Randomised controlled trial comparing narrative exposure therapy with present-centred therapy for older patients with post-traumatic stress disorder

BACKGROUND

Evidence-based treatment and age-specific services are required to address the needs of trauma-affected older populations. Narrative exposure therapy (NET) may present an appropriate treatment approach for this population since it provides prolonged exposure in a lifespan perspective. As yet, however, no trial on this intervention has been conducted with older adults from Western Europe.AimsExamining the efficacy of NET in a sample of older adults.

METHOD

Out-patients with post-traumatic stress disorder (PTSD), aged 55 years and over, were randomly assigned to either 11 sessions of NET (n = 18) or 11 sessions of present-centred therapy (PCT) (n = 15) and assessed on the Clinician-Administered PTSD Scale (CAPS) pre-treatment, post-treatment and at follow-up. Total scores as well as symptom scores (re-experience, avoidance and hyperarousal) were evaluated.

RESULTS

Using a piecewise mixed-effects growth model, at post-treatment a medium between-treatment effect size for CAPS total score (Cohen's d = 0.44) was found, favouring PCT. At follow-up, however, the between-treatment differences were non-significant. Drop-out rates were low (NET 6.7%, PCT 14.3%) and no participant dropped out of the study because of increased distress.

CONCLUSIONS

Both NET and PCT appear to be safe and efficacious treatments with older adults: PCT is non-intrusive and NET allows for imaginal exposure in a lifespan perspective. By selectively providing these approaches in clinical practice, patient matching can be optimised.Declaration of interestNone.

[Predicting aggression during the treatment of forensic psychiatric patients by means of the HCR-20]

BACKGROUND

A substantial number of forensic psychiatric patients also show aggressive behaviour while being admitted to a psychiatric hospital. Risk assessment can therefore be of importance not only for estimating the risk of recidivism after treatment, but can also be used to protect the hospital staff.

AIM

To find out to what extent scores on the Historical Clinical Risk Management-20 (HCR-20) can predict aggressive behaviour during inpatient treatment in a forensic psychiatric department.

METHOD

In total, 102 patients were included in our analysis. Of these, 43 patients had caused 174 aggressive incidents between January 2005 and August 2008. The incidents were recorded by staff members who used the Staff Observation Aggression Scale-Revised (SOAS).

RESULTS

On average, the group of patients involved in one or more aggressive incidents were found to have higher hcr-scores than patients who were not involved in aggressive incidents. The area under the curve (AUC)-value of the HCR-20 total score was 0.70 as far as the prediction of aggression was concerned. Logistic aggression analysis suggested that particularly the C-subscale items assessing impulsivity (item C4) and the patient's response to treatment (item C5) may be able to predict aggressive behaviour fairly accurately in a particular department.

CONCLUSION

The HCR-20 can predict to a certain extent which patients will engage in violent behaviour while receiving treatment in a forensic psychiatric department. These results correspond to those of similar earlier investigations which showed that the HCR-20 could predict that patients would engage in further violent or criminal behaviour after being discharged from hospital.

A prospective study on parental coping 4 months after termination of pregnancy for fetal anomalies

OBJECTIVE

To identify short-term factors influencing psychological outcome of termination of pregnancy for fetal anomaly, in order to define those patients most vulnerable to psychopathology.

STUDY DESIGN

A prospective cohort of 217 women and 169 men completed standardized questionnaires 4 months after termination. Psychological adjustment was measured by the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Edinburgh Postnatal Depression Scale (EPDS), and the Symptom Checklist-90 (SCL-90).

RESULTS

Women and men showed high levels of posttraumatic stress (PTS) symptoms (44 and 22%, respectively) and symptoms of depression (28 and 16%, respectively). Determinants of adverse psychological outcome were the following: high level of doubt in the decision period, inadequate partner support, low self-efficacy, lower parental age, being religious, and advanced gestational age. Whether the condition was Down syndrome or another disability was irrelevant to the outcome. Termination did not have an important effect on future reproductive intentions. Only 2% of women and less than 1% of men regretted the decision to terminate.

CONCLUSION

Termination of pregnancy (TOP) for fetal anomaly affects parents deeply. Four months after termination a considerable part still suffers from posttraumatic stress symptoms and depressive feelings. Patients who are at high risk could benefit from intensified support.

Can parents adjust to the idea that their child is at risk for a sudden death?: Psychological impact of risk for long QT syndrome

Can a parent adjust to the idea that its child is at risk for a sudden death? This question is raised by a diagnostic procedure in which children were tested for an inherited Long QT Syndrome (LQTS). This potentially life-threatening but treatable cardiac arrhythmia syndrome may cause sudden death, especially in children and young adults. The long-term psychological effects are described for parents whose children were tested for inherited LQTS. The adverse short-term impact of such testing has been described previously. The goal of this investigation is to determine whether this distress endures. Thirty-six parents completed measures of psychological distress. With the twenty-four parents of carrier children, a semi-structured interview was held 18 months after DNA disclosure. Parents of carrier children reported more distress than parents of non-carrier children. Parents of carrier children remained vulnerable to high levels of distress; up to one-third of these parents showed clinically relevant high levels of distress. High levels of distress were reported by parents of carrier children who (1) were highly distressed at previous assessments, (2) were familiar with the disease for a longer time, (3) had experienced a sudden death in the family, (4) were lesser educated, and who (5) were unsatisfied with the given information. Parents were particularly concerned about possible hazardous behavior during puberty. We conclude that the continuous threat of developing LQTS symptoms despite prophylactic treatment affected the psychological well-being of the parents for a long time. In light of the tempetuous developments in the areas of cardiac genetics, periodical information on new insight and developments may act as a buffer for the parents' (growing) concerns about their child's inherited disorder.

High Distress in Parents Whose Children Undergo Predictive Testing for Long QT Syndrome

OBJECTIVES

To assess the psychological effect of predictive testing in parents of children at risk for long QT syndrome (LQTS) in a prospective study.

METHODS

After their child was clinically screened by electrocardiography and blood was taken for DNA analysis, and shortly after delivery of the DNA test result, 36 parents completed measures of psychological distress.

RESULTS

24 parents were informed that at least one of their children is a mutation carrier. Up to 50% of the parents of carrier children showed clinically relevant high levels of distress. Parents who were familiar with the disease for a longer time, who had more experiences with the disease in their family and who received positive test results for all their children were most distressed.

CONCLUSIONS

Predictive ECG testing together with DNA testing has a profound impact on parents whose minors undergo predictive testing for LQTS.

Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study

OBJECTIVE

We examined women's long-term psychological well-being after termination of pregnancy (TOP) for fetal anomaly in order to identify risk factors for psychological morbidity.

METHODS

A cross-sectional study was performed in 254 women, 2 to 7 years after TOP for fetal anomaly before 24 weeks of gestation. We used standardised questionnaires to investigate grief, posttraumatic symptoms, and psychological and somatic complaints.

RESULTS

Women generally adapted well to grief. However, a substantial number of the participants (17.3%) showed pathological scores for posttraumatic stress. Low-educated women and women who had experienced little support from their partners had the most unfavourable psychological outcome. Advanced gestational age at TOP was associated with higher levels of grief, and posttraumatic stress symptoms and long-term psychological morbidity was rare in TOP before 14 completed weeks of gestation. Higher levels of grief and doubt were found if the fetal anomaly was presumably compatible with life.

CONCLUSION

Termination of pregnancy for fetal anomaly is associated with long-lasting consequences for a substantial number of women. Clinically relevant determinants are gestational age, perceived partner support, and educational level.

Perception of risk and subjective health among victims of the Chernobyl disaster

Several studies have demonstrated that the nuclear power plant accident at Chernobyl in 1986 had a strong impact on the subjective health of the inhabitants in the surrounding regions and that the majority of these health complaints appear to be stress-related. An epidemiological survey among the adult population of the Gomel region in Belarus near Chernobyl showed higher rates of self-reported health problems, psychological distress and medical service use in this region than in a comparable unexposed region. This paper presents an analysis of data on cognitive factors that were collected in this study. The findings support the hypothesis that cognitive variables such as risk perception and sense of control play an important role as mediating factors in the explanation of the observed health differences between the exposed and non-exposed regions. A tentative model is presented to further clarify the role of risk perception in the occurrence of non-specific health complaints after such ecological disasters.

Suicidal behaviour and family factors among Dutch and Slovenian high school students: a comparison

OBJECTIVE

East European countries have much higher suicide rates than West European countries. Whether this also applies for suicidal ideation and suicide attempts is not known. In addition, the role of family factors in relation to suicidal behaviour has not been investigated in East European countries.

METHOD

Two representative samples of 19,250 Dutch and 4706 Slovenian high school students were compared on the basis of self-report data.

RESULTS

Slovenian students report more suicidal behaviour (ideation and attempts) as well as more unfavourable family circumstances than Dutch students. This applies especially to the death of parent(s), the number of changes in their living situation, and to conflicts between or with parents.

CONCLUSION

A relation between family characteristics and suicidal behaviour is established in both samples, but proved to be strongest in Slovenian girls. Complicated cultural and socioeconomic differences between the two countries may account for the reported differences.

On the classification and diagnosis of pathological grief

It has been suggested that pathological grief should become either a separate category of mental disorder or be integrated within existing, extended classifications in systems such as the Diagnostic and Statistical Manual of Mental Disorders. Despite strong arguments for inclusion, and advancements by scientists toward development of diagnostic classification, there has been a lack of critical evaluation. Several issues need further scrutiny and clarification. These concern the definition of pathological grief, the distinction of pathological from normal grief, its relationship with other disorders, and the lack of agreement among scientists about criteria for pathological grief. Further research needs to focus on delineation of syndromes that comprise "pathological grief," and on derivation of acceptable, valid, diagnostic criteria. Evaluation of the ramifications--both positive and potentially negative--associated with the revision of the diagnostic status of pathological grief needs also to be undertaken.

Psychotherapy in Russia. Historical backgrounds and current practice

During recent years, the former Soviet states have witnessed enormous social and cultural changes, which have also greatly influenced the field of mental health, including psychotherapy. In this article, the historical backgrounds of Russian psychotherapy and its current practice are described. Psychotherapy in Russia and in Western countries share common roots, but have developed into different directions during the 70 years of Soviet regime. In more recent years, they have begun to slowly converge again. In the West, a trend away from insight-oriented, nondirective psychotherapy is taking place in favor of more directive approaches, aimed at changing overt behavior. In contrast, there is a tendency for therapies in Russian-speaking countries to become gradually less directive and authoritarian. In these countries there is an increasing interest in psychodynamic, insight-oriented therapies.

Health effects of the Chernobyl disaster: illness or illness behavior? A comparative general health survey in two former Soviet regions

Results are described of a general health survey (n = 3044) that was conducted 6.5 years after the Chernobyl accident in 1986 in a seriously contaminated region in Belarus and a socioeconomically comparable, but unaffected, region in the Russian Federation. The purpose of the study was to investigate whether there are differences in the general health status of the inhabitants of the two regions that may be attributed to the Chernobyl disaster. A broad-based population sample from each of these regions was studied using a variety of self-report questionnaires. A subsample (n = 449) was further examined with a standardized physical and psychiatric examination. The results show significantly higher scores on the self-report questionnaires and higher medical service utilization in the exposed region. No significant differences were observed in global clinical indices of health. Although there were trends for some disorders to be more prevalent in the exposed region, none of these could be directly attributed to exposure to ionizing radiation. The results of this study suggest that the Chernobyl disaster had a significant long-term impact on psychological well-being, health-related quality of life, and illness behavior in the exposed population.

Long-term mental health effects of the Chernobyl disaster: an epidemiologic survey in two former Soviet regions

OBJECTIVE

This study assessed the long-term mental health effects of the nuclear accident at Chernobyl.

METHOD

Two population samples (N = 3,044), one from the Gomel region, close to the accident site, and one from Tver, 500 miles away, were studied 6 1/2 years after the event with the use of a variety of self-report questionnaires and a standardized psychiatric interview.

RESULTS

The prevalence of psychological distress and DSM-III-R psychiatric disorders was exceptionally high in both regions. Scores on the self-report scales were consistently higher in the exposed region; however, a higher risk of DSM-III-R psychiatric disorders could be demonstrated only among women with children under 18 years of age in the exposed region.

CONCLUSIONS

A substantial long-term mental health effect of the Chernobyl incident was demonstrated, mainly at a subclinical level.

Intervention for the bereaved: gender differences in the efficacy of two counselling programmes

This article describes an investigation of emotion-focused versus problem-focused intervention for widowers (N = 23) and widowers (N = 23) who were suffering elevated levels of distress 11 months after their loss. They were randomly assigned to an intervention condition and improvement (on the General Health Questionnaire) was compared with non-intervention controls (N = 59). Two alternative hypotheses were considered: (1) men, since they focus less on their emotions, would benefit from problem-focused counselling, while women, focusing more on their emotions, would benefit from emotion-focused intervention; (2) each gender, having been comparatively unsuccessful in coping through these usual strategies, would benefit more from intervention directed towards the less familiar strategy. Results supported the second hypothesis: widowers benefited more from emotion-focused, widows from problem-focused interventions. Implications for supporting widows and widowers are discussed.

Cross-modality grief therapy: description and assessment of a new program

A recently developed program for extensive inpatient grief therapy in groups, administered on a time-limited basis, is outlined, an illustrative case study is described, and empirical assessment of the program's efficacy is provided. During a 3-month stay in a Dutch Health Care Centre, a combined treatment program was offered that integrated behavior and art therapy [so-called Cross-Modality Grief Therapy, (CMGT)]. Assessment (levels of symptomatology on the General Health Questionnaire) was made at pretest, post-test, and follow-up and was compared with levels at comparable time points among participants in a more traditional program. Systematic advantages were found for CMGT. Discussion focuses on the identification of elements within CMGT that were responsible for its effectiveness.

Experiences with a checklist for DSM-III-R in the Russian Federation and Belarus. A study about the interrater reliability and the concurrent validity of the Munich Diagnostic Checklist for DSM-III-R

The interrater reliability of the Munich Diagnostic Checklist (MDCL) was assessed in a small clinical sample and two population samples in the Russian Federation and Belarus. A team of Russian and Belarussian psychiatrists made DSM-III-R diagnoses, using the MDCL as the basis for a standardized interview. The interrater reliability was found to be satisfactory (kappa = 0.86 for case vs non-case distinction). In the population samples, the interviewing psychiatrist, in addition to making a DSM-III-R diagnosis, classified each respondent on a checklist of 11 clinical syndromes familiar to Russian psychiatry and made a severity rating. The overall concurrent validity indices based on the comparison of these diagnostic ratings were fairly high (kappa 0.48-0.82), suggesting considerable agreement between the DSM-III-R and traditional Russian diagnostic concepts.

A conceptual scheme for assessing evenhandedness and (counter) self-serving attributional biases in relation to depression

Various hypotheses have been proposed concerning the attributional styles of depressive and nondepressive persons. Some hypotheses are compatible with others; some are mutually exclusive. In this paper we present a scheme for organizing these hypotheses. A method is offered for deciding which hypothesis best fits data from samples which are heterogeneous with regard to extent of depression. The concepts reviewed include "self-serving bias," "counter-self-serving bias," "evenhandedness," "depressive lower self-enhancement," "counter-defensive attribution," the "Abramson, et al. hypothesis" that depressed persons attribute events with bad outcomes more to internal, stable, and global causes than do nondepressed persons, and the "Seligman, et al. hypothesis" that depressed persons attribute events of good outcome less to these causes than do nondepressed persons.

Two subtypes of adolescent suicide attempters. An empirical classification

An empirical classification of 203 adolescent suicide attempters (mean age 17.3) was achieved using multiple correspondence analysis. The characteristics upon which the classification is based concern sociodemographic as well as psychological variables. Two groups are identified: the first is predominantly characterized by recent problematic behaviors, whereas the second group is primarily characterized by problematic circumstances. Analyzing related variables, the first group seems to have special clinical and preventive interest, because of its high risk for recidivism. The second group seems to have a satisfactory level of functioning.

Self-reported suicidal behavior in Dutch secondary education students

From nearly 10,000 secondary education students in The Netherlands, aged 14-20, data were collected on the prevalence of suicide attempts and recent thoughts about suicide and death. In this sample, 3.3% of the girls and 1.3% of the boys indicated that they had attempted suicide. The youngest students already reported as many attempts as the eldest, which is remarkable. Differences between boys and girls and between various types of schools were not substantial. We also found that 5.2% of the girls and 2.2% of the boys currently had thoughts of suicide. Again, there was no substantial difference as regards sex, type of school, and age. There was, however, a (small) difference between boys and girls concerning thoughts of death--namely, 9.3% of the girls versus 4.8% of the boys.

Attributional cognitions, coping behavior, and self-esteem in inpatients with severe spinal cord injuries

The purpose of this study was to examine the relation between attributional cognitions, coping behavior, and self-esteem of inpatients with severe spinal cord injuries. Thirty inpatients from rehabilitation centers were interviewed. Their coping behavior was assessed by a physician, a nurse, and a psychologist. The results showed sometimes different tendencies for the recently vs. long-disabled patients with respect to the direction of the relation between attributional cognitions and rehabilitation outcome (coping behavior and self-esteem). Especially noteworthy is the evident adaptiveness in the group of the long-disabled inpatients with regard to being concerned with the causes of the accident and being concerned with the avoidability of the accident that led to the injury, while in the recently disabled group these cognitions are related to nonadaptiveness. To be concerned with the question, "Why did this have to occur to me?" was strongly related for the long-disabled inpatients with poor coping behavior, while this was not the case for the recently disabled.