for refugees is required, a key to improving professionals' understanding of MBI, providing them with explicit prescription criteria, and encouraging stakeholders to implement these innovative interventions.

Examining the risk factors of chronic pelvic pain and its effect on the quality of life in refugee and non-refugee women

BACKGROUND

This study aimed to determine the prevalence of chronic pelvic pain(CPP) in refugee and non-refugee women, determine the factors associated with CPP, and evaluate the effect of CPP on life quality.

METHODS

This was a cross-sectional study conducted among 283 non-refugee and 278 refugee women in Turkey. A questionnaire including questions assessing chronic pelvic pain and related factors, World Health Organization Quality of Life Scale Short Form(WHOQOL-BREF), Depression Anxiety Stress Scale-21, were administered to the participants. Chi-square test, Mann-Whitney U test and multiple logistic regression analysis were used for statistical analysis.

RESULTS

The prevalence of chronic pelvic pain was 41.0% in refugee women and 19.1% in non-refugee women (p< 0.001). The prevalence of CPP was 1.68 times higher in refugee women than in non-refugee women (OR;95%CI:1.68;1.01-2.81). In the multivariate analysis performed in the study group, refugee status, low family income status(OR;95%CI:2.09;1.26-3.46), low back pain(OR;95%CI:2.02;1.21-3.35), dyspareunia (OR; 95%CI:2.96;1.75-4.99), number of three or more miscarriages (OR;95%CI:3.07;1.18-8.01), history of gynaecological surgery (OR;95%CI:2.44;1.33-4.50), diarrhea (OR;95%CI:2.01;1.07-3.76), urinary tract infections(OR; 95%CI:1.66;1.02-2.71) and anxiety(OR; 95%CI:1.17;1.10-1.24) were found to be risk factors for CPP. In the refugee and non-refugee groups, those with CPP had lower scores in all subdomains of the WHOQOL-BREF scale than those without CPP (p < 0.05).

CONCLUSIONS

Refugee status independently contributes to the risk of developing CPP. Targeted interventions to address CPP and its associated risk factors are needed, particularly in vulnerable refugee populations, to improve their quality of life.

A cross- sectional study of refugees in Norway and Serbia: Levels of mental distress and social-demographic risk factors

This cross-sectional study has assessed and compared symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) among one refugee group during flight (in Serbia) and another refugee group after flight (in Norway). Results indicate high levels of mental distress in both samples of refugees (Serbia: N = 100, Norway: N = 78). Participants in Serbia reported higher levels of symptoms than the participants in Norway. Moreover, the study found that female gender, low education, refused asylum, high age, and concerns about family correlated with mental distress among the participants.

Sertraline versus venlafaxine combined with psychotherapy in trauma-affected refugees - a follow-up study on a pragmatic randomised trial

BACKGROUND

Research on long-term pharmacotherapy for trauma-affected refugees is scarce. The purpose of this follow-up study of a randomised trial was to investigate the effects of sertraline compared to venlafaxine in combination with psychotherapy, 6 and 18 months after end of trial.

METHOD

The primary outcome was PTSD symptoms, measured by the Harvard Trauma Questionnaire (HTQ). The secondary outcomes included: Hopkins Symptom Checklist-25 (HSCL-25), somatisation items of the Symptoms Checklist-90 (SCL), pain on a visual analogue scale, well-being on the WHO-5, Sheehan Disability Scale, Hamilton Depression and Anxiety scales and Global Assessment of Functioning. Moreover, the shorter version of the Recent Life Events (IRLE) was adopted to obtain information regarding the patients' treatment and life events between the follow-up periods.

RESULTS

Out of 195 patients eligible for intention-to-treat analyses during trial, 116 participated in the 6-month follow-up and 97 participated in the 18-month follow-up. The results of our intention-to-treat analyses revealed no significant long-term differences between the groups on the primary outcome assessing PTSD symptoms (HTQ). For the secondary outcomes significant differences were found at the 18-month follow-up in favour of venlafaxine assessing symptoms of anxiety, depression and somatisation (HSCL-25 and SCL), although only in intention-to-treat and not per-protocol analyses.

CONCLUSIONS

No conclusions could be drawn due to conflicting results between our intention-to-treat and per-protocol analyses.

Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review

OBJECTIVE

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

METHODS

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

RESULTS

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

CONCLUSIONS

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees

Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.

Post-traumatic stress disorder burden among female Syrian war refugees is associated with dysmenorrhea severity but not with the analgesics

Dysmenorrhea association with post-traumatic stress disorder (PTSD) has not been studied in refugees. We aimed to examine the associations between dysmenorrhea severity, dysmenorrhea analgesics self-medications, and PTSD in a cohort of Syrian war refugees residing in Jordan.<br /> This is a cross-sectional study based on predetermined inclusion criteria held at Caritas primary care centers in Jordanian districts between September and October 2022. The participants’ demographics and analgesic self-medication type were recorded through a structured questionnaire. The dysmenorrhea severity was measured by (working ability, location, intensity, days of pain, and dysmenorrhea) WaLiDD scale, PTSD was measured by Davidson trauma scale (DTS)-DSM-IV.<br /> Data from 347 Syrian female war refugees were analyzed. The multivariate analysis showed that dysmenorrhea severity demonstrated significantly higher estimates for PTSD (10.48 [6.72-14.23], p=0.001), however, the analgesic type was not associated with PTSD burden.<br /> In conclusion, dysmenorrhea severity, but not self-medication, was associated with a higher PTSD burden.

Migrant women's engagement in health-promotive activities through a women's health collaboration

Introduction

Social determinants of health impact health, and migrants are exposed to an inequitable distribution of resources that may impact their health negatively, leading to health inequality and social injustice. Migrant women are difficult to engage in health-promotional activities because of language barriers, socioeconomic circumstances, and other social determinants. Based on the framework of Paulo Freire, a community health promotion program was established in a community-academic partnership with a community-based participatory research approach.

Aim

The aim of this study was to describe how a collaborative women's health initiative contributed to migrant women's engagement in health promotion activities.

Materials and methods

This study was part of a larger program, carried out in a disadvantaged city area in Sweden. It had a qualitative design with a participatory approach, following up on actions taken to promote health. Health-promotional activities were developed in collaboration with a women's health group, facilitated by a lay health promoter. The study population was formed by 17 mainly Middle Eastern migrant women. Data was collected using the story-dialog method and the material was analyzed using thematic analysis.

Result

Three important contributors to engagement in health promotion were identified at an early stage of the analysis process, namely, the group forming a social network, the local facilitator from the community, and the use of social places close to home. Later in the analysis process, a connection was made between these contributors and the rationale behind their importance, that is, how they motivated and supported the women and how the dialog was conducted. This therefore became the designated themes and were connected to all contributors, forming three main themes and nine sub-themes.

Conclusion

The key implication was that the women made use of their health knowledge and put it into practice. Thus, a progression from functional health literacy to a level of critical health literacy may be said to have occurred.

Baicalein exerts anxiolytic and antinociceptive effects in a mouse model of posttraumatic stress disorder: Involvement of the serotonergic system and spinal delta-opioid receptors

Post-traumatic stress disorder (PTSD) is a serious mental disease featured by a stress dysfunction that occurs after an individual has faced intense mental stress, often accompanied by anxiety and chronic pain. Currently, the mainstream drug for PTSD is serotonin reuptake inhibitors (SSRIs), however, their pain management for patients is limited. Baicalein, a Chinese traditional herbal medicine, has shown promising results in treating anxiety, depression, and pain. In this study, we found that baicalein may alleviate single prolonged stress (SPS)-induced PTSD-like behaviors in mice without altering baseline nociceptive sensitivity or activity. Meanwhile, baicalein increased the noradrenaline (NE) and serotonin (5-HT) content and decreased the ratio of 5-hydroxyindoleacetic acid (5-HIAA)/5-HT by inhibiting the activity of monoamine oxidase A (MAO-A) in SPS-induce mice. The anxiolytic and antinociceptive effects induced by baicalein were totally abolished by 5-HT depleting agents. Moreover, the anxiolytic effects of baicalein could be abolished by the 5-HT_1A receptor antagonist WAY-100635, and the analgesic effects could be abolished by delta-opioid receptor antagonists in the spinal. Taken together, our study provides compelling evidence that baicalein reversed anxiety-like behaviors and neuropathic pain in PTSD through serotonergic system and spinal delta-opioid receptors.

Headache comorbidity in refugees and migrants with post-traumatic stress disorder

BACKGROUND

Headache is often comorbid with post-traumatic stress disorder yet overlooked in health assessments of refugees.

OBJECTIVES

To describe prevalence of severe headache among refugees with post-traumatic stress disorder and compare severity of post-traumatic stress disorder symptoms and treatment outcomes among those with and without severe headache.

METHODS

This follow-up study used data from the Danish Database on Refugees with Trauma. Participants were recruited from 2009 to 2015 at a specialized psychiatric clinic. Prevalence of severe headache was computed by age, sex, and history of head injury or torture. Severe headache was defined as maximum headache scores on the Hopkins Symptom Checklist, Symptom Checklist-90 or the Visual Analogue Scale. Groups with and without severe headache were described according to validated questionnaires before and after 12-18 months of multidisciplinary treatment for post-traumatic stress disorder. Regression analyses were used to analyze associations between headache at start of treatment and symptom burden post-treatment, controlled for pre-treatment scores and possible confounders.

RESULTS

Among 403 female and 489 male participants, nearly all (97.5%) complained of headaches. Severe headache prevalence was 31.4% to 50.0% (depending on which questionnaire was used) and was significantly more common among females and those aged 30-49 years. There was no clear relationship between headache and head injury or torture. Participants with severe headache had heavier symptom burdens compared to those without severe headache. Post-treatment, headache prevalence by age and sex did not change significantly. Those without severe headache showed a tendency toward improvement in outcome measures; this was not seen among those with severe headache. Pre-treatment headache scores were correlated with all outcome measures. Regression analyses controlled for pre-treatment scores of the outcome variables showed associations between pre-treatment headache scores (Hopkins Symptom Checklist or Symptom Checklist-90) and post-treatment scores for intrusion, numbing, hyperarousal, anxiety, disability, and quality of life (all p < 0.02).

CONCLUSION

Headache is a prevalent comorbid condition among refugees with post-traumatic stress disorder. Measures of pre-treatment headache severity appear to predict post-traumatic stress disorder treatment outcomes. Severe headache adversely affects post-traumatic stress disorder prognosis. Assessment and treatment options should be studied further.

Torture Survivors and Asylum: Legal, Medical, and Psychological Perspectives

Torture occurs worldwide. Survivors seeking asylum are detained and must complete a complicated legal process to prove a "well-founded fear of persecution" if returned to their home countries. Forensic evaluations guided by the United Nations Istanbul Protocol increase asylum grant rates. Medical evaluation emphasizes skin examination, which can provide strong evidence of torture. Female genital mutilation and cutting, a basis for asylum, is classified according to the World Health Organization. Many resettled refugees and foreign-born immigrants at urban health care facilities have been tortured, but few report it to physicians due to factors affecting both survivors and physicians. Specific torture methods can cause characteristic long-term sequelae. Painful somatic disorders of mind-body interaction and psychological disorders are common. Practices derived from cultural factors and traumatized individuals' feedback enhance management of survivors. Individual and group psychotherapy provide modest proven benefit, but assessment is limited. Physicians and psychotherapists should coordinate care.

Association of Rheumatoid Arthritis with Opioid Pain Medication Overuse among Persons Exposed to the 9/11 World Trade Center Disaster

We examined the association of post-9/11 rheumatoid arthritis (RA) diagnosis with opioid pain medication overuse among enrollees in the World Trade Center Health Registry (WTCHR). Opioid overuse was defined as the self-reported intake of prescribed opioids at a higher dosage or more often than directed in the last 12 months on one of the two most recent WTCHR surveys (2015-2016, 2020-2021). Post-9/11 RA was ascertained through self-reports and subsequently validated following medical record release by the enrollees' physicians or medical records review. We excluded those with self-reported RA that was not validated by their physicians and those who did not report being prescribed opioid pain medication in the last 12 months. Multivariable log-binomial regression was conducted to examine the relationship between post-9/11 RA diagnosis and opioid pain medication overuse, adjusting for sociodemographic characteristics and 9/11-related posttraumatic stress disorder (PTSD) symptoms. Of the 10,196 study enrollees, 46 had confirmed post-9/11 RA. The post-9/11 RA patients were mostly females (69.6% vs. 37.7%), less frequently non-Hispanic White (58.7% vs. 73.2%) individuals, and less often had attained a higher level of education (76.1% vs. 84.4%) compared to those without post-9/11 RA. Opioid pain medication overuse was significantly associated with a post-9/11 RA diagnosis (Adjusted Risk Ratio: 2.13, 95% CI: 1.44-3.17). More research is needed to better understand the use and management of prescribed opioids among WTC-exposed individuals with RA.

Considerations in designing trauma-focused interventions for displaced Afghan women

In light of the 2021 United States military withdrawal from Afghanistan, as well as the humanitarian crises of mass displacement and subsequent health system strain that have ensued, practitioners worldwide will need to develop a more nuanced understanding of the adverse life experiences that women from Afghanistan frequently endorse. As they bear a disproportionate impact of constraints within Afghan society, and as patriarchal systems affect most of their life domains, women from Afghanistan may present with high levels of baseline trauma upon resettlement, and health systems may seek to attenuate this distress; However, the nature of these traumatogenic events may shape women's receptivity to psychosocial interventions, particularly those which are at least partially rooted in Western modalities. In the absence of sufficient literature on evidence-based interventions for this population, a diversity of ethnographic and clinical literature is synthesized, including literature on interventions alleged to be compatible with Afghan norms. As it will be essential to support Afghan women's mental health following social reorganization on a massive scale, considerations arising from the interdisciplinary literature are offered so that they may inform the development of structured, trauma-focused interventions and so that the health systems with which they interface may be better prepared to serve them.

The feasibility of implementing a cultural mentoring program alongside pain management and physical rehabilitation for chronic musculoskeletal conditions: results of a controlled before-and-after pilot study

BACKGROUND

Culturally diverse communities face barriers managing chronic musculoskeletal pain conditions including navigation challenges, sub-optimal healthcare provider engagement and difficulty adopting self-management behaviours.

OBJECTIVES

To explore the feasibility and trends of effectiveness of implementing a cultural mentoring program alongside clinical service delivery.

METHODS

This quasi-experimental controlled before-and-after multiple case study was conducted in three hospital-based services that provide treatment for patients with musculoskeletal pain. Two prospective cohorts, a pre-implementation and a post-implementation cohort, of adults with chronic musculoskeletal pain who attended during the 6-month recruitment phase, were eligible if they self-identified with one of the cultures prioritised for mentoring by the clinic. The pre-implementation cohort received routine care for up to 3-months, while the post-implementation cohort received up to 3-months of cultural mentoring integrated into routine care (3 to 10 sessions), provided by a consumer (n = 6) with lived experience. Feasibility measures (recruitment and completion rates, attendance, satisfaction), and trends of effectiveness (Patient Activation Measure and Health Literacy Questionnaire items one and six) were collated over 3-months for both cohorts. Outcomes were presented descriptively and analysed using Mann-Whitney U-tests for between-group comparisons. Translation and transcription of post-treatment semi-structured interviews allowed both cohorts' perspectives of treatment to be analysed using a Rapid Assessment Process.

RESULTS

The cultural mentor program was feasible to implement in clinical services with comparable recruitment rates (66% pre-implementation; 61% post-implementation), adequate treatment attendance (75% pre-implementation; 89% post-implementation), high treatment satisfaction (97% pre-implementation; 96% post-implementation), and minimal participant drop-out (< 5%). Compared to routine care (n = 71), patients receiving mentoring (n = 55) achieved significantly higher Patient Activation Measure scores (median change 0 vs 10.3 points, p < 0.01) at 3-months, while Health Literacy Questionnaire items did not change for either cohort over time. Three themes underpinned participant experiences and acceptability of the mentoring intervention: 'expectational priming', 'lived expertise' and 'collectivist orientation' to understand shared participant experiences and explore the potential differential effect of the mentoring intervention.

CONCLUSION

Participant experiences and observations of improved patient activation provide support for the acceptability of the mentoring intervention integrated into routine care. These results support the feasibility of conducting a definitive trial, while also exploring issues of scalability and sustainability.

Chronic Pain and Psychiatric Conditions

Introduction

Chronic pain is a common condition with high socioeconomic and public health burden. A wide range of psychiatric conditions are often comorbid with chronic pain and chronic pain conditions, negatively impacting successful treatment of either condition. The psychiatric condition receiving most attention in the past with regard to chronic pain comorbidity has been major depressive disorder, despite the fact that many other psychiatric conditions also demonstrate epidemiological and genetic overlap with chronic pain. Further understanding potential mechanisms involved in psychiatric and chronic pain comorbidity could lead to new treatment strategies both for each type of disorder in isolation and in scenarios of comorbidity.

Methods

This article provides an overview of relationships between DSM-5 psychiatric diagnoses and chronic pain, with particular focus on PTSD, ADHD, and BPD, disorders which are less commonly studied in conjunction with chronic pain. We also discuss potential mechanisms that may drive comorbidity, and present new findings on the genetic overlap of chronic pain and ADHD, and chronic pain and BPD using linkage disequilibrium score regression analyses.

Results

Almost all psychiatric conditions listed in the DSM-5 are associated with increased rates of chronic pain. ADHD and BPD are significantly genetically correlated with chronic pain. Psychiatric conditions aside from major depression are often under-researched with respect to their relationship with chronic pain.

Conclusion

Further understanding relationships between psychiatric conditions other than major depression (such as ADHD, BPD, and PTSD as exemplified here) and chronic pain can positively impact understanding of these disorders, and treatment of both psychiatric conditions and chronic pain.

Stress while lacking of control induces ventral hippocampal autophagic flux hyperactivity and a depression-like behavior

BACKGROUND

Stressed animals may perform depression-like behavior insomuch as stress-provoking blood-brain barrier (BBB) disruption, central immune activation, and autophagic flux changes. This study was undertaken to assess whether adult mice having (executive) vs. lacking (yoke) of behavioral control in otherwise equivalent stress magnitude condition, may display differences in their BBB integrity, ventral hippocampal (VH) interleukin-6 (IL-6) and autophagic flux level and VH-related depression-like behavior. To further understand the causative relation of enhanced autophagic flux and stress-primed depression-like behavior, we assessed the effects of bilateral intra-VH 3-methyladenine (3-MA), an autophagic flux inhibitor, infusion in stressed mice.

METHODS

Adult mice used had comparable genetic background and housing condition. Executive/yoke pairs of mice received a 10-day (1 h/day) footshock stressor regimen. Throughout the regimen, the ongoing footshock was terminated immediately contingent on the executive mouse', while irrelevant to the respective yoke mouse' voluntary behavior, or lasting for 7 s. Each dyad's cage-mate receiving no such regimen served as no stressor controls.

RESULTS

Yoke mice displayed disrupted BBB integrity (escalated Evans blue extravasation and decreased VH ZO-1, claudin-5 expression), increases in VH autophagic flux (increased LC3II/LC3I and decreased p62) and immobility duration in forced swimming test. Most of these indices remained unaltered in executive mice. Administration of 3-MA did not affect immobility duration in control mice, while prevented the increases in immobility duration in yoke mice.

CONCLUSIONS

(1) stress susceptibility may be determined by their differences in stress-coping results; (2) VH autophagic flux increase plays a permissive role in priming the stressed animals susceptible to exhibit depression-like behavior.

Chronicity of posttraumatic stress disorder and comorbid pain as predictors of treatment response for trauma-affected refugees

Predictors of treatment outcomes have received limited attention in the field of trauma-affected refugees. Symptom chronicity is potentially a particularly relevant predictor, as it would instruct earlier interventions for a population less familiar with psychiatric treatment options, and its identification may also reduce or delay the onset of comorbidities, such as chronic pain. Accordingly, this study examined the impacts of posttraumatic stress disorder (PTSD) chronicity and baseline comorbid pain on treatment response in trauma-affected refugees. Multiple regression was used to analyze data from a randomized controlled trial of 318 trauma-affected refugees with PTSD that was conducted at a specialized psychiatric clinic in Denmark. Treatment response was measured by changes in symptoms of PTSD (Harvard Trauma Questionnaire) and depression (Hopkins Symptom Checklist-25). Duration of functional impairment was found to be a significant predictor of PTSD outcomes, p = .003, ΔR²  = .02, f²  = .03; it was not predictive of outcomes for depression. Baseline pain severity was a significant predictor of outcomes for both PTSD, p = .009, ΔR²  = .02, f²  = .02, and depression, p = .041, ΔR²  = .01, f² = .01. These findings suggest that trauma-affected refugees with long-lasting functional impairment and a high pain score are likely to show less improvement from treatments for PTSD and depression. This points to a need for early intervention to prevent chronic functional impairment and suggests comorbid pain is an important therapeutic target.

Effect of a self-help group intervention using Teaching Recovery Techniques to improve mental health among Syrian refugees in Norway: a randomized controlled trial

Background

Mental health symptoms among refugees are common, often related to chronic pain disorders, and their management is usually challenging. Studies evaluating the effect of group therapies among adult refugees to improve mental health symptoms are scarce.

Aims

To assess the effect of Teaching Recovery Techniques (TRT) on mental health and to reduce pain disorder among adult Syrian refugees.

Method

A randomized controlled trial was designed to study the effect of a self-help group intervention using TRT. The outcomes, mental health symptoms measured by Impact of Event Scale-Revised (IES-R) and General Health Questionnaire (GHQ-12) and chronic pain measured by Brief Pain Inventory (BPI), were reported as regression coefficients (B) with 95% confidence intervals.

Results

Seventy-six adults participated: 38 in the intervention and 38 in the control groups. Intention-to-treat analyses showed a significant effect on general mental health as measured by GHQ-12 with B (95% CI) of -3.8 (-7.2, -0.4). There was no effect of TRT on mental health when assessed by IES-R (-1.3 (-8.7, 6.2)) or on pain levels assessed by BPI (-0.04 (-4.0, 3.9)).

Conclusions

This self-help group intervention significantly improved general mental health symptoms among adult refugees but had no effect on trauma symptoms or chronic pain. Higher participation rates might be necessary to achieve the full potential of TRT.

Trial registration: The trial was registered with Clinical Trials.gov at https://clinicaltrials.gov/ct2/show/NCT03951909. To include user participation in the design of the interventions, the study was retrospectively registered on 19 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00557-4.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Self-rated health and quality of life among Syrian refugees in Ireland - data from a cross-sectional study

INTRODUCTION

As a response to the humanitarian crisis in Syria, the Irish government agreed to accept up to 4000 refugees for resettlement in Ireland in 2016. Prior to their arrival in Ireland, health screening was carried out by the International Organisation for Migration. However, no population-level measurement of the health status or needs takes place in Ireland to inform policy or health services requirements.

METHODS

Cross-sectional data from a self-completed questionnaire among 194 Syrian Refugees aged 16 years and older resident in reception centres in Ireland in 2017/2018 is reported upon. The questionnaire measured self-reported health including quality of life and all study material were available in English and Arabic. The data was examined applying descriptive statistics and regression analysis.

RESULTS

Syrian Refugees in Ireland consist of a relatively young cohort; in this study the majority of participants were younger than 35 years (69.5%). Two-thirds of the respondents reported their overall health status to be good or very good. The most common health condition was found to be headache and the most common medications used were painkillers. Chronic pain was experienced by one quarter of respondents; 27.5% were considered as suffering from anxiety and 10.0% had symptoms compatible with post-traumatic stress disorder (PTSD). A significant relationship was observed between chronic pain and self-rated health, as well as between chronic pain and anxiety. Quality of life (QoL) scores were lowest for the QoL environment domain.

CONCLUSIONS

Chronic pain is relatively widespread among these young and otherwise healthy refugees. Psychological distress and trauma are important factors in respondents' quality of life scores. Chronic pain is associated with one's mental health. Our findings and the literature suggests that the diagnosis and treatment of pain and providing care in a culturally sensitive manner should be a priority and included in the preparation and training of the relevant care providers. Additionally, the impact of living conditions on quality of life should not be underestimated.

The association between chronic pain and pre-and-post migration experiences in resettled humanitarian refugee women residing in Australia

Background

Refugee women are potentially at increased risk for chronic pain due to circumstances both in the pre-migration and post-settlement setting. However, this relationship between refugee-related challenges introduced along their migration trajectories and chronic pain remains unclear. This study will therefore examine the association between pre- and post-migration factors and chronic pain in refugee women five years into resettlement in Australia.

Methods

The first five waves of data from the ‘Building a New Life in Australia’ longitudinal study of humanitarian refugees living in Australia was analysed using logistic regression models to investigate the association between predictor variables and chronic pain. The study outcome was chronic pain and predictors were migration process and resettlement factors in both the pre-and post-settlement setting.

Results

Chronic pain was reported in 45% (n = 139) of women, and among these a further 66% (n = 120) also reported having a long-term disability or health condition that had lasted 12 months. Pre- migration factors such as increasing age (OR 1.08; 95% CI 1.05, 1.11) and women who migrated under the Women at Risk Visa category (OR 2.40; 95% CI 1.26, 4.56) had greater odds of experiencing chronic pain. Interestingly, post migration factors such as women with better general health (OR 0.04; 95% CI 0.01, 0.11) or those who settled within metropolitan cities (OR 0.29; 95% CI 0.13, 0.68) had lower odds of experiencing chronic pain, and those who experience discrimination (OR 11.23; 95% CI 1.76, 71.51) had greater odds of experiencing chronic pain.

Conclusion

Our results show that there is a high prevalence of chronic pain in refugee women across the initial years of resettlement in Australia. This may be in part due to pre-migration factors such as age and migration pathway, but more significantly the post migration context that these women settle into such as rurality of settlement, poorer general health and perceived discriminatory experiences. These findings suggest that there may be many unmet health needs which are compounded by the challenges of resettlement in a new society, highlighting the need for increased clinical awareness to help inform refugee health care and settlement service providers managing chronic pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13226-5.

Perceived health, adversity, and posttraumatic stress disorder in Syrian and Iraqi refugees

BACKGROUND

Exposure to armed conflict and fleeing country of origin for refugees has been associated with poorer psychological health.

METHODS

Within the first month following their arrival in the United States, 152 Syrian and Iraqi refugees were screened in a primary care setting for posttraumatic stress disorder (PTSD), anxiety, and depression and rated their perceived health, and perceived level of adversity of violence, armed conflict/flight. The moderating effects of psychiatric symptoms on the relation between perceived adversity and perceived health were assessed.

RESULTS

Three models based on diagnosis (PTSD, anxiety, and depression) were tested. While significant effects were found on perceived adversity negatively influencing perceived health across diagnoses, slightly different patterns emerged based on diagnosis.

DISCUSSION

Findings suggest that refugees' perception regarding adversity of violence, armed conflict, and flight may contribute to perceived health, with a moderating role of clinically significant symptoms of PTSD, anxiety, and depression.

The Comprehensive Communal Trauma Intervention Model (CCTIM), an Innovative Transdisciplinary Population-Level Model for Treating Trauma-Induced Illness and Mental Health in Global Vulnerable Communities: Palestine, a Case Study

This paper explores how Western medicine may not fully understand and address post-traumatic stress disorder (PTSD) and other trauma-induced illnesses in a culturally appropriate manner in marginalized communities and offers a theoretical framework to develop comprehensive, effective, and sustainable solutions that comprehensively address and treat the trauma on both a collective and individual level. Focused on Palestinians, this paper discusses the collective trauma Palestinians experienced and how it manifests in transgenerational effects on the body and mind that may be post-traumatic stress disorder (PTSD) or perhaps another distinct condition that is yet to be codified in the Western medical lexicon. It describes local alternatives to Western medical diagnostic tools like the "ease to disease" diagnostic scale and the sociopolitical context-in this case, the Palestinian fight for karamah, or dignity-from which such alternatives arise. Based on these findings, a novel theoretical framework, the comprehensive communal trauma intervention model (CCTIM), a truly transdisciplinary population-level model for treating mental health in vulnerable communities globally, is proposed. It articulates the need to address the root cause of collective trauma, make modifications to the healthcare system, and cultivate strategic equity-oriented and research-based partnerships.

Understand My Language, to Understand My Pain: Challenges of Neurological Evaluation Among Refugees

The increasing number of migrants and refugees entering Albania during the last decade has been a challenge to the medical service of the country. Many of the migrants arrive from remote areas of Middle East or other Asian regions, heading toward northern Europe, deprived from medical assistance during their tormenting journey. An exacerbation of previous m"unicodeedical conditions is expected and is related to the hardship of traveling conditions. The medical professionals working in migration medicine have little, if any, training on the field and need to familiarize themselves with a variety of previously unknown conditions. Empathy, necessary on an individual basis, may not be sufficient in itself; the burden of medically treating migrants needs a holistic and multidisciplinary approach.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain

OBJECTIVE

This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.

DESIGN AND METHODS

This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts.

RESULTS

ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort.

CONCLUSION

This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study

OBJECTIVES

This study aims to examine associations, predictors and pharmacological treatment of chronic pain and mental health problems among Syrian refugees in a longitudinal perspective.

DESIGN

Prospective cohort study.

SETTING

We collected survey data among Syrian refugees in Lebanon granted resettlement to Norway (self-administered questionnaires) and at follow-up 1 year after arrival in Norway (structured telephone interviews).

PARTICIPANTS

Adult Syrian refugees attending mandatory pretravel courses in Lebanon in 2017-2018 were invited to participate. In total, 353 individuals participated at both time points.

PRIMARY AND SECONDARY OUTCOMES

We examined the cross-sectional associations between pain, mental health and migration-related exposures at baseline and follow-up and assessed whether associations changed significantly with time. Furthermore, we investigated the longitudinal association between mental health at baseline and pain at follow-up. We also evaluated temporal changes in use of analgesics and psychotropic drugs.

RESULTS

While most refugees reported improved health from the transit phase in Lebanon to the early resettlement phase in Norway, a few had persisting and intertwined health problems. Most migration-related stressors were more closely associated with chronic pain and mental health problems after resettlement as compared with the transit phase. In parallel, poor mental health was associated with chronic pain in the follow-up (adjusted risk ratio (ARR) 1.5 (1.0, 2.2)), but not at baseline (ARR 1.1 (0.8, 1.5)). Poor mental health at baseline was a statistically significant predictor of chronic pain at follow-up among those not reporting chronic pain at baseline. At both timepoints, one in four of those with chronic pain used analgesics regularly. None with mental health problems used antidepressants daily.

CONCLUSIONS

Providers of healthcare services to refugees should be attentive to the adverse effect of postmigration stressors and acknowledge the interrelations between pain and mental health. Possible gaps in pharmacological treatment of pain and mental health problems need further clarification.

Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study

BACKGROUND

Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden.

METHODS

A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture.

RESULTS

About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F(2, 316) = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001).

CONCLUSIONS

Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

A Walk-In Clinic for Newly Arrived Mentally Burdened Refugees: The Patient Perspective

Providing refugees with psychosocial support is particularly important considering the high level of mental health problems prevalent in this population. A psychosocial walk-in clinic operating within a state reception and registration center in Germany has been supporting mentally burdened refugees since 2016. This study focused on patients' perspectives on their mental health burden, the psychosocial walk-in clinic, and future help seeking. We conducted interviews with n = 22 refugees attending the walk-in clinic from March to May 2019. Qualitative analysis focused on the following four topics: (1) mental burden from the patients' perspective, (2) access to the psychosocial walk-in clinic, (3) perception of counseling sessions, and (4) perception of follow-up treatment. The results show that the majority of interviewees were burdened by psychological and somatic complaints, mostly attributed to past experiences and post-migratory stress. Therapeutic counseling and psychiatric medication were found to be particularly helpful. Most of the participants felt motivated to seek further psychosocial support. Key barriers to seeking psychosocial help included shame, fear of stigma, and lack of information. Overall, the psychosocial walk-in clinic is a highly valued support service for newly arrived refugees with mental health issues.

Association of symptom severity, pain and other behavioral and medical comorbidities with diverse measures of functioning among adults with post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an often disabling mental disorder whose management typically focuses on reducing PTSD symptoms. Chronic pain and other comorbidities that commonly accompany PTSD symptoms may also be independently associated with disability. Using data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions, we examined the independent association of PTSD symptom severity, pain interference, non-PTSD psychiatric and substance use disorders (SUD), and medical illnesses with each of four domains of function: mental health-related quality of life and physical functioning assessed with the Mental Health Composite Score (MCS) and Physical Function Score (PFS) of the Short Form-12; perceived social support from the Interpersonal Support and Evaluation List-12 (ISEL-12); and self-reported past year employment. Among 1779 individuals representing 11 million U.S. adults who met the Diagnostic and Statistical Manual-5 (DSM-5) criteria for Past Year PTSD, the MCS (41.2; SD 12.5), PFS (44.8; SD 13.2) and ISEL-12 (33.6; SD 7.2) indicated substantial disability when compared to population norms, and only 63.6% were employed. Multiple regression showed the MCS had a modest negative association with PTSD symptoms, pain interference, psychiatric multimorbidity and medical comorbidity although not with SUD. PFS and employment had significant negative associations with pain interference and medical comorbidity. ISEL-12 had a weak negative association with PTSD symptoms and non-PTSD psychiatric comorbidity. Common comorbidities thus significantly influence disability associated with PTSD, often more strongly than PTSD symptoms. PTSD treatment may require integrative multimorbidity management beyond a focus on PTSD symptoms.

Advances in Treatment of Post-Traumatic Stress Disorder with Chinese Medicine

"Timely, near, and expectation" is the main principle of battlefield rescue for military combat stress reaction (CSR). Post-traumatic stress disorder (PTSD) is the most common form of CSR and a long-term persistent mental disorder that is caused by unusual threatening or catastrophic psychological trauma. Chinese medicine (CM) has abundant resources, is simple, easy to master, with few side effects. This article summarizes the cellular and animal experimental mechanisms of CM treatment on PTSD, suggesting that traditional Chinese herbs and acupuncture can protect brain functional areas, and adjust hypothalamus-pituitary-adrenal axis. Traditional Chinese herbs and acupuncture have shown good anti-stress efficacy and fewer side effects in clinical application, which may improve the CSR in the battlefield.

The 10-year course of mental health, quality of life, and exile life functioning in traumatized refugees from treatment start

Refugee patients with severe traumatic experiences may need mental health treatment, but treatment results vary, and there is scarcity of studies demonstrating refugees' long-term health and well-being after treatment. In a 10-year naturalistic and longitudinal study, 54 multi-origin traumatized adult refugee patients, with a background of war and persecution, and with a mean stay in Norway of 10.5 years, were recruited as they entered psychological treatment in mental health specialist services. The participants were interviewed face-to-face with multiple methods at admittance, and at varying points in time during and after psychotherapy. The aim was to study the participants' trajectories of symptoms of post-traumatic stress, anxiety and depression, four aspects of quality of life, and two aspects of exile life functioning. Linear mixed effects analyses included all symptoms and quality of life measures obtained at different times and intervals for the participants. Changes in exile life functioning was investigated by exact McNemar tests. Participants responded to the quantitative assessments up to eight times. Length of therapy varied, with a mean of 61.3 sessions (SD = 74.5). The participants improved significantly in symptoms, quality of life, and exile life functioning. Improvement in symptoms of posttraumatic stress, anxiety, and depression yielded small effect sizes (r = .05 to .13), while improvement in quality of psychological and physical health yielded medium effect sizes (r = .38 and .32). Thus, long-time improvement after psychological therapy in these severely traumatized and mostly chronified refugee patients, was more notable in quality of life and exile life functioning than in symptom reduction. The results imply that major symptom reduction may not be attainable, and may not be the most important indication of long-term improvement among refugees with long-standing trauma-related suffering. Other indications of beneficial effects should be applied as well.

The Effect of Physiotherapy Group Intervention in Reducing Pain Disorders and Mental Health Symptoms among Syrian Refugees: A Randomized Controlled Trial

Chronic pain is common among refugees, and often related to mental health problems. Its management, however, is often challenging. A randomized waitlist-controlled trial was designed to study the effect of group physiotherapy activity and awareness intervention (PAAI) on reducing pain disorders, and secondarily improving mental health, among Syrian refugees. A total of 101 adult Syrian refugees suffering from chronic pain were randomized to either the intervention group or the control group, which thereafter also received PAAI after a waiting period. Pain intensity measured by the Brief Pain Inventory (BPI) was the primary outcome. Scores from the Impact of Events Scale-Revised (IES-R 22) and the General Health Questionnaire (GHQ-12) were secondary outcomes. Intention-to-treat analyses (ITT) showed no effect of the intervention on either pain levels (regression coefficient [B {95% CI} of 0.03 {-0.91, 0.96}], IESR scores [4.8 {-3.7, 13.4}] or GHQ-12 scores [-0.4 {-3.1, 2.3}]). Yet, participants highly appreciated the intervention. Despite the negative findings, our study contributes to the evidence base necessary to plan targeted and effective health care services for refugees suffering from chronic pain and highlights the challenge of evaluating complex interventions adapted to a specific group.

Care providers' views on burden of psychosomatic symptoms of IS-traumatized female refugees participating in a Humanitarian Admission Program in Germany: A qualitative analysis

BACKGROUND

Traumatized refugees often suffer from diverse psychosomatic symptoms. Female Yazidi refugees from Northern Iraq who survived attacks of the so-called "Islamic State" were brought to Germany to receive special medical and psychotherapeutic treatment in a unique worldwide humanitarian admission program (HAP). Here, we report on their psychosomatic symptoms and helpful strategies from the perspective of care providers.

METHODS

Care providers (N = 84) in this HAP were interviewed in an individual setting as well as in focus groups to gather information about the HAP beneficiaries' psychosomatic symptoms. Data analysis followed Qualitative Content Analysis by Mayring.

RESULTS

The care providers reported five main psychological burdens of the Yazidis: 1) insecurity regarding loss, 2) worries about family members, 3) ambivalence about staying in Germany or returning to Iraq, 4) life between two worlds and 5) re-actualization of the traumatic experiences. The predominant psychological symptoms the care providers noticed were fear, depressive symptoms, feelings of guilt, and sleep and eating disorders. Regarding somatic symptoms, the care providers mainly received complaints about pain in the head, back, chest and stomach. Helpful strategies for providing adequate health care were care providers' cooperating with physicians, precise documentation of beneficiaries' symptoms, and additional support in directing the beneficiaries through the health care system. Regarding psychotherapy, interpreters help to overcome language barriers, onsite psychotherapy, flexible therapy appointments, psychoeducational methods, time for stabilization, and support in coping with daily life aspects. In the care providers' experience, psychotherapists have to build a relationship of trust. After grief therapy, a trauma-specific therapy in a culturally adapted way is possible.

CONCLUSION

The HAP is a unique model health care program to offer highly traumatized refugees medical and psychological help. Care providers reported on several (psycho-)somatic symptoms of the traumatized women. The strategies the HAP care providers perceived as helpful can be recommended for similar projects in the future.

Time series analysis of intensive longitudinal data in psychosomatic research: A methodological overview

Time series analysis of intensive longitudinal data provides the psychological literature with a powerful tool for assessing how psychological processes evolve through time. Recent applications in the field of psychosomatic research have provided insights into the dynamical nature of the relationship between somatic symptoms, physiological measures, and emotional states. These promising results highlight the intrinsic value of employing time series analysis, although application comes with some important challenges. This paper aims to present an approachable, non-technical overview of the state of the art on these challenges and the solutions that have been proposed, with emphasis on application towards psychosomatic hypotheses. Specifically, we elaborate on issues related to measurement intervals, the number and nature of the variables used in the analysis, modeling stable and changing processes, concurrent relationships, and extending time series analysis to incorporate the data of multiple individuals. We also briefly discuss some general modeling issues, such as lag-specification, sample size and time series length, and the role of measurement errors. We hope to arm applied researchers with an overview from which to select appropriate techniques from the ever growing variety of time series analysis approaches.

trans-Resveratrol ameliorates anxiety-like behaviors and neuropathic pain in mouse model of post-traumatic stress disorder

BACKGROUND

trans-Resveratrol has been extensively investigated for its anti-inflammatory, antioxidant, and anti-psychiatric properties. However, whether it could rescue posttraumatic stress disorder-like stress-induced pain abnormality is unknown.

AIM

The present study examined the effects of trans-resveratrol on anxiety-like behavior and neuropathic pain induced by single-prolonged stress, which is a classical animal model for mimicking posttraumatic stress disorder.

METHODS

The single-prolonged stress-induced anxiety-like behavior and pain response were detected by the novelty suppressed feeding, marble burying, locomotor activity, von Frey, and acetone-induced cold allodynia tests in mice. The serum corticosterone levels and glucocorticoid receptor, protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor expression were detected by enzyme-linked immunosorbent assay and immunoblot analyses.

RESULTS

trans-Resveratrol reversed single-prolonged stress-induced increased latency to feed and the number of marbles buried in the novelty suppressed feeding and marble burying tests, but did not significantly influence locomotion distance in the locomotor activity test. trans-Resveratrol also reversed single-prolonged stress-induced cold and mechanical allodynia. Moreover, single-prolonged stress induced abnormality in the limbic hypothalamus-pituitary-adrenal axis was reversed by trans-resveratrol, as evidenced by the fact that trans-resveratrol reversed the differential expression of glucocorticoid receptor in the anxiety- and pain-related regions. In addition, trans-resveratrol increased protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor levels, which were decreased in mice subjected to single-prolonged stress.

CONCLUSIONS

These results provide compelling evidence that trans-resveratrol protects neurons against posttraumatic stress disorder-like stress insults through regulation of limbic hypothalamus-pituitary-adrenal axis function and activation of downstream neuroprotective molecules such as protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor expression.

Context- and Subgroup-Specific Language Changes in Individuals Who Develop PTSD After Trauma

Post-traumatic stress disorder (PTSD) is a very common condition with more than 3 million new cases per year in the US alone. The right diagnosis in a timely manner is key to ensuring a prompt treatment that could lead to a full recovery. Unfortunately, avoidance of trauma reminders, social stigma, self-presentation, and self-assessment biases often prevent individuals from seeking timely evaluation, leading to delays in treatment and suboptimal outcomes. Previous studies show that various mental health conditions are associated with distinct patterns of language use. Analyzing language use may also help to avoid response bias in self-reports. In this study, we analyze text data from online forum users, showing that language use differences between PTSD sufferers and controls. In all groups of PTSD sufferers, the usage of singular first-person pronouns was higher and that of plural first-person pronouns was lower than in control groups. However, the analysis of other word categories suggests that subgroups of people with the same mental health disorder (here PTSD) may have salient differences in their language use, particularly in word usage frequencies. Additionally, we show that word usage patterns may vary depending on the type of the text analyzed. Nevertheless, more studies will be needed to increase precision by further examine a variety of text types and different comorbidities. If properly developed, such tools may facilitate earlier PTSD diagnosis, leading to timely support and treatment, which are associated with better outcomes.

Pain and Evil: From Local Nociception to Misery Following Social Harm

Experiencing pain, especially when chronic, is an excruciating condition that should be regarded as a syndrome, if not a disease. People suffering from chronic pain tend to develop psychological discomfort mostly due to lack of acceptance, disbelief, blame. The complexity of pain pathophysiology, plus a wide range of negative psychosocial factors, leads to a more complex suffering that deserves attention and multidisciplinary treatments. The possibility that chronic pain may occur following physical aggression, torture, or persecution raises the issue of evil as a major contributor to pain in its worst representation - when individuals or groups are attacked based on racial, social, gender, religious, political, or other grounds. To explore the complex issue of chronic pain following physical or psychological harm, and to underscore the need for a multidisciplinary approach to reduce the burden of chronic pain, we discuss the biological mechanisms underlying pain state. We seek to clarify those factors leading to pain chronification, as well as personal and social attitudes that confound patients with chronic pain. The importance of family and social environment is also investigated, as well as personality traits of chronic pain patients that may further hamper successful treatment. The presence of chronic pain, modulated by, for example, acceptance of being a victim of premeditated physical and social violence, makes the issue more difficult to comprehend.

Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the "Islamic State" (IS)

BACKGROUND

Refugees with a history of war or sexual violence often experience somatic symptoms along with mental disorders. After being held in captivity by the so-called "Islamic State" (IS), 1100 especially vulnerable Yazidi women and children (around 400 women) received special medical and psychological support. We report on their (psycho-) somatic complaints and concepts of illness.

METHODS

Female refugees (N = 116) were surveyed regarding their somatic complaints and concepts of illness. The Impact of Event Scale-Revised (IES-R) and self-developed questionnaire items with ratings on a five-point Likert scale from 0 ("not at all") to 4 ("extremely") were used. Subgroup analyses and a multiple linear regression model were computed.

RESULTS

Pain (M = 2.43, SD = 1.70) is the main somatic complaint with a moderate rated severity, followed by feelings of suffocation (M = 2.37, SD = 1.53), and movement disorders (M = 1.62, SD = 1.70). In a linear regression model, pain explains variance (R² = 0.325) in the refugees' self-reported health-related wellbeing. Somatic symptoms are mainly attributed to psychological causes, followed by physical (e.g., physical origin of symptoms), religious, and supernatural causes. Women with pain symptoms attributed their symptoms more to physical causes (M = 1.90, SD = 1.78) than did women without pain symptoms (M = 1.07, SD = 1.59).

CONCLUSION

Female Yazidi refugees being kept in IS captivity mainly suffer from pain, which is attributed to an explanatory psychological model. The study results show the specific psychosomatic and psychotherapeutic needs and demands for specifically tailored psychotherapy.

Two interventions to treat pain disorders and post-traumatic symptoms among Syrian refugees: protocol for a randomized controlled trial

Background

There is a high prevalence of pain and post-traumatic symptoms among refugees and feasible interventions to manage these are needed. However, knowledge about the effect of physiotherapy and psychological group interventions among refugees is scarce. Our aim is to determine whether two different interventions, the Physiotherapy Activity and Awareness Intervention (PAAI) and Teaching Recovery Techniques (TRT), reduce pain and post-traumatic symptoms among refugees from Syria living in Norway.

Methods/design

Syrian adults with either pain disorders or post-traumatic symptoms, or both, will be recruited to this randomized control trial. The trial will include two separate interventions: participants with dominating pain symptoms will be assigned to the PAAI; and those with a predominance of post-traumatic symptoms will be assigned to the TRT intervention. Participants will be randomized to either the immediate intervention group or the delayed intervention group, for each of the interventions (PAAI and TRT). A minimum of 68 participants will be recruited for the PAAI and 78 participants for TRT, in order to detect clinically and statistically significant symptom improvement, assuming 25–30% attrition after recruitment. The main outcomes for the analyses will be pain intensity measured by the Brief Pain Inventory questionnaire and the scores of the Impact of Events Scale — Revised. The effect will be evaluated at the end of interventions lasting 8 weeks (PAAI) and 6 weeks (TRT) using the same instruments after the end of the intervention, and again 4–6 weeks later. Additionally, a qualitative evaluation will be conducted through an embedded process evaluation and personal interviews with participants after each of the interventions is finished.

Discussion

Our study will determine the feasibility of the implementation of two different interventions and the effect of these interventions among refugees from Syria with pain disorders and/or post-traumatic symptoms.

Trial registration

Clinical Trials.gov, NCT03951909. Retrospectively registered on 19 February 2019.

Health-related quality of life among Syrian refugees resettled in Sweden

PURPOSE

The main purpose of this study was to assess health-related quality of life (HRQoL) among Syrian refugees resettled in Sweden. Further, we wanted to investigate whether sex, age, education, area of residence, cohabitation and social support were associated with HRQoL in this population.

METHODS

This is a cross-sectional study including 1215 Syrian refugees from a randomly selected sample frame resettled in Sweden between the years 2011 and 2013. HRQoL was measured by the EQ-5D-5L descriptive system, and EQ-5D-5L index values were calculated. Associations between sex, age, education, area of residence, cohabitation, social support and EQ-5D-5L were investigated using multiple linear regression analysis.

RESULTS

Depression/anxiety was the most commonly (61.9%) reported EQ-5D-5L problem among the group of Syrian refugees. The mean EQ-5D-5L index value was found to be 0.754. Male sex, younger age, cohabitation and social support were found associated with a higher EQ-5D-5L index score.

CONCLUSIONS

Our results concerning long-lasting health problems among the study population indicate that there is a profound need for policies and interventions promoting refugees' health. Our results also show that social support, a modifiable factor, is relevant to refugees' overall health, pointing to the importance of public health interventions and policies targeting the facilitation, mobilization and enhancing of refugees' social support.

Stabilizing Techniques and Guided Imagery for Traumatized Male Refugees in a German State Registration and Reception Center: A Qualitative Study on a Psychotherapeutic Group Intervention

Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.

Medical Clerkship in a State Registration and Reception Center for Forced Migrants in Germany: Students' Experiences, Teachable Moments, and Psychological Burden

Aspects of global health are becoming increasingly relevant for doctors of future generations. However, medical curricula rarely include courses which focus on global health or forced migration. Furthermore, it remains unclear whether students are at risk to develop psychological strain, after being confronted with highly burdened or even traumatized asylum seekers. This is a prospective study using a mixed-methods approach. We included n = 22 medical students performing a medical clerkship in a state registration and reception center for refugees. By applying (1) qualitative interviews, (2) reflective diaries, and (3) psychometric questionnaires, we examined the students’ experiences, teachable moments, and potential psychological burdens. In the interviews, the students emphasized the importance of cultural sensitivity during their clerkship. However, they also reported cognitive changes concerning their views of themselves and the world in general; this could indicate vicarious traumatization. The reflective diaries displayed high learning achievements. According to the psychometric questionnaires, the assignment in the reception center had not caused any significant psychological strain for the students. By completing their medical clerkship in a reception center, students were able to improve their medical, organizational, and interactional knowledge and skills. Furthermore, they reported that they had broadened their personal and cultural horizons.

Mast Cells in Stress, Pain, Blood-Brain Barrier, Neuroinflammation and Alzheimer's Disease

Mast cell activation plays an important role in stress-mediated disease pathogenesis. Chronic stress cause or exacerbate aging and age-dependent neurodegenerative diseases. The severity of inflammatory diseases is worsened by the stress. Mast cell activation-dependent inflammatory mediators augment stress associated pain and neuroinflammation. Stress is the second most common trigger of headache due to mast cell activation. Alzheimer's disease (AD) is a progressive irreversible neurodegenerative disease that affects more women than men and woman's increased susceptibility to chronic stress could increase the risk for AD. Modern life-related stress, social stress, isolation stress, restraint stress, early life stress are associated with an increased level of neurotoxic beta amyloid (Aβ) peptide. Stress increases cognitive dysfunction, generates amyloid precursor protein (APP), hyperphosphorylated tau, neurofibrillary tangles (NFTs), and amyloid plaques (APs) in the brain. Stress-induced Aβ persists for years and generates APs even several years after the stress exposure. Stress activates hypothalamic-pituitary adrenal (HPA) axis and releases corticotropin-releasing hormone (CRH) from hypothalamus and in peripheral system, which increases the formation of Aβ, tau hyperphosphorylation, and blood-brain barrier (BBB) disruption in the brain. Mast cells are implicated in nociception and pain. Mast cells are the source and target of CRH and other neuropeptides that mediate neuroinflammation. Microglia express receptor for CRH that mediate neurodegeneration in AD. However, the exact mechanisms of how stress-mediated mast cell activation contribute to the pathogenesis of AD remains elusive. This mini-review highlights the possible role of stress and mast cell activation in neuroinflammation, BBB, and tight junction disruption and AD pathogenesis.