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Kim HJ, Lee DH, Kim JH, Kang SE. Validation of the Dimensions of Anger Reactions Scale (the DAR-5) in non-clinical South Korean adults. BMC Psychol 2023; 11:74. [PMID: 36927713 PMCID: PMC10019409 DOI: 10.1186/s40359-023-01084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 02/10/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Posttraumatic anger is a commonly reported emotion among people who have experienced traumatic events. The current study aimed to demonstrate the reliability and validity of the South Korean version of the DAR-5 (DAR-5-K). The DAR-5 is a single scale with 5 items which measures posttraumatic anger. The DAR-5 is composed of five items that measure anger frequency, intensity, duration, aggression, and its interference with social relations. METHODS Data were collected from 814 South Korean adults who had experienced traumatic events and participated in the study and analyzed via the combination of exploratory factor analysis (n = 405) and confirmatory factor analysis (n = 409). RESULTS Results supported the one-factor structure, as reported in previous validation studies. The scale demonstrated robust internal reliability and concurrent validity with measures of posttraumatic stress disorder (PTSD) symptoms, depression, anxiety, and self-esteem. The DAR-5 cut-off score of 12 that was established in the original validation study successfully differentiated high from low scorers with regard to PTSD symptoms, depression, anxiety, and self-esteem. CONCLUSION The results confirm that the DAR-5-K is a brief and psychometrically robust measure of anger that can be used to examine South Korean adults who have experienced traumatic events.
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Affiliation(s)
- Hae Jin Kim
- Traumatic Stress Center, Department of Education, Sungkyunkwan University, Seoul, Republic of Korea
| | - Dong Hun Lee
- Traumatic Stress Center, Department of Education, Sungkyunkwan University, Seoul, Republic of Korea.
| | - Jeong Han Kim
- School of Rehabilitation Services and Counseling, University of Texas-Rio Grande Valley, Edinburg, TX, USA
| | - Su-Eun Kang
- Traumatic Stress Center, Department of Education, Sungkyunkwan University, Seoul, Republic of Korea
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Cork C, Kaiser BN, White RG. The integration of idioms of distress into mental health assessments and interventions: a systematic review. Glob Ment Health (Camb) 2019; 6:e7. [PMID: 31143467 PMCID: PMC6521171 DOI: 10.1017/gmh.2019.5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 03/12/2019] [Accepted: 04/08/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Psychiatric diagnostic manuals recognise the importance of local expressions of distress in culturally diverse settings [i.e. idioms/cultural concepts of distress (CCDs)], yet there is a lack of consensus on how these should be incorporated into mental health related research. AIMS To perform a narrative synthesis and critical review of research exploring how idioms/CCDs have been integrated into assessment measures and interventions. METHOD A systematic review was conducted in accordance with PRISMA guidelines. An adapted version of the COSMIN checklist was used to assess the quality of the linguistic translation of the idioms/CCDs. RESULTS Twenty-nine papers were included in the final review. Primary qualitative research was the most common method of gathering information about idioms/CCDs. The majority of studies described integrating idioms/CCDs into assessment measures as opposed to interventions. Some studies used information relating to idioms/CCDs to develop novel assessment measures, while others adapted pre-existing assessment measures. The measures generated moderate to high levels of validity. Information relating to the linguistic translation conducted in the completion of the studies tended to be inadequately reported. CONCLUSIONS Integrating information about idioms/CCDs into assessment measures can enhance the validity of these assessments. Allocating greater research attention to idioms/CCDs can also promote more equitable exchanges of knowledge about mental health and wellbeing between the Global North and the Global South.
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Affiliation(s)
- C. Cork
- School of Education, University of Glasgow, 11 Eldon Street, Glasgow G3 6NH, UK
| | - B. N. Kaiser
- Department of Anthropology, University of California San Diego, La Jolla, CA, USA
| | - R. G. White
- Institute of Human and Life Sciences, University of Liverpool, G.10, Whelan Building, Brownlow Hill, Liverpool L69 3GQ, UK
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Spiller TR, Liddell BJ, Schick M, Morina N, Schnyder U, Pfaltz M, Bryant RA, Nickerson A. Emotional Reactivity, Emotion Regulation Capacity, and Posttraumatic Stress Disorder in Traumatized Refugees: An Experimental Investigation. J Trauma Stress 2019; 32:32-41. [PMID: 30729584 DOI: 10.1002/jts.22371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 10/02/2018] [Accepted: 10/06/2018] [Indexed: 11/08/2022]
Abstract
Refugees who suffer from posttraumatic stress disorder (PTSD) often react with strong emotions when confronted with trauma reminders. In this study, we aimed to investigate the associations between low emotion regulation capacity (as indexed by low heart rate variability [HRV]), probable PTSD diagnosis, and fear and anger reaction and recovery to trauma-related stimuli. Participants were 81 trauma-exposed refugees (probable PTSD, n = 23; trauma-exposed controls, n = 58). The experiment comprised three 5-min phases: a resting phase (baseline); an exposition phase, during which participants were exposed to trauma-related images (stimulus); and another resting phase (recovery). We assessed HRV at baseline, and fear and anger were rated at the end of each phase. Linear mixed model analyses were used to investigate the associations between baseline HRV and probable DSM-5 PTSD diagnosis in influencing anger and fear responses both immediately after viewing trauma-related stimuli and at the end of the recovery phase. Compared to controls, participants with probable PTSD showed a greater increase in fear from baseline to stimulus presentation, d = 0.606. Compared to participants with low emotion regulation capacity, participants with high emotion regulation capacity showed a smaller reduction in anger from stimulus presentation to recovery, d = 0.548. Our findings indicated that following exposure to trauma-related stimuli, probable PTSD diagnosis predicted increased fear reactivity, and low emotion regulation capacity predicted decreased anger recovery. Impaired anger recovery following trauma reminders in the context of low emotion regulation capacity might contribute to the increased levels of anger found in postconflict samples.
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Affiliation(s)
- Tobias R Spiller
- University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland
| | - Belinda J Liddell
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Matthis Schick
- University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland
| | - Naser Morina
- University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland
| | - Ulrich Schnyder
- University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland
| | - Monique Pfaltz
- University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Angela Nickerson
- School of Psychology, University of New South Wales, Sydney, Australia
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Tuomisto MT, Roche JE. Beyond PTSD and Fear-Based Conditioning: Anger-Related Responses Following Experiences of Forced Migration-A Systematic Review. Front Psychol 2018; 9:2592. [PMID: 30619002 PMCID: PMC6306035 DOI: 10.3389/fpsyg.2018.02592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 12/03/2018] [Indexed: 01/27/2023] Open
Abstract
Introduction: Experiences of forced migration include traumas that are interpersonal in nature, as well as ongoing emotional responses, stress, and frustration in post-migration setti ngs. Open questions exist, regarding anger/anger-like responses following experiences of persecution and ongoing stress. The aim of this study was to explore the adaptive and maladaptive underlying mechanisms of anger/anger-like responses, cultural, linguistic, and social contingencies, and possible interventions for problematic anger behavior. Method: We searched two databases (PsycINFO and PILOTS) with the following search terms: (refugee OR "asylum seek*" OR IDP OR "internal* displac*" OR "forced migra*" OR "involuntary migra*") AND anger. Findings: This search yielded 34 studies that were included in the final review. Although, anger is a moral, adaptive, and prosocial response, dysfunctional anger/anger-like responses arise from PTSD, "moral injury," complicated grief, and independent forms of anger behavior. Cultural, linguistic, and social issues also emerged from the search. Finally, considerations for treatment and intervention are discussed. Discussion: Anger responses following experiences of forced migration may require assessment beyond PTSD models currently framed by DSM and ICD. A very promising framework is the Adaptation and Development after Persecution and Trauma (ADAPT) model. Implications: Further longitudinal and epidemiological research will be necessary to continue testing the ADAPT model and to begin the process of assessing its cross-cultural coherence in other refugee populations (e.g., see Hinton et al., 2003). As anger behavior is also a societal issue, avenues for reconciliation, expression of grievances, employment, civic participation, and integration are needed.
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Affiliation(s)
- Martti T. Tuomisto
- Faculty of Social Sciences (Psychology), University of Tampere, Tampere, Finland
| | - Jane E. Roche
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
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Hoffman J, Liddell B, Bryant RA, Nickerson A. The relationship between moral injury appraisals, trauma exposure, and mental health in refugees. Depress Anxiety 2018; 35:1030-1039. [PMID: 30095203 DOI: 10.1002/da.22787] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Refugees are often exposed to multiple traumatic experiences, leading to elevated rates of psychological disorders. There is emerging evidence that appraisals of traumatic events as violating deeply held moral beliefs and frameworks (i.e., moral injury) impact negatively on refugee mental health. Despite this, no research has systematically investigated moral injury appraisals in refugees. METHOD Participants were 222 refugees from diverse backgrounds who had recently resettled in Australia. They completed measures of mental health in Arabic, Farsi, Tamil, or English through an online survey. This study first investigated the factor structure of the Moral Injury Appraisals Scale (MIAS), and then examined the relationship between the moral injury factors and key predictor (age, gender, trauma exposure) and outcome (Posttraumatic stress disorder [PTSD] symptom clusters, anger, and depression) variables. RESULTS Confirmatory factor analyses of the MIAS supported a two-factor model, comprising a Moral Injury-Other (MI-Other) factor (i.e., interpreting the violation as being enacted by others) and a Moral Injury-Self (MI-Self) factor (i.e., interpreting the violation as being enacted by oneself). Structural equation modeling analyses indicated that both factors were predicted by higher trauma exposure, and both predicted more severe anger and depression. Notably, while MI-Other was associated with more severe PTSD, MI-Self was associated with lower levels of intrusions. CONCLUSION These results suggest that there may be subtypes of moral injury appraisals that are associated with different mental health outcomes. These findings have potential implications for designing treatments that address the psychological impact of the refugee experience.
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Affiliation(s)
- Joel Hoffman
- School of Psychology, UNSW Australia, Sydney, New South Wales, Australia
| | - Belinda Liddell
- School of Psychology, UNSW Australia, Sydney, New South Wales, Australia
| | - Richard A Bryant
- School of Psychology, UNSW Australia, Sydney, New South Wales, Australia
| | - Angela Nickerson
- School of Psychology, UNSW Australia, Sydney, New South Wales, Australia
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Amone-P'Olak K, Omech B. Coping with post-war mental health problems among survivors of violence in Northern Uganda: Findings from the WAYS study. J Health Psychol 2018; 25:1857-1870. [PMID: 29781333 DOI: 10.1177/1359105318775185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Cognitive emotion regulation strategies and mental health problems were assessed in a sample of war-affected youth in Northern Uganda. Univariable and multivariable regression models were fitted to assess the influence of CERS on mental health problems. Maladaptive cognitive emotion regulation strategies (e.g., rumination) were significantly associated with more mental health problems while adaptive cognitive emotion regulation strategies (e.g., putting into perspective) were associated with reporting fewer symptoms of mental health problems. The youth with significant scores on mental health problems (scores ≥ 85th percentile) reported more frequent use of maladaptive than adaptive strategies. Interventions to reduce mental health problems should focus on enhancing the use of adaptive strategies.
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Amone-P'Olak K, Elklit A. Interpersonal Sensitivity as Mediator of the Relations Between War Experiences and Mental Illness in War-Affected Youth in Northern Uganda: Findings From the WAYS Study. ACTA ACUST UNITED AC 2018; 24:200-208. [PMID: 30190654 PMCID: PMC6116889 DOI: 10.1037/trm0000145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 12/14/2017] [Accepted: 12/20/2017] [Indexed: 11/30/2022]
Abstract
The pathways from war experiences to mental health problems are poorly understood. The current study aims to assess the role of interpersonal sensitivity in the relations between war experiences and mental health problems based on data from the War-Affected Youth Survey cohort study. The War-Affected Youth Survey is an ongoing research project of formerly abducted children in Northern Uganda assessing their war experiences and the risk and protective factors in the development of mental health problems. Mediation of the relations between war experiences and mental health problems by interpersonal sensitivity was analyzed using structural equation modeling. War experiences were related to posttraumatic stress disorder through interpersonal sensitivity accounting for 55% of the variance in their relations, to depression/anxiety through interpersonal sensitivity accounting for 89% of the variance in their relations (i.e., near complete mediation), and to psychotic symptoms through interpersonal sensitivity accounting for 53% of the variance in their relations. The direct relation between war experiences, on the one hand, and posttraumatic stress disorder and psychotic symptoms, on the other hand, attenuated but remained statistically significant. For depression/anxiety, the direct relationship ceased to be significant after including interpersonal sensitivity in the model. Interpersonal sensitivity is an important determinant of long-term mental health problems in war-affected youth. Interventions to improve mental health should target youth with high scores on interpersonal sensitivity. Cognitive–behavioral therapy to recognize and change cognitive schemas in youth prone to interpersonal sensitivity is recommended.
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Affiliation(s)
- Kennedy Amone-P'Olak
- Department of Psychology, University of Botswana, and National Center for Psychotraumatology, University of Southern Denmark
| | - Ask Elklit
- National Center for Psychotraumatology, University of Southern Denmark
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Dawson K, Joscelyne A, Meijer C, Steel Z, Silove D, Bryant RA. A controlled trial of trauma-focused therapy versus problem-solving in Islamic children affected by civil conflict and disaster in Aceh, Indonesia. Aust N Z J Psychiatry 2018; 52:253-261. [PMID: 28606000 DOI: 10.1177/0004867417714333] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the relative efficacies of trauma-focused cognitive behavior therapy and problem-solving therapy in treating post-traumatic stress disorder in children affected by civil conflict in Aceh, Indonesia. METHOD A controlled trial of children with post-traumatic stress disorder ( N = 64) randomized children to either five individual weekly sessions of trauma-focused cognitive behavior therapy or problem-solving therapy provided by lay-counselors who were provided with brief training. Children were assessed by blind independent assessors at pretreatment, posttreatment and 3-month follow-up on post-traumatic stress disorder, depression and anger, as well as caregiver ratings of the child's post-traumatic stress disorder levels. RESULTS Intent-to-treat analyses indicated no significant linear time × treatment condition interaction effects for post-traumatic stress disorder at follow-up ( t(129.05) = -0.55, p = 0.58), indicating the two conditions did not differ. Across both conditions, there were significant reductions in post-traumatic stress disorder on self-reported ( t(131.26) = -9.26, p < 0.001) and caregiver-reported ( t(170.65) = 3.53, p = 0.001) measures and anger ( t(127.66) = -7.14, p < 0.001). Across both conditions, there was a large effect size for self-reported post-traumatic stress disorder (cognitive behavior therapy: 3.73, 95% confidence interval = [2.75, 3.97]; problem-solving: 2.68, 95% confidence interval = [2.07, 3.29]). CONCLUSIONS These findings suggest that trauma-focused cognitive behavior therapy and problem-solving approaches are comparably successful in reducing post-traumatic stress disorder and anger in treating mental health in children in a post-conflict setting. This pattern may reflect the benefits of non-specific therapy effects or gains associated with trauma-focused or problem-solving approaches.
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Affiliation(s)
- Katie Dawson
- 1 School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Amy Joscelyne
- 1 School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | | | - Zachary Steel
- 1 School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Derrick Silove
- 1 School of Psychology, University of New South Wales, Sydney, NSW, Australia.,3 Psychiatry Research & Teaching Unit, Liverpool Hospital, Liverpool, NSW, Australia
| | - Richard A Bryant
- 1 School of Psychology, University of New South Wales, Sydney, NSW, Australia
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Tol WA, Rees SJ, Tay AK, Tam N, da Costa Saldanha Segurado A, da Costa ZM, da Costa Soares ES, da Costa Alves A, Martins N, Silove DM. Cohort Profile: Maternal mental health and child development in situations of past violent conflict and ongoing adversity: the DILI birth cohort study. Int J Epidemiol 2018; 47:17-17h. [PMID: 29471471 DOI: 10.1093/ije/dyw130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- W A Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - S J Rees
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia
| | - A K Tay
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia
| | - N Tam
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia.,Alola Foundation, Dili, Timor-Leste
| | | | - Z M da Costa
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia.,Alola Foundation, Dili, Timor-Leste
| | - E S da Costa Soares
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia.,Alola Foundation, Dili, Timor-Leste
| | - A da Costa Alves
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia.,Alola Foundation, Dili, Timor-Leste
| | - N Martins
- Faculty of Medicine & Health Science, Universidade Nacional Timor Lorosa'e, Dili, Timor-Leste
| | - D M Silove
- Psychiatry Research and Teaching Unit, University of New South Wales, and Academic Mental Health Unit, Sydney South West Local Health District, Sydney, NSW, Australia
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Silove D, Mohsin M, Tay AK, Steel Z, Tam N, Savio E, Da Costa ZM, Rees S. Six-year longitudinal study of pathways leading to explosive anger involving the traumas of recurrent conflict and the cumulative sense of injustice in Timor-Leste. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1281-1294. [PMID: 28825139 DOI: 10.1007/s00127-017-1428-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/06/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Cumulative evidence suggests that explosive anger may be a common reaction among survivors of mass conflict. However, little is known about the course of explosive anger in the years following mass conflict, or the psychosocial factors that influence the trajectory of that reaction pattern. We examined these issues in a 6-year longitudinal study (2004-2010) conducted among adult residents of a rural and an urban village in Timor-Leste (n = 1022). METHODS We derived a brief, context-specific index of explosive anger using qualitative methods. Widely used measures of post-traumatic stress disorder (PTSD) and severe psychological distress were calibrated to the Timor context. We developed an index of the cumulative sense of injustice related to consecutive historical periods associated with conflict in Timor-Leste. We applied partial structural equation modeling (SEM) to examine pathways from baseline explosive anger, socio-demographic factors, recurrent trauma, mental health indices (PTSD, severe psychological distress) and the sense of injustice, to explosive anger. RESULTS Half of the sample with explosive anger at baseline continued to report that reaction pattern after 6 years; and a third of those who did not report explosive anger at baseline developed the response by follow-up. A symmetrical pattern of younger age, female gender and the trauma count for the preceding historical period predicted explosive anger at each assessment point. The sense of injustice was related to explosive anger at follow-up. Explosive anger was associated with impairment in functioning and conflict with the intimate partner and wider family. CONCLUSIONS Sampling constraints caution against generalizing our findings to other populations. Nevertheless, our data suggest that explosive anger may persist for a prolonged period of time following mass conflict and that the response pattern is initiated and maintained by recurrent trauma exposure associated with a sense of injustice. Averting recurrence of mass violence and addressing persisting feelings of injustice may assist in reducing anger in conflict-affected societies. Whether explosive anger at the individual level increases risk of collective violence under conditions of social and political instability requires further inquiry.
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Affiliation(s)
- Derrick Silove
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia. .,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia.
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
| | - Alvin Kuowei Tay
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
| | - Zachary Steel
- School of Psychiatry, St Johns of God, Richmond Hospital, The Black Dog Institute, University of New South Wales, St. John of God, Australia
| | | | | | | | - Susan Rees
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
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11
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Identifying a combined construct of grief and explosive anger as a response to injustice amongst survivors of mass conflict: A latent class analysis of data from Timor-Leste. PLoS One 2017; 12:e0175019. [PMID: 28430793 PMCID: PMC5400232 DOI: 10.1371/journal.pone.0175019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/20/2017] [Indexed: 11/19/2022] Open
Abstract
Previous studies have identified high rates of explosive anger amongst post-conflict populations including Timor-Leste. We sought to test whether explosive anger was integrally associated with symptoms of grief amongst the Timorese, a society that has experienced extensive conflict-related losses. In 2010 and 2011 we recruited adults (n = 2964), 18-years and older, living in an urban and a rural village in Timor-Leste. We applied latent class analysis to identify subpopulations based on symptoms of explosive anger and grief. The best fitting model comprised three classes: grief (24%), grief-anger (25%), and a low symptom group (51%). There were more women and urban dwellers in the grief and grief-anger classes compared to the reference class. Persons in the grief and grief-anger classes experienced higher rates of witnessing murder and atrocities and traumatic losses, ongoing poverty, and preoccupations with injustice for the two historical periods of conflict (the Indonesian occupation and the later internal conflict). Compared to the reference class, only the grief-anger class reported greater exposure to extreme deprivations during the conflict, ongoing family conflict, and preoccupations with injustice for contemporary times; and compared to the grief class, greater exposure to traumatic losses, poverty, family conflict and preoccupations with injustice for both the internal conflict and contemporary times. A substantial number of adults in this post-conflict country experienced a combined constellation of grief and explosive anger associated with extensive traumatic losses, deprivations, and preoccupations with injustice. Importantly, grief-anger may be linked to family conflict in this post-conflict environment.
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12
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Silove DM, Tay AK, Steel Z, Tam N, Soares Z, Soares C, Dos Reis N, Alves A, Rees S. Symptoms of post-traumatic stress disorder, severe psychological distress, explosive anger and grief amongst partners of survivors of high levels of trauma in post-conflict Timor-Leste. Psychol Med 2017; 47:149-159. [PMID: 27682000 DOI: 10.1017/s0033291716002233] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Little is known about the mental health of partners of survivors of high levels of trauma in post-conflict countries. METHOD We studied 677 spouse dyads (n = 1354) drawn from a community survey (response 82.4%) in post-conflict Timor-Leste. We used culturally adapted measures of post-traumatic stress disorder (PTSD), psychological distress, explosive anger and grief. RESULTS Latent class analysis identified three classes of couples: class 1, comprising women with higher trauma events (TEs), men with intermediate TEs (19%); class 2, including men with higher TEs, women with lower TEs (23%); and class 3, comprising couples in which men and women had lower TE exposure (58%) (the reference group). Men and women partners of survivors of higher TE exposure (classes 1 and 2) had increased symptoms of explosive anger and grief compared with the reference class (class 3). Women partners of survivors of higher TE exposure (class 2) had a 20-fold increased rate of PTSD symptoms compared with the reference class, a pattern that was not evident for men living with women exposed to higher levels of trauma (class 1). CONCLUSIONS Men and women living with survivors of higher levels of trauma showed an increase in symptoms of grief and explosive anger. The manifold higher rate of PTSD symptoms amongst women living with men exposed to high levels of trauma requires replication. It is important to assess the mental health of partners when treating survivors of high levels of trauma in post-conflict settings.
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Affiliation(s)
- D M Silove
- Academic Mental Health Unit and Ingham Institute,University of New South Wales and South Western Sydney Local Health District,Level 2, Mental Health Centre,Liverpool Hospital,Sydney, NSW 2170,Australia
| | - A K Tay
- Academic Mental Health Unit and Ingham Institute,University of New South Wales and South Western Sydney Local Health District,Level 2, Mental Health Centre,Liverpool Hospital,Sydney, NSW 2170,Australia
| | - Z Steel
- St John of God Richmond Hospital,School of Psychiatry,University of New South Wales,North Richmond,NSW 2754,Australia
| | - N Tam
- Academic Mental Health Unit and Ingham Institute,University of New South Wales and South Western Sydney Local Health District,Level 2, Mental Health Centre,Liverpool Hospital,Sydney, NSW 2170,Australia
| | - Z Soares
- Alola Foundation,Dili, Timor-Leste
| | - C Soares
- Alola Foundation,Dili, Timor-Leste
| | | | - A Alves
- Alola Foundation,Dili, Timor-Leste
| | - S Rees
- Academic Mental Health Unit and Ingham Institute,University of New South Wales and South Western Sydney Local Health District,Level 2, Mental Health Centre,Liverpool Hospital,Sydney, NSW 2170,Australia
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Arandjelovic K, Eyre HA, Forbes MP, Bauer R, Aggarwal S, Singh AB, Baune BT, Everall I, Berk M, Ng C. Mental health system development in Asia: Does Australia have a role? Aust N Z J Psychiatry 2016; 50:834-41. [PMID: 27164923 DOI: 10.1177/0004867416647798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Socioeconomic trends herald what many describe as the Asian Century, whereby Asian economic, political and cultural influence is in global ascendency. Broadening relevant ties between Australia and Asia is evident and logical and may include strengthening alliances in mental health systems. AIM We argue the importance of strengthening Asian mental health systems and some of the roles Australian mental health workers could have in promoting strengthening the Asian mental health system. METHODS This paper is a narrative review which sources data from reputable search databases. RESULTS A well-articulated Australian strategy to support strengthening the mental health system in Asia is lacking. While there are active initiatives operating in this space, these remain fragmented and underdeveloped. Coordinated, collaborative and culturally respectful efforts to enhance health education, research, policy, leadership and development assistance are key opportunities. CONCLUSION Psychiatrists and other mental health professionals have a unique opportunity to contribute to improved mental health outcomes in Asia.
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Affiliation(s)
- Katarina Arandjelovic
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Harris A Eyre
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia Discipline of Psychiatry, The University of Adelaide, Adelaide, SA, Australia College of Medicine and Dentistry, James Cook University Australia, Townsville, QLD, Australia
| | - Malcolm P Forbes
- College of Medicine and Dentistry, James Cook University Australia, Townsville, QLD, Australia
| | - Renee Bauer
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Shilpa Aggarwal
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Ajeet B Singh
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Bernhard T Baune
- Discipline of Psychiatry, The University of Adelaide, Adelaide, SA, Australia
| | - Ian Everall
- Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia Orygen - The National Centre of Excellence in Youth Mental Health and Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Chee Ng
- Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia
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Nguyen AJ, Feo C, Idrisov K, Pintaldi G, Lenglet A, Tsatsaeva Z, Bolton P, Bass J. Mental health problems among conflict-affected adults in Grozny, Chechnya: a qualitative study. Confl Health 2016; 10:16. [PMID: 27489565 PMCID: PMC4971629 DOI: 10.1186/s13031-016-0083-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/20/2016] [Indexed: 01/09/2023] Open
Abstract
Background A decade of conflict in Chechnya destroyed infrastructure and resulted in widespread exposure to violence. Amidst substantial reconstruction, periodic violence has contributed to an ongoing atmosphere of insecurity. We conducted a qualitative study to understand the mental health and psychosocial problems affecting adult Chechens in this context to inform development of assessment tools for an evaluation study related to individual counseling. Methods Data were collected in July 2014. A convenience sample of 59 Chechen adults was asked to Free List all problems affecting people in the area. Four problems were explored further in 19 Key Interviewee (KI) interviews, with respondents identified using snowball sampling. Data analysis was conducted in Russian by the Chechen interviewers. Results Multiple mental health and psychosocial problems emerged, including ‘bad psychological health’, ‘depression’, ‘stress and nervous people’, and ‘problems in the family’. Aggression, ‘emotional blowing’, and ‘not adequate’ behavior were frequently reported indicators of these problems, with negative effects on the whole family. Chechens reported seeking help through informal social networks, psychiatric and psychological services, and Islamic Centers. Conclusion Chechens reported mental health and psychosocial problems similar to those experienced in other post-conflict settings. The description of ‘emotional blowing’ mirrored prior findings in Chechen asylum seekers and fits within a cluster of cultural concepts of distress featuring anger that has been identified in other conflict-affected populations. Further exploration of the nature and prevalence of this construct, as well as evaluations of interventions aimed at reducing these symptoms, is warranted.
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Affiliation(s)
- Amanda J Nguyen
- Department of Mental Health, Johns Hopkins School of Public Health, 624 N. Broadway, Baltimore, MD 21205 USA
| | | | - Kyuri Idrisov
- Department of Psychiatry, Chechen State University, Grozny, Chechen Republic Russian Federation
| | - Giovanni Pintaldi
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Annick Lenglet
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | | | - Paul Bolton
- Department of Mental Health, Johns Hopkins School of Public Health, 624 N. Broadway, Baltimore, MD 21205 USA ; Center for Refugee and Disaster Response, Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
| | - Judith Bass
- Department of Mental Health, Johns Hopkins School of Public Health, 624 N. Broadway, Baltimore, MD 21205 USA ; Center for Refugee and Disaster Response, Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
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15
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Liddell BJ, Kemp AH, Steel Z, Nickerson A, Bryant RA, Tam N, Tay AK, Silove D. Heart rate variability and the relationship between trauma exposure age, and psychopathology in a post-conflict setting. BMC Psychiatry 2016; 16:133. [PMID: 27165346 PMCID: PMC4862083 DOI: 10.1186/s12888-016-0850-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 05/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cumulative exposure to potentially traumatic events (PTEs) increases risk for mental distress in conflict-affected settings, but the psychophysiological mechanisms that mediate this dose-response relationship are unknown. We investigated diminished heart rate variability (HRV) - an index of vagus nerve function and a robust predictor of emotion regulation capacity - as a vulnerability marker that potentially mediates the association between PTE exposure, age and symptoms of posttraumatic stress disorder (PTSD), psychological distress and aggressive behavior, in a community sample from Timor-Leste - a post-conflict country with a history of mass violence. METHOD Resting state heart rate data was recorded from 45 cases of PTSD, depression and intermittent explosive disorder (IED); and 29 non-case controls. RESULTS Resting HRV was significantly reduced in the combined case group compared with non-cases (p = .021; Cohen's d = 0.5). A significant mediation effect was also observed, whereby a sequence of increased age, reduced HRV and elevated PTSD symptoms mediated the association between PTE exposure and distress (B = .06, SE = .05, 95% CI = [.00-.217]) and aggression (B = .02, SE = .02, 95% CI = [.0003-.069])). CONCLUSION The findings demonstrate an association between diminished resting HRV and psychopathology. Moreover, age-related HRV reductions emerged as a potential psychophysiological mechanism that underlies enhanced vulnerability to distress and aggression following cumulative PTE exposure.
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Affiliation(s)
- Belinda J. Liddell
- The Psychiatry Research and Teaching Unit (PRTU), School of Psychiatry, University of New South Wales, Sydney, Australia ,School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia
| | - Andrew H. Kemp
- Discipline of Psychiatry, University of Sydney, Sydney, NSW Australia
| | - Zachary Steel
- The Psychiatry Research and Teaching Unit (PRTU), School of Psychiatry, University of New South Wales, Sydney, Australia ,St John of God, Richmond Hospital, North Richmond, NSW 2754 Australia ,Black Dog Institute, School of Psychiatry, University of New South Wales, NSW Sydney, Australia
| | - Angela Nickerson
- School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia
| | - Richard A. Bryant
- School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia
| | - Natalino Tam
- Academic Mental Health Unit, South Western Sydney Local Health District, Sydney, Australia
| | - Alvin Kuowei Tay
- The Psychiatry Research and Teaching Unit (PRTU), School of Psychiatry, University of New South Wales, Sydney, Australia ,Academic Mental Health Unit, South Western Sydney Local Health District, Sydney, Australia
| | - Derrick Silove
- The Psychiatry Research and Teaching Unit (PRTU), School of Psychiatry, University of New South Wales, Sydney, Australia ,Academic Mental Health Unit, South Western Sydney Local Health District, Sydney, Australia
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16
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Schubert SJ, Lee CW, de Araujo G, Butler SR, Taylor G, Drummond PD. The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy to Treat Symptoms Following Trauma in Timor Leste. J Trauma Stress 2016; 29:141-8. [PMID: 26934487 DOI: 10.1002/jts.22084] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 10/23/2015] [Accepted: 12/16/2015] [Indexed: 11/06/2022]
Abstract
The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy for treating trauma symptoms was examined in a postwar/conflict, developing nation, Timor Leste. Participants were 21 Timorese adults with symptoms of posttraumatic stress disorder (PTSD), assessed as those who scored ≥2 on the Harvard Trauma Questionnaire (HTQ). Participants were treated with EMDR therapy. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist. Symptom changes post-EMDR treatment were compared to a stabilization control intervention period in which participants served as their own waitlist control. Sessions were 60-90 mins. The average number of sessions was 4.15 (SD = 2.06). Despite difficulties providing treatment cross-culturally (i.e., language barriers), EMDR therapy was followed by significant and large reductions in trauma symptoms (Cohen's d = 2.48), depression (d = 2.09), and anxiety (d = 1.77). At posttreatment, 20 (95.2%) participants scored below the HTQ PTSD cutoff of 2. Reliable reductions in trauma symptoms were reported by 18 participants (85.7%) posttreatment and 16 (76.2%) at 3-month follow-up. Symptoms did not improve during the control period. Findings support the use of EMDR therapy for treatment of adults with PTSD in a cross-cultural, postwar/conflict setting, and suggest that structured trauma treatments can be applied in Timor Leste.
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Affiliation(s)
- Sarah J Schubert
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | - Christopher W Lee
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Susan R Butler
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | - Graham Taylor
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | - Peter D Drummond
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
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Tay AK, Rees S, Chen J, Kareth M, Silove D. Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees. Soc Psychiatry Psychiatr Epidemiol 2016; 51:395-406. [PMID: 26228854 DOI: 10.1007/s00127-015-1099-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/11/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Definitions of complicated grief vary across diagnostic systems, being represented as persistent complex bereavement (PCB) in DSM-5 and prolonged grief disorder (PGD) in the proposed revision of the ICD system. A past study in a high-income country has identified a six-factor structure for complicated grief, but there are no data testing this or any other model across cultures. The present study reports findings from a survey amongst West Papuan refugees (n = 230, response rate = 92 %) residing in Port Moresby, Papua New Guinea. MATERIALS AND METHODS We applied culturally adapted measures of conflict-related traumatic event (TEs) (drawing specifically on domains of conflict and loss), symptoms of complicated grief adapted and modified to the culture, and a multidimensional psychosocial index of the broader effects of conflict and displacement. RESULTS Confirmatory factor analysis yielded a single higher order construct of complicated grief comprising six factors of yearning/preoccupation; shock/disbelief; anger/negative appraisal; behavioural change; estrangement from others/impairment; and a novel dimension of confusion/diminished identity. In contrast, our analysis failed to support DSM or ICD models of PCB or PGD. A Multiple Indicators Multiple Causes (MIMIC) model revealed that traumatic loss and the sense of injustice each were associated with the unitary construct of complicated grief and its subdomains of yearning/preoccupation; shock/disbelief; anger/negative appraisal (exclusive to injustice); and estrangement from others/social impairment (exclusive to TE domain of conflict and loss). CONCLUSIONS Conflict and loss associated with feelings of injustice may be especially pathogenic in generating the anger/negative appraisal component of complicated grief amongst refugees.
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Affiliation(s)
- Alvin Kuowei Tay
- Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia. .,Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.
| | - Susan Rees
- Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.,Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.,The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia
| | - Jack Chen
- Simpson Centre for Health Services Research, University of New South Wales, Sydney, Australia.,The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia
| | - Moses Kareth
- Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.,Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia
| | - Derrick Silove
- Psychiatry Research and Teaching Unit, Liverpool Hospital, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.,Centre for Population Mental Health Research, Liverpool Hospital, Cnr Forbes and Campbell Streets, Liverpool, NSW, 2170, Australia.,The Ingham Institute, Applied Medical Research Centre, Liverpool, NSW, Australia
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18
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Tay AK, Rees S, Steel Z, Tam N, Soares Z, Soares C, Silove DM. Six-year trajectories of post-traumatic stress and severe psychological distress symptoms and associations with timing of trauma exposure, ongoing adversity and sense of injustice: a latent transition analysis of a community cohort in conflict-affected Timor-Leste. BMJ Open 2016; 6:e010205. [PMID: 26908525 PMCID: PMC4769389 DOI: 10.1136/bmjopen-2015-010205] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify the 6-year trajectories of post-traumatic stress symptoms (PTSS) and psychological distress symptoms, and examine for associations with timing of trauma exposure, ongoing adversity and with the sense of injustice in conflict-affected Timor-Leste. SETTING A whole-of-household survey was conducted in 2004 and 2010 in Dili, the capital of Timor-Leste. PARTICIPANTS 1022 adults were followed up over 6 years (retention rate 84.5%). Interviews were conducted by field workers applying measures of traumatic events (TEs), ongoing adversity, a sense of injustice, PTS symptoms and psychological distress. RESULTS Latent transition analysis supported a 3-class longitudinal model (psychological distress, comorbid symptoms and low symptoms). We derived 4 composite trajectories comprising recovery (20.8%), a persisting morbidity trajectory (7.2%), an incident trajectory (37.2%) and a low-symptom trajectory (34.7%). Compared with the low-symptom trajectory, the persistent and incident trajectories reported greater stress arising from poverty and family conflict, higher TE exposure for 2 historical periods, and a sense of injustice for 2 historical periods. The persistent trajectory was unique in reporting greater TE exposure in the Indonesian occupation, whereas the incident trajectory reported greater TE exposure during the later internal conflict that occurred between baseline and follow-up. Compared with the low-symptom trajectory, the incident trajectory reported a greater sense of injustice relating to the periods of the Indonesian occupation and independence. The persistent trajectory was characterised by a sense of injustice relating to the internal conflict and contemporary times. The recovery trajectory was characterised by the absence of these risk factors, the only difference from the low-symptom trajectory being that the former reported a sense of injustice for the period surrounding independence. CONCLUSIONS Our findings suggest that the timing of both TE exposure and the focus of a sense of injustice may differentiate those with persisting and new-onset mental health morbidity in settings of recurrent conflict.
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Affiliation(s)
- AK Tay
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, New South Wales, Australia
- Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, New South Wales, Australia
| | - S Rees
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, New South Wales, Australia
- Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Z Steel
- St John of God Richmond Hospital, School of Psychiatry, University of New South Wales
| | - N Tam
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, New South Wales, Australia
- Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Z Soares
- Alola Foundation, Dili, Timor-Leste
| | - C Soares
- Alola Foundation, Dili, Timor-Leste
| | - DM Silove
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, New South Wales, Australia
- Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, New South Wales, Australia
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Khanal V, Brites da Cruz JLN, Mishra SR, Karkee R, Lee AH. Under-utilization of antenatal care services in Timor-Leste: results from Demographic and Health Survey 2009-2010. BMC Pregnancy Childbirth 2015; 15:211. [PMID: 26350207 PMCID: PMC4563848 DOI: 10.1186/s12884-015-0646-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 09/02/2015] [Indexed: 11/19/2022] Open
Abstract
Background Timor-Leste is a young country in the Asia-Pacific region with a high maternal mortality rate of 557 per 100,000 live births. As most maternal deaths can be prevented by providing quality antenatal care (ANC) and skilled assistance during childbirth, understanding the barriers to the utilization of ANC services can enhance program implementation. This study aimed to investigate the prevalence and factors associated with the under-utilization of ANC services in Timor-Leste. Methods Timor-Leste Demographic and Health Survey (TDHS) 2009–2010 was a nationally representative multi-stage cross-sectional study involving 11,463 households and 9,828 childbirths. Information on last born child was recorded for 5,895 mother-child pairs. Factors influencing under-utilization of ANC were assessed using hierarchical logistic regression analysis. Results Only 3311 (55.2, 95 % confidence interval (CI) 53.1 to 57.3 %) made the recommended four ANC visits, while 2584 (44.8; 95 % CI 42.7 to 46.9 %) of them reported attending three or less ANC services. Significant factors positively associated with the under-utilization of ANC were low wealth status (odds ratio (OR) 2.09; 95 % CI 1.68 to 2.60), no maternal education (OR 1.54; 95 % CI 1.30 to 1.82) or primary maternal education (OR 1.21; 95 % CI 1.04 to 1.41), no paternal education (OR 1.34; 95 % CI 1.13 to 1.60), and having a big problem in permission to visit health facility (OR 1.65; 95 % CI 1.39 to 1.96). Conclusions Despite the apparently good progress made in re-establishing the healthcare infrastructure, 45 % of mothers remained in need of a focused intervention to increase their use of ANC services. Further prenatal care program should pay attention to women with low wealth status and those and their partners who are uneducated. Moreover, women should be encouraged to make decision on their own health.
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Affiliation(s)
| | | | | | - Rajendra Karkee
- School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Andy H Lee
- School of Public Health, Curtin University, Perth, Australia.
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20
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Silove D, Rees S, Tam N, Mohsin M, Tay AK, Tol W. Prevalence and correlates of explosive anger among pregnant and post-partum women in post-conflict Timor-Leste. BJPsych Open 2015; 1:34-41. [PMID: 27703721 PMCID: PMC4995583 DOI: 10.1192/bjpo.bp.115.000190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/14/2015] [Accepted: 05/27/2015] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Little is known about explosive anger as a response pattern among pregnant and post-partum women in conflict-affected societies. AIMS To investigate the prevalence and correlates of explosive anger among this population in Timor-Leste. METHOD We assessed traumatic events, intimate partner violence, an index of adversity, explosive anger, psychological distress and post-traumatic stress disorder among 427 women (257 in the second trimester of pregnancy, 170 who were 3-6 months post-partum) residing in two districts of Timor-Leste (response >99%). RESULTS Two-fifths (43.6%) had explosive anger. Levels of functional impairment were related to frequency of explosive anger episodes. Explosive anger was associated with age (>35 years), being married, low levels of education, being employed, traumatic event count, ongoing adversity and intimate partner violence. CONCLUSIONS A combination of social programmes and novel psychological therapies may assist in reducing severe anger among pregnant and post-partum women in conflict-affected countries such as Timor-Leste. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Derrick Silove
- , MB ChB, FRANZCP, MD, Professor and Director, Psychiatry Research and Teaching Unit and Ingham Institute, University of New South Wales, Sydney, Australia
| | - Susan Rees
- , PhD, MSocPol, Senior Lecturer, Psychiatry Research and Teaching Unit, University of New South Wales and Ingham Institute, Liverpool Hospital, Sydney, Australia
| | - Natalino Tam
- , In Country Project Manager, Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia
| | - Mohammed Mohsin
- , PhD, Senior Research Officer, Psychiatry Research and Teaching Unit, Southwest Sydney Local Health District, Sydney, Australia
| | - Alvin Kuowei Tay
- , MForPsych, Senior Research Officer, Psychiatry Research and Teaching Unit, Southwest Sydney Local Health District, Sydney, Australia
| | - Wietse Tol
- , PhD, Dr Ali & Rose Kawi Assistant Professor, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nickerson A, Bryant RA, Schnyder U, Schick M, Mueller J, Morina N. Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees. J Affect Disord 2015; 173:185-92. [PMID: 25462415 DOI: 10.1016/j.jad.2014.10.043] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/22/2014] [Accepted: 10/22/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND While emotion dysregulation represents an important mechanism underpinning psychological responses to trauma, little research has investigated this in refugees. In the current study, we examined the mediating role of emotion dysregulation in the relationship between refugee experiences (trauma and living difficulties) and psychological outcomes. METHODS Participants were 134 traumatized treatment-seeking refugees who completed measures indexing trauma exposure, post-migration living difficulties, difficulties in emotion regulation, posttraumatic stress disorder, depression, and explosive anger. RESULTS Findings revealed distinctive patterns of emotion dysregulation associated with each of these psychological disorders. Results also indicated that emotion regulation difficulties mediated the association between both trauma and psychological symptoms, and living difficulties and psychological symptoms. LIMITATIONS Limitations include a cross-sectional design and the use of measures that had not been validated across all cultural groups in this study. CONCLUSIONS These findings underscore the key role of emotion dysregulation in psychological responses of refugees, and highlight potential directions for treatment interventions for traumatized refugees.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, UNSW Australia, Sydney, NSW 2052, Australia.
| | - Richard A Bryant
- School of Psychology, UNSW Australia, Sydney, NSW 2052, Australia
| | - Ulrich Schnyder
- Department of Psychiatry and Psychotherapy, Zurich University Hospital, Zurich 8091, Switzerland
| | - Matthis Schick
- Department of Psychiatry and Psychotherapy, Zurich University Hospital, Zurich 8091, Switzerland
| | - Julia Mueller
- Psychiatric Services Thurgau, Münsterlingen 8596, Switzerland
| | - Naser Morina
- Department of Psychiatry and Psychotherapy, Zurich University Hospital, Zurich 8091, Switzerland
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22
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Rees S, Thorpe R, Tol W, Fonseca M, Silove D. Testing a cycle of family violence model in conflict-affected, low-income countries: a qualitative study from Timor-Leste. Soc Sci Med 2015; 130:284-91. [PMID: 25753169 DOI: 10.1016/j.socscimed.2015.02.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The present study examines key aspects of an emerging cycle of violence model as applied to conflict-affected countries. We focus specifically on the roles of intimate partner violence (IPV), consequent experiences of explosive anger amongst women, and associated patterns of harsh parenting. Between 2010 and 2011, we conducted a women-centred and culturally sensitive qualitative inquiry with 77 mothers drawn consecutively from a data-base of all adults residing in two villages in Timor-Leste. We over-sampled women who in the preceding whole of household survey met criteria for Intermittent Explosive Disorder (IED). Our methodology included in-depth qualitative interviews followed by a focus group with a comprehensive array of service providers. We used the NVivo software package to manage and analyse data. Our findings provide support for a link between IPV and experiences of explosive anger amongst Timorese mothers. Furthermore, women commonly reported that experiences of explosive anger were accompanied by harsh parenting directed at their children. Women identified the role of patriarchy in legitimizing and perpetuating IPV. Our findings suggest that empowering women to address IPV and poverty may allow them to overcome or manage feelings of anger in a manner that will reduce risk of associated harsh parenting. A fuller examination of the cycle of violence model will need to take into account wider contributing factors at the macro-level (historical, conflict-related, political), the meso-level (community-wide adherence to patriarchal norms affecting the rights and roles of women), and the micro-level (family interactions and gendered role expectations, individual psychological responses, and parenting). Longitudinal studies in post-conflict settings are needed to examine whether the sequence of male violence against women, mothers experience of explosive anger, and consequent harsh parenting contributes to risk of aggression and mental disorder in offspring, both in childhood and adulthood.
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Affiliation(s)
- Susan Rees
- University of New South Wales, Australia.
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23
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Lee R, Meyerhoff J, Coccaro EF. Intermittent Explosive Disorder and aversive parental care. Psychiatry Res 2014; 220:477-82. [PMID: 25064384 DOI: 10.1016/j.psychres.2014.05.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 05/20/2014] [Accepted: 05/25/2014] [Indexed: 11/28/2022]
Abstract
Parental bonding has been shown to have lasting impacts on the psychological development of children. Despite a growing body of research examining trauma as it relates to Intermittent Explosive Disorder (IED), no prior research has examined the relationship between parental bonding and IED. Six hundred fifty eight subjects were studied and categorized into one of three groups: Normal Control (no history of current or lifetime Axis I or Axis II disorder), Psychiatric Control (current and/or lifetime Axis I and/or Axis II disorders without IED), and IED (met current and/or lifetime criteria for IED). Self-reported parental care was assessed using the Parental Bonding Inventory (PBI). PBI Care scores were lowest among IED subjects, which were lower than among Psychiatric Control subjects, which were lower than among Normal Control subjects. PBI Control scores were highest among IED and Psychiatric Control subjects, which were higher than among Normal Control subjects. The diagnostic group differences in PBI Care/PBI Control scores were not impacted by the number of Axis I/II diagnoses. The findings in this study expand the link between childhood trauma exposure, violent behavior, and IED. This is the first report of an association of IED with an aversive childhood parenting environment.
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Affiliation(s)
- Royce Lee
- Clinical Neuroscience Research Unit, Department of Psychiatry and Behavioral Neuroscience, Pritzker School of Medicine, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Jonah Meyerhoff
- Department of Psychology, The University of Vermont, Burlington, VT, USA
| | - Emil F Coccaro
- Clinical Neuroscience Research Unit, Department of Psychiatry and Behavioral Neuroscience, Pritzker School of Medicine, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Meiksin R, Meekers D, Thompson S, Hagopian A, Mercer MA. Domestic Violence, Marital Control, and Family Planning, Maternal, and Birth Outcomes in Timor-Leste. Matern Child Health J 2014; 19:1338-47. [DOI: 10.1007/s10995-014-1638-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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25
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Forbes D, Alkemade N, Hopcraft D, Hawthorne G, O'Halloran P, Elhai JD, McHugh T, Bates G, Novaco RW, Bryant R, Lewis V. Evaluation of the dimensions of anger reactions-5 (DAR-5) scale in combat veterans with posttraumatic stress disorder. J Anxiety Disord 2014; 28:830-5. [PMID: 25445072 DOI: 10.1016/j.janxdis.2014.09.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/25/2014] [Indexed: 11/16/2022]
Abstract
After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α=.86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g., HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166-173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.
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Affiliation(s)
- David Forbes
- Australian Centre for Posttraumatic Mental Health and Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia.
| | - Nathan Alkemade
- Australian Centre for Posttraumatic Mental Health and Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Dale Hopcraft
- School of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Graeme Hawthorne
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Paul O'Halloran
- School of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Jon D Elhai
- Department of Psychology, University of Toledo, Toledo, OH, USA
| | - Tony McHugh
- Veterans' Psychiatry Unit, Austin Health, Heidelberg, VIC, Australia
| | - Glen Bates
- Swinburne University of Technology, Faculty of Life and Social Sciences, Hawthorn, VIC, Australia
| | - Raymond W Novaco
- Department of Psychology and Social Behavior, University of California, Irvine, Irvine, CA, USA
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Virginia Lewis
- Australian Centre for Posttraumatic Mental Health and Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia; Australian Institute for Primary Care & Ageing, La Trobe University, Melbourne, VIC, Australia
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Silove D, Ivancic L, Rees S, Bateman-Steel C, Steel Z. Clustering of symptoms of mental disorder in the medium-term following conflict: an epidemiological study in Timor-Leste. Psychiatry Res 2014; 219:341-6. [PMID: 24930578 DOI: 10.1016/j.psychres.2014.05.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 05/20/2014] [Accepted: 05/25/2014] [Indexed: 10/25/2022]
Abstract
It is important to define subpopulations with mental health and psychosocial reactions in the medium-term following conflict to ensure that an appropriate array of services are provided to meet the diversity of needs. We conducted a latent class analysis (LCA) on epidemiological data drawn from an urban and rural sample of 1221 adults (581 men and 640 women, response 82%) in post-conflict Timor Leste 4 years after the cessation of violence. The prevalence of PTSD was 4.9%; severe distress 4.8%; anger attacks 38.3%; and paranoid-like symptoms 10.9%. The best fitting LCA yielded three classes comprising those with no or minimal symptoms (86%), a class with anger-paranoia (13%) and a comorbid mental disorder class (1.5%) characterized by PTSD (100%) and severe distress (98%). The comorbid mental disorder class had an over-representation of men, the unemployed, residents in the urban area and persons with the greatest exposure to human rights trauma, murder and health stress. The anger-paranoia class experienced moderate levels of trauma and had an over-representation of urban dwellers, women, and those with higher levels of education. The analysis assists in clarifying the populations with mental disorder and adverse psychosocial reactions in need of intervention in the medium-term following conflict.
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Affiliation(s)
- Derrick Silove
- Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia.
| | - Lorraine Ivancic
- Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia
| | - Susan Rees
- Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia
| | - Catherine Bateman-Steel
- Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia
| | - Zachary Steel
- Centre for Population Mental Health Research, Sydney South West Area Health Service and School of Psychiatry, The University of New South Wales, Australia
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Rasmussen A, Ventevogel P, Sancilio A, Eggerman M, Panter-Brick C. Comparing the validity of the self reporting questionnaire and the Afghan symptom checklist: dysphoria, aggression, and gender in transcultural assessment of mental health. BMC Psychiatry 2014; 14:206. [PMID: 25034331 PMCID: PMC4107970 DOI: 10.1186/1471-244x-14-206] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/10/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The relative performance of local and international assessment instruments is subject to ongoing discussion in transcultural research on mental health and psychosocial support. We examined the construct and external validity of two instruments, one developed for use in Afghanistan, the other developed by the World Health Organization for use in resource-poor settings. METHODS We used data collected on 1003 Afghan adults (500 men, 503 women) randomly sampled at three sites in Afghanistan. We compared the 22-item Afghan Symptom Checklist (ASCL), a culturally-grounded assessment of psychosocial wellbeing, with Pashto and Dari versions of the 20-item Self-Reporting Questionnaire (SRQ-20). We derived subscales using exploratory and confirmatory factor analyses (EFA and CFA) and tested total and subscale scores for external validity with respect to lifetime trauma and household wealth using block model regressions. RESULTS EFA suggested a three-factor structure for SRQ-20--somatic complaints, negative affect, and emotional numbing--and a two-factor structure for ASCL--jigar khun (dysphoria) and aggression. Both factor models were supported by CFA in separate subsamples. Women had higher scores for each of the five subscales than men (p < 0.001), and larger bivariate associations with trauma (rs .24 to .29, and .10 to .19, women and men respectively) and household wealth (rs -.27 to -.39, and .05 to -.22, respectively). The three SRQ-20 subscales and the ASCL jigar khun subscale were equally associated with variance in trauma exposures. However, interactions between gender and jigar khun suggested that, relative to SRQ-20, the jigar khun subscale was more strongly associated with household wealth for women; similarly, gender interactions with aggression indicated that the aggression subscale was more strongly associated with trauma and wealth. CONCLUSIONS Two central elements of Afghan conceptualizations of mental distress--aggression and the syndrome jigar khun--were captured by the ASCL and not by the SRQ-20. The appropriateness of the culturally-grounded instrument was more salient for women, indicating that the validity of instruments may be gender-differentiated. Transcultural validation processes for tools measuring mental distress need to explicitly take gender into account. Culturally relevant measures are worth developing for long-term psychosocial programming.
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Affiliation(s)
- Andrew Rasmussen
- Fordham University, Dealy Hall 226, 441 East Fordham Rd, Bronx, NY 11215, USA
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Nickerson A, Bryant RA, Rosebrock L, Litz BT. The mechanisms of psychosocial injury following human rights violations, mass trauma, and torture. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/cpsp.12064] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reardon AF, Hein CL, Wolf EJ, Prince LB, Ryabchenko K, Miller MW. Intermittent explosive disorder: associations with PTSD and other Axis I disorders in a US military veteran sample. J Anxiety Disord 2014; 28:488-94. [PMID: 24907536 PMCID: PMC4378832 DOI: 10.1016/j.janxdis.2014.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
Abstract
This study examined the prevalence of intermittent explosive disorder (IED) and its associations with trauma exposure, posttraumatic stress disorder (PTSD), and other psychiatric diagnoses in a sample of trauma-exposed veterans (n=232) with a high prevalence of PTSD. Structural associations between IED and latent dimensions of internalizing and externalizing psychopathology were also modeled to examine the location of IED within this influential structure. Twenty-four percent of the sample met criteria for a lifetime IED diagnosis and those with the diagnosis were more likely to meet criteria for lifetime PTSD than those without (30.3% vs. 14.3% respectively). Furthermore, regression analyses revealed lifetime PTSD severity to be a significant predictor of IED severity after controlling for combat, trauma exposure, and age. Finally, confirmatory factor analysis revealed significant cross-loadings of IED on both the externalizing and distress dimensions of psychopathology, suggesting that the association between IED and other psychiatric disorders may reflect underlying tendencies toward impulsivity and aggression and generalized distress and negative emotionality, respectively.
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Affiliation(s)
| | - Christina L Hein
- National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University School of Medicine, United States
| | - Erika J Wolf
- National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University School of Medicine, United States
| | - Lauren B Prince
- National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University School of Medicine, United States
| | - Karen Ryabchenko
- National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University School of Medicine, United States
| | - Mark W Miller
- National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University School of Medicine, United States.
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Silove D, Liddell B, Rees S, Chey T, Nickerson A, Tam N, Zwi AB, Brooks R, Sila LL, Steel Z. Effects of recurrent violence on post-traumatic stress disorder and severe distress in conflict-affected Timor-Leste: a 6-year longitudinal study. LANCET GLOBAL HEALTH 2014; 2:e293-300. [DOI: 10.1016/s2214-109x(14)70196-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rasmussen A, Keatley E, Joscelyne A. Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature. Soc Sci Med 2014; 109:44-54. [PMID: 24698712 PMCID: PMC4070307 DOI: 10.1016/j.socscimed.2014.03.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 03/17/2014] [Accepted: 03/18/2014] [Indexed: 11/22/2022]
Abstract
Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.
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Affiliation(s)
- Andrew Rasmussen
- Fordham University, Department of Psychology, 441 East Fordham Rd., Dealy Hall 226, Bronx, NY 10458, USA.
| | | | - Amy Joscelyne
- New York University School of Medicine, Bellevue/NYU Program for Survivors of Torture, USA
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Nickerson A, Priebe S, Bryant RA, Morina N. Mechanisms of psychological distress following war in the former Yugoslavia: the role of interpersonal sensitivity. PLoS One 2014; 9:e90503. [PMID: 24658334 PMCID: PMC3962331 DOI: 10.1371/journal.pone.0090503] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/02/2014] [Indexed: 11/19/2022] Open
Abstract
While high prevalence rates of psychological symptoms have been documented in civilian survivors of war, little is known about the mechanisms by which trauma exposure might lead to poor psychological outcomes in these populations. One potential mechanism that may underpin the association between war-related traumatic experiences and psychopathology is interpersonal sensitivity. In the current study, we applied structural equation modeling to investigate the impact of interpersonal sensitivity on posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and anger responses following exposure to war trauma. 3313 survivors of the war in the former Yugoslavia were identified and selected using a multistage, probabilistic sampling frame and random walk technique. Participants were interviewed regarding trauma exposure, interpersonal sensitivity, and PTSD symptoms, depression symptoms, and anger responses. Structural equation modeling analyses revealed that the relationship between trauma and PTSD symptoms and depression symptoms was partly statistically mediated by interpersonal sensitivity. Further, findings indicated that the relationship between trauma and anger responses was fully statistically mediated by interpersonal sensitivity. These results suggest that interpersonal sensitivity may function as a key mechanism that contributes to psychopathology following trauma.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, NSW, Sydney, Australia
- * E-mail:
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Barts' and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Richard A. Bryant
- School of Psychology, University of New South Wales, NSW, Sydney, Australia
| | - Nexhmedin Morina
- Department of Clinical Psychology, University of Amsterdam, The Netherlands
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33
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Forbes D, Alkemade N, Mitchell D, Elhai JD, McHugh T, Bates G, Novaco RW, Bryant R, Lewis V. Utility of the Dimensions of Anger Reactions-5 (DAR-5) scale as a brief anger measure. Depress Anxiety 2014; 31:166-73. [PMID: 23801571 DOI: 10.1002/da.22148] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/29/2013] [Accepted: 06/01/2013] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self-report batteries or as screening tools. This study examines the psychometric properties of a shortened 5-item version of the Dimensions of Anger Reactions (DAR), an existing screening tool. METHODS Responses to the DAR-5 were analysed from a sample of 486 college students with and without a history of trauma exposure. RESULTS The DAR-5 demonstrated strong internal reliability and concurrent validity with the State Trait Anger Expression Inventory-2 (STAXI-2). Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and nontrauma subsamples. A screening cut-off point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores. Further discriminant validity was found with depression symptom scores. CONCLUSIONS The results support use of the DAR-5 for screening for anger when a short scale is required.
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Affiliation(s)
- David Forbes
- Department of Psychiatry, Australian Centre for Posttraumatic Mental Health, University of Melbourne, Victoria, Australia
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Sakti VK. ‘Thinking Too Much’: Tracing Local Patterns of Emotional Distress After Mass Violence in Timor-Leste. ASIA PACIFIC JOURNAL OF ANTHROPOLOGY 2013. [DOI: 10.1080/14442213.2013.826733] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Liddell BJ, Silove D, Tay K, Tam N, Nickerson A, Brooks R, Rees S, Zwi AB, Steel Z. Achieving convergence between a community-based measure of explosive anger and a clinical interview for intermittent explosive disorder in Timor-Leste. J Affect Disord 2013; 150:1242-6. [PMID: 23835102 DOI: 10.1016/j.jad.2013.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 06/06/2013] [Accepted: 06/06/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is growing research interest in understanding and analyzing explosive forms of anger. General epidemiological studies have focused on the DSM-IV category of Intermittent Explosive Disorder (IED), while refugee and post-conflict research have used culturally-based indices of explosive anger. The aim of this study was to test the convergence of a culturally-sensitive community measure of explosive anger with a structured clinical interview diagnosis of IED in Timor-Leste, a country with a history of significant mass violence and displacement. METHODS A double-blind clinical concordance study was conducted amongst a stratified community sample in post-conflict Timor-Leste (n=85) to compare a community measure of anger against the Structured Clinical Interview (SCID) module for IED. RESULTS Clinical concordance between the two measures was high: the area under the curve (AUC) index was 0.90 (95% CI: 0.83-0.98); sensitivity and specificity were 93.3% and 87.5% respectively. LIMITATIONS Response rates were modest due to the participant's time commitments. CONCLUSIONS It is possible to achieve convergence between culturally-sensitive measures of explosive anger and the DSM-IV construct of IED, allowing comparison of findings across settings and populations.
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Affiliation(s)
- Belinda J Liddell
- Psychiatry Research and Teaching Unit (PRTU), School of Psychiatry, University of New South Wales, NSW Australia; School of Psychology, University of New South Wales, Sydney, NSW, 2052, Australia.
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Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion. Epidemiol Psychiatr Sci 2013; 22:197-203. [PMID: 23941725 PMCID: PMC8367339 DOI: 10.1017/s2045796013000188] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This editorial proposes a shift in emphasis in the field of mental health epidemiology in conflict-affected settings. After a brief summary of the nature of contemporary armed conflicts, we consider the current and potential roles that epidemiology can play with regard to: (1) establishing the burden of mental disorders; (2) identifying risk and protective factors; and (3) intervention research. We advocate for improved methodological rigor; more attention to mixed methods approaches and multi-level longitudinal research; inclusion of the determinants of mental health beyond conflict-related violence; and consideration of a wider array of mental health outcomes. We particularly highlight the importance of expanding interest to epidemiological research that advances prevention and promotion interventions (e.g., in the early childhood period), in order to fill the gap between epidemiology and mental health practice in conflict-affected settings.
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Rees S, Silove D, Verdial T, Tam N, Savio E, Fonseca Z, Thorpe R, Liddell B, Zwi A, Tay K, Brooks R, Steel Z. Intermittent explosive disorder amongst women in conflict affected Timor-Leste: associations with human rights trauma, ongoing violence, poverty, and injustice. PLoS One 2013; 8:e69207. [PMID: 23950885 PMCID: PMC3737215 DOI: 10.1371/journal.pone.0069207] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/28/2013] [Indexed: 11/23/2022] Open
Abstract
Introduction Women in conflict-affected countries are at risk of mental disorders such as posttraumatic stress disorder and depression. No studies have investigated the association between experiences of abuse and injustice and explosive anger amongst women in these settings, and the impact of anger on women's health, family relationships and ability to participate in development. Methods A mixed methods study including an epidemiological survey (n = 1513, 92.6% response) and qualitative interviews (n = 77) was conducted in Timor-Leste. The indices measured included Intermittent Explosive Disorder, posttraumatic stress disorder; severe distress; days out of role (the number of days that the person was unable to undertake normal activities); gender-specific trauma; conflict/violence; poverty; and preoccupations with injustice. Results Women with Intermittent Explosive Disorder (n = 184, 12.2%) were more disabled than those without the disorder (for >5 days out of role, 40.8% versus 31.5%, X2(2) = 12.93 p = 0.0016). Multivariable associations with Intermittent Explosive Disorder, controlling for the presence of PTSD, psychological distress and other predictors in the model, included the sense of being sick (OR 1.73; 95% CI 1.08–2.77); victimization as a result of helping the resistance movement (OR 2.33, 95% CI 1.48–3.68); war-related trauma specific to being a woman (OR 1.95, 95%, CI 1.09–3.50); ongoing family violence and community conflict (OR 1.88, 95% CI 1.27–2.77); extreme poverty (OR 1.23, 95%, CI 1.08–1.39); and distressing preoccupations with injustice (relating to 2/3 historical periods, OR 2.10, 95% CI 1.35–3.28). In the qualitative study, women elaborated on the determinants of anger and its impact on their health, family and community functioning, child-rearing, and capacity to engage in development. Women reflected on the strategies that might help them overcome their anger. Conclusions Intermittent Explosive Disorder is prevalent and disabling amongst women in conflict-affected Timor-Leste, impacting on their health, child-rearing and ability to participate fully in socio-economic development.
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Affiliation(s)
- Susan Rees
- Psychiatry Research and Teaching Unit, University of New South Wales, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia.
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Ayazi T, Lien L, Eide AH, Ruom MM, Hauff E. What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? A cross-sectional community study in South Sudan. BMC Psychiatry 2012; 12:175. [PMID: 23083301 PMCID: PMC3534332 DOI: 10.1186/1471-244x-12-175] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 10/16/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Limited data exists on the association of war trauma with comorbid posttraumatic stress disorder (PTSD)-depression in the general population of low-income countries. The present study aimed to evaluate socioeconomic and trauma-related risk factors associated with PTSD, depression, and PTSD-depression comorbidity in the population of Greater Bahr el Ghazal States, South Sudan. METHODS In this cross-sectional community study (n=1200) we applied the Harvard Trauma Questionnaire (HTQ) and MINI International Neuropsychiatric Interview (MINI) to investigate the prevalence of PTSD, depression, and PTSD-depression comorbidity. Multinomial logistic regression analyses were conducted to examine the association between these disorders, previous trauma exposure, sociodemographic, and socioeconomic factors. RESULTS PTSD only was found in 331 (28%) and depression only in 75 (6.4%) of the study population. One hundred and twelve (9.5%) of the participants had PTSD-depression comorbid diagnosis. Exposure to traumatic events and socioeconomic disadvantage were significantly associated with having PTSD or PTSD-depression comorbidity but not with depression. Participants with a comorbid condition were more likely to be socioeconomic disadvantaged, have experienced more traumatic events, and showed higher level of psychological distress than participants with PTSD or depression alone. CONCLUSIONS In individuals exposed to war trauma, attention should be given to those who may fulfill criteria for a diagnosis of both PTSD and depression.
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Affiliation(s)
- Touraj Ayazi
- Institute of Clinical Medicine, University of Oslo, Blindern, Oslo 0318, Norway.
| | - Lars Lien
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O box 1171, Blindern, Oslo, 0318, Norway,Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Ulleval, Kirkeveien 166, Building 20, Oslo, 0407, Norway,Center for dual diagnosis, Hospital Innlandet Trust, Ottestad, 2312, Norway
| | | | - Majok Malek Ruom
- Wau Teaching Hospital, Western Bahr el Ghazal State, Wau, Ghazal, South Sudan
| | - Edvard Hauff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O box 1171, Blindern, Oslo, 0318, Norway,Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Ulleval, Kirkeveien 166, Building 20, Oslo, 0407, Norway
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Nickerson A, Aderka IM, Bryant RA, Hofmann SG. The relationship between childhood exposure to trauma and intermittent explosive disorder. Psychiatry Res 2012; 197:128-34. [PMID: 22464047 DOI: 10.1016/j.psychres.2012.01.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 01/09/2012] [Accepted: 01/11/2012] [Indexed: 10/28/2022]
Abstract
There has been a paucity of research linking intermittent explosive disorder (IED) to trauma and posttraumatic stress responses, despite evidence that trauma is strongly associated with anger reactions. The present study investigated the relationship between IED and a number of trauma-related factors, including trauma dosage, timing of first trauma, and posttraumatic stress disorder (PTSD). Participants were 4844 trauma-exposed and 731 non trauma-exposed adults who took part in the National Comorbidity Survey-Replication (NCS-R). Findings indicated that IED was associated with greater trauma exposure, PTSD and generalized anxiety disorder (GAD) diagnosis, and first exposure to traumatic events in childhood. Exploratory analyses investigating the link between IED and age at first trauma exposure across trauma types suggested that IED is related to childhood exposure to interpersonal traumatic events. These findings are discussed in the context of developmental trauma and cycles of violence models.
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Explosive anger in postconflict Timor Leste: interaction of socio-economic disadvantage and past human rights-related trauma. J Affect Disord 2011; 131:268-76. [PMID: 21310496 DOI: 10.1016/j.jad.2010.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 12/30/2010] [Accepted: 12/30/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Countries emerging from major conflict commonly experience recurrent periods of communal instability. A psychosocial theory, Adaptation and Development after Persecution and Trauma (ADAPT), suggests that experiences of past human rights abuses interact with socio-economic disadvantage in the postconflict period to generate or maintain explosive forms of anger. Previous research has supported a link between trauma exposure and anger but the role of ongoing socio-economic disadvantage requires further clarification. METHODS The present study examined a structural equation model based on cross-sectional epidemiological data (n = 1245) collected in post-conflict Timor Leste in 2004. The model included four trauma dimensions derived from a prior factor analysis; a latent variable of post-conflict distress symptoms (derived from measures of PTSD and depression/anxiety); an index of socio-economic distress; and an indigenously-based measure of explosive anger. RESULTS The final model yielded a good fit (chi-square = 26.59 df = 20 p = 0.15 CFI = 0.99; TLI = 0.99; RMSEA = 0.016). Postconflict distress symptoms mediated the associations of trauma dimensions and socio-economic disadvantage with anger. Trauma dimensions associated with human rights violations and witnessing murder were partly mediated by ongoing socio-economic disadvantage in the path to postconflict distress and anger. LIMITATIONS Longitudinal studies will be needed to confirm the chronological sequencing of these relationships. CONCLUSIONS The study offers empirical support for a link between past trauma related to human rights violations and ongoing socio-economic disadvantage in the path to distress and anger.
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Rees S, Silove D. Sakit Hati: A state of chronic mental distress related to resentment and anger amongst West Papuan refugees exposed to persecution. Soc Sci Med 2011; 73:103-10. [PMID: 21665342 DOI: 10.1016/j.socscimed.2011.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 04/26/2011] [Accepted: 05/02/2011] [Indexed: 10/18/2022]
Abstract
There has been an increasing interest in the role of gross injustices in generating pathological states of anger. The goal of this study amongst 41 West Papuan refugees conducted in Australia between 2007 and 2010 was to explore the phenomenology of Sakit Hati, a condition in which there appeared to be a close link between human rights violations and anger. West Papuan refugee participants made repeated reference to the condition of Sakit Hati in the early phase of the study so that the remainder of the study focused specifically on this construct. The qualitative approach involved an iterative process including focus groups, in-depth interviews, and semi-structured confirmatory interviews. The research revealed that Sakit Hati included elements of chronic brooding, resentment and anger attributed to experiences of injustice, a state that created vulnerability to episodes of explosive rage and aggression in response to reminders of persecution. Sakit Hati was distinguished from a depression-loss constellation, Susah Hati, although the two reactions overlapped. Sakit Hati led to substantial personal suffering and interpersonal difficulties. The intractable political conditions in West Papua made it difficult to achieve a durable resolution for the condition. Sakit Hati provides a cross-cultural illustration of the nexus between injustice and chronic anger, demonstrating how this dynamic interaction can be perpetuated by ongoing social and political forces. Greater attention may be warranted by psychiatric classification systems to the recognition of anger as an affective state that may be provoked and maintained by experiences of injustice.
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Affiliation(s)
- Susan Rees
- Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Level 1, Mental Health Center, The Liverpool Hospital, Corner of Forbes and Campbell Streets, Liverpool NSW 2170, Australia.
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Experience of human rights violations and subsequent mental disorders – A study following the war in the Balkans. Soc Sci Med 2010; 71:2170-7. [DOI: 10.1016/j.socscimed.2010.09.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 07/12/2010] [Accepted: 09/16/2010] [Indexed: 11/23/2022]
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Shiokawa H. Children draw with rulers: a symbolic sign of post-conflict adjustment? Pediatr Int 2010; 52:327-8. [PMID: 20042015 DOI: 10.1111/j.1442-200x.2009.03035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Hirosato Shiokawa
- Embassy of Japan in Timor-Leste, Avenida de Portugal, Pantai Kelapa, Dili, Timor Leste P.O. BOX 175.
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