Examination of ICD-11 PTSD and CPTSD using the International Trauma Questionnaire – Child and Adolescent version (ITQ-CA) in a sample of Danish children and adolescents exposed to abuse

Background: International research has established that children and adolescents are at risk for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as defined by the WHO ICD-11. There is a need for a Danish language version of the International Trauma Questionnaire – Child and Adolescent (ITQ-CA) to assess symptoms of PTSD and CPTSD.

Objective: To test the ICD-11 formulations of PTSD and DSO (Disturbances of Self-Organization) using the ITQ-CA version in a sample of children exposed to abuse. Additionally, to study the distribution of symptoms and probable prevalence of ICD-11 PTSD and CPTSD among the population of children exposed to violence or sexual abuse.

Method: Confirmatory factor analysis of competing models of the dimensionality of the ITQ-CA was tested among a sample of 119 children and adolescents that were referred to the Danish Children Centres on suspicion of physical or sexual abuse or both. Latent class analysis (LCA) was used to study the distribution of symptoms and consequences of different operationalisations of functional impairment were explored.

Results: Findings supported a two-factor second-order model corresponding to the operationalisation of CPTSD in ICD-11 as the best representation of the data. Findings from the LCA suggested that symptoms were distributed in a pattern consistent with the ICD-11 proposal for CPTSD. CPTSD was more prevalent than PTSD regardless of the operationalisation of functional impairment.

Conclusion: ITQ-CA is a valid tool for identifying symptoms of ICD-11 PTSD and CPTSD among Danish children exposed to physical or sexual abuse. Further research is needed to study the relationship between ICD-11 C/PTSD symptomatology and anxiety and depression in this population.

The International Trauma Questionnaire – Child and Adolescent version (ITQ-CA) is a valid measure of symptoms of ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD among Danish children exposed to physical or sexual violence.

The structure of the ITQ-CA in the Danish sample reflects the ICD-11 diagnostic algorithm.

CPTSD is a more prevalent disorder among children recently exposed to violence than PTSD.

Improving mental health following multiple disasters in Australia: a randomized controlled trial of the Skills for Life Adjustment and Resilience (SOLAR) programme

Background: The mental health impacts of climate change-related disasters are significant. However, access to mental health services is often limited by the availability of trained clinicians. Although building local community capability for the mental health response is often prioritised in policy settings, the lack of evidence-based programs is problematic. The aim of this study was to test the efficacy of the Skills for Life Adjustment and Resilience programme (SOLAR) delivered by trained local community members following compound disasters (drought, wildfires, pandemic-related lockdowns) in Australia.Method: Thirty-six community members were trained to deliver the SOLAR programme, a skills-based, trauma informed, psychosocial programme. Sixty-six people with anxiety, depression and/or posttraumatic stress symptoms, and impairment were randomised into the SOLAR programme or a Self-Help condition. They were assessed pre, post and two months following the interventions. The SOLAR programme was delivered across five 1-hourly sessions (either face to face or virtually). Those in the Self-Help condition received weekly emails with self-help information including links to online educational videos.Results: Multigroup analyses indicated that participants in the SOLAR condition experienced significantly lower levels of anxiety and depression, and PTSD symptom severity between pre - and post-intervention (T1 to T2), relative to the Self-Help condition, while controlling for scores at intake. These differences were not statistically different at follow-up. The SOLAR programme was associated with large effect size improvements in posttraumatic stress symptoms over time.Conclusion: The SOLAR programme was effective in improving anxiety, depression and posttraumatic stress symptoms over time. However, by follow-up the size of the effect was similar to an active self-help condition. Given the ongoing stressors in the community associated with compounding disasters it may be that booster sessions would have been useful to sustain programme impact.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12621000283875..

The psychological consequences of stalking: cross-sectional findings in a sample of Danish help-seeking stalking victims

Background: The experience of stalking presents a threat to the mental and physical health and wellbeing of victims. Although some studies have explored the impact of stalking on victims, few have gone into detail about specific mental health outcomes and their association with various types of stalking behaviour.Objective: To investigate the psychological consequences among Danish help-seeking victims of stalking who have contacted and received help through the Danish Stalking Center (DSC).Methods: We used survey-data from stalking victims who sought and received help from the DSC during 2015-2020 (N = 591). Descriptive statistics, correlation analysis, T-tests, and hierarchical logistic regression analysis were used to examine psychological distress symptoms and the relationship between psychopathological symptoms and stalking behaviour characteristics.Results: Victims reported considerable levels of stalking and psychological distress. Almost 80% of victims reported symptom levels indicative of a diagnosable disorder of PTSD, depression, or anxiety. T-test shoved that following behaviour had the greatest effect size for PTSD-symptoms (t(575) = -5.81, p < .01, d = -.58), anxiety (t(576) = -4.21, p < .01, d = -.42), and somatization (t(572) = -4.29, p < .01, d = -.43). Hierarchical logistic regression analysis showed that stalking victims who experienced following had significantly higher odds of experiencing symptoms of PTSD (OR 2.869; 95% CI, [1.641-5.016]) and anxiety (OR 2.274; 95% CI [1.265; 4.090]).Conclusion: Being stalked is associated with substantial PTSD-, affective and trauma-related symptoms and psychological distress in general. Together with the strikingly high levels of psychopathology and the particularly grave effects of being followed, it is indicated that stalking is a special type of trauma with many negative and harmful effects. Hence, further research into how to properly help stalking victims through preventive interventions and treatment is needed.

Seeing in the Dark: A View into Dissociation and Healing

In this paper, I will explore the role of art-making, the experience of trauma and dissociation, and the process of working with self-states from an analytic and creative frame. Relevant literature on dissociation, trauma, and the use of art will be discussed. A case involving my work with an adolescent girl who had experienced sexual abuse from a family member will be shared, with an emphasis on the meaningful role images played during the therapeutic process. Both Jungian and psychoanalytic models of conceptualizing and working with dissociation are included, following Donald Kalsched's (2013) recommendation for a "binocular stance" to treatment, including both a focus on the inner, intrapsychic world and the interpersonal, relational realm, and how art images both illuminated and expressed these realms. Within the therapeutic process, art images allowed the therapist a view into the client's unconscious process, and created a meeting ground for dissociative barriers to be gradually seen, felt and known, by both therapist and client. The experience of dissociation, in images and in session, provided a reference point for myself and my client, Taylor, to develop a shared understanding and a framework for growth.

3MDR treatment in an adolescent with PTSD: a case report

Background: As Posttraumatic stress disorder (PTSD) in adolescents significantly impacts their well-being, effective treatment is of great importance. Little is known, however, about the novel, multi-modal virtual reality supported, exposure-based psychotherapeutic interventions such as 3MDR in this population.Objective: To describe the 3MDR treatment of an adolescent with PTSD who did not respond to previous exposure-based PTSD interventions.Method: A 14-year-old girl diagnosed with PTSD received six sessions of 3MDR embedded in family therapy.Result: The patient tolerated the 3MDR intervention very well. Personalized music and self-selected pictures appeared to be a good fit, contributing to enhanced engagement in and adherence to the therapy. She no longer met criteria for PTSD post-intervention, and at 18 months follow-up.Conclusion: This case report suggests that 3MDR has potential as a trauma treatment for adolescents with treatment-resistant PTSD.

Moderate-intensity aerobic exercise training as an adjunct to trauma-focused psychotherapy in traumatized refugees and asylum seekers: study protocol of a randomized controlled trial

Background: Refugees with exposure to multiple traumatic events are at high risk for developing posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an effective treatment for the core symptoms of PTSD, but it does not reliably reduce depressive symptoms. Endurance exercise on the other hand was consistently found to be effective in treating depression making it a promising adjunct to NET. Up to date, no studies exist investigating the combination of NET and endurance exercise in a sample of refugees with PTSD and comorbid depression.Objectives: In the proposed randomized controlled trial, we aim to investigate whether a combination of NET and moderate-intensity aerobic exercise training (MAET) enhances treatment outcome for refugees with PTSD and comorbid depressive symptoms. We expect a greater improvement in psychopathology in participants who receive the combined treatment.Methods and analysis: 68 refugees and asylum seekers with PTSD and clinically relevant depressive symptoms will be recruited in the proposed study. Participants will be randomly assigned to receive either NET only (NET-group) or NET plus MAET (NET+-group). All participants will receive 10 NET sessions. Participants in the NET+-group will additionally take part in MAET. Primary (PTSD, depression) and secondary (general mental distress, agoraphobia and somatoform complaints, sleep quality) outcome measures will be assessed before treatment, after treatment, and at six-month follow-up. The hypotheses will be tested with multiple 2 × 3 mixed ANOVA's.Trial registration: German Clinical Trials Register identifier: DRKS00022145.

A comparison of PTSD and traumatic event rates in a clinical sample of non-refugee immigrants and native-born individuals with a psychotic disorder: a case-control study

Background: Migration is a multi-stage social process linked to traumatic event exposure and a notably increased risk of psychosis. Although these conditions affect refugee and non-refugee immigrants, prior trauma research has focused mainly on the refugee population.Objective: To compare and describe the rate and the clinical characterization of PTSD and traumatic events between non-refugee immigrants and native-born individuals with psychotic disorder.Methods: 99 immigrants and 99 native-born individuals (n = 198) with at least one psychotic episode according to DSM-5 criteria were compared on the rate of PTSD diagnosis and traumatic events, using standardized and validated trauma scales.Results: In the non-refugee immigrant group, 31% met diagnostic criteria for PTSD compared to only 7.1% in the native-born group. Total scores in childhood trauma and last year stressful events were 1.5 and 2 times higher in non-refugee immigrants, respectively. Likewise, cumulative lifetime trauma was three times higher in non-refugee immigrants. Finally, non-refugee immigrants reported more violent and life-threatening traumatic events than native-born individuals.Conclusions: These results are relevant since they highlight that non-refugee immigrants with psychotic disorders are highly trauma-exposed, meaning a routine trauma assessment and a trauma-focused intervention for this population should be included in individualized treatment plans.

Initial validation of the International Trauma Questionnaire (ITQ) in a sample of Chilean adults

BACKGROUND

ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) are stress-related disorders. The International Trauma Questionnaire (ITQ) is a widely used instrument to assess PTSD and CPTSD. To date, there is no evidence of the psychometric characteristics of the ITQ in Latin American countries.

OBJECTIVE

The aim of this study was to assess the construct and concurrent validity of the Latin American Spanish adaptation of the ITQ in a sample of Chilean adults.

METHODS

A sample of 275 Chilean young adults completed the ITQ, a traumatic life events checklist, the Adverse Childhood Experiences Questionnaire, the Depression Anxiety Stress Scales-21, and the Columbia-Suicide Severity Rating Scale short version. Four alternative confirmatory factor analysis models were tested. Correlation analyses were performed to determine concurrent validity with associated measures (number of reported traumatic events, number of adverse childhood experiences, anxiety, depression, and suicidal risk).

RESULTS

The second-order two-factor (PTSD and DSO) and the correlated first-order six-factor model provided acceptable fit; however, the first model showed a better fit based on the BIC difference. The PTSD and DSO dimensions, as well as the six ITQ clusters showed positive correlations with reported number of traumatic life-events, reported number of adverse childhood experiences, levels of anxiety, depression, and suicidal risk.

CONCLUSIONS

The ITQ Latin American Spanish adaptation provides acceptable psychometric evidence to assess PTSD and CPTSD in accordance with the ICD-11.

'The phoenix that always rises from the ashes': an exploratory qualitative study of the experiences of an initiative informed by principles of psychological first aid following the Beirut blast

Background: On 4 August 2020, an explosion occurred in Beirut, Lebanon. Hundreds of people were killed, thousands injured and displaced. An initiative was rapidly initiated to provide remote support informed by psychological first aid for the mental health of Lebanese young adults affected by the blast. However, little is known about recipients' experiences of such initiatives.Objective: This study aimed to qualitatively explore the experiences of supporters and recipients in the community-led initiative following the blast.Method: We recruited a diverse sample of four supporters and four Lebanese recipients who took part in the Beirut initiative. Semi-structured interviews were conducted with participants. Reflexive thematic analysis was used to analyse the qualitative data.Results: We developed five themes from the qualitative interviews, which highlighted ideas around accessibility, alienation, the relationship, elements of the safe space created by the initiative, and unmet needs and areas for improvement. Recipients described the detrimental impact of the blast on their mental health within the Lebanese context and beyond. Recipients and supporters elucidated complex experiences of the support and its impact.Conclusions: Our findings suggest remote support has the potential to be acceptable for young adults in Lebanon. Further research into support informed by psychological first aid after similar crisis events is warranted.

Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties

BACKGROUND

Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties.

METHOD

The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis.

RESULTS

Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing.

CONCLUSIONS

These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes

Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.

The protective effects of social support and family functioning on parenting stress among Hispanic/Latino/a American immigrant parents with traumatic life experiences: A mediation analysis

Despite high rates of traumatic experiences reported among Hispanic/Latino/a immigrants in the U.S., the effect of post-traumatic stress on parenting stress among Hispanic/Latino/a immigrant parents with young children has been overlooked. The present study tested the direct and indirect relationships of self-reported maternal post-traumatic stress symptoms on parenting stress, and the mediating role of protective factors among Hispanic/Latino/a mothers with young children. Baseline data collected from mothers participating in a community-based child-parent dyadic intervention were analyzed. Measures included the post-traumatic stress disorder (PTSD) Checklist, the Protective Factors Survey, and the Parenting Stress Index-Short Form (PSI). The sample included 80 mothers with a child between ages 0-6 years. About 75% of these mothers were migrants from Central America. A multivariate regression analysis showed that maternal post-traumatic stress symptoms predicted higher levels of PSI, and two protective factors (social support and family functioning/resilience) fully mediated the relationship between maternal post-traumatic stress symptoms and PSI. Higher social support and family functioning/resiliency may have protective effects on Hispanic/Latino/a mothers with post-traumatic stress, leading to lower levels of stress related to parenting. Findings underscore the importance of interventions that enhance access to social support and promote family functioning/resilience for Hispanic/Latino/a immigrant mothers with trauma histories to cope better with parenting stress.

Enforced Disappearances and Torture Today: A View from Analytical Psychology 2. Torture Survivors and the Unthinkable: A Hyper-Present Body in the Therapeutic Process: 2. Torture Survivors and the Unthinkable: A Hyper-Present Body in the Therapeutic Process1

In very rare cases, individuals survive the atrocities of abduction, imprisonment and torture that are part of the hallmark of enforced disappearances. Cases of people who survive torture and seek asylum in a third country help us understand some important aspects related to the crime of enforced disappearance. In the psychotherapy of torture survivors, at an early stage and for a long time, words often do not convey the core of the patient's experience. Survivors usually have tormented bodies in which individual and collective violence, hatred, anger, guilt and shame are painfully inscribed. Corporeal countertransference becomes the only possible way for a therapist to get in touch with a survivor's experience through a kind of body-to-body communication. The centrality of the body in these therapies suggests that the body is the involuntary recipient and container of mass political atrocities and, for this reason, the place where, in the case of horrific social violence, the possibility of social "knowing" is stored and can be retrieved. Thus, when it comes to forced disappearance, the determination of the relatives to get to the truth through the discovery of the remains of their disappeared demonstrates the importance of the body as the final witness of what happened, beyond any possible manipulation.

Facets of emotion dysregulation differentially predict depression and PTSD symptom severity following traumatic injury

Background: Emotion dysregulation is a hallmark characteristic of psychopathology following trauma. Yet, emotion dysregulation is multifaceted, and little is known about which aspects of emotion dysregulation predict depression and posttraumatic stress disorder (PTSD) symptom severity following traumatic injury.Objective: The aim of this longitudinal study was to evaluate how facets of dysregulation differentially predicted the severity of PTSD symptom clusters and depressive symptoms six months after a traumatic injury requiring medical treatment.Methods: Traumatically injured adults (N = 99) presenting to a Level 1 trauma centre completed a measure of emotion dysregulation 2 weeks post-injury, and PTSD and depression were assessed at 2-weeks and 6 months later.Results: Using stepwise regressions controlling for baseline symptoms, age, gender, race, and injury severity, results showed baseline emotion dysregulation significantly predicted the four symptom clusters of PTSD 6 months post-injury. Notably, hyperarousal symptoms and negative alterations in mood and cognition were predicted by a lack of clarity. On the other hand, depressive symptoms were significantly predicted by difficulty accessing emotion regulation strategies.Conclusion: Results highlight that specific facets of emotion dysregulation predict PTSD and depression symptom severity differentially after injury. Indeed, lack of emotional clarity appears to predict PTSD symptomatology, suggesting a potential mechanism driving worsening symptoms. Lack of clarity could also be detrimental to engagement in PTSD treatment. Conversely, lack of regulation strategies may represent a sense of helplessness in managing depression after trauma. As such, future research should elucidate whether interventions targeting aspects of emotion dysregulation based on symptom presentations are useful in treating PTSD and depression following injury.

The psychological impact of the Turkey-Syria earthquake on children: addressing the need for ongoing mental health support and global humanitarian response

This letter aims to explore the potential impact of the Turkey-Syria earthquake on the psychological well-being of the affected children and adolescents. It emphasises the crucial importance of prompt identification and management of emerging mental health disorders in this vulnerable population. The letter draws on existing research evidence to highlight the need for suitable mental health interventions to mitigate the anticipated suffering of many children and adolescents affected by the earthquake. A comprehensive overview of the mediating factors which may play a role in the extent of the impact of an earthquake on the mental health of children is discussed. A range of appropriate strategies and interventions are recommended and the call for continued global support is renewed. We have concluded that major earthquakes can potentially contribute to the development of mental health disorders among children and adolescents. However, by providing timely and effective support, it is possible to prevent long-term psychological consequences and facilitate early recovery. We propose the urgent implementation of effective mental health interventions in the aftermath of the Turkey-Syria earthquake to foster the recovery and resilience of the affected young population.

'Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel

Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.

Attenuated psychotic symptoms, substance use and self-reported PTSD in adolescence

Background: The occurrence of attenuated psychotic symptoms (APS) is a major concern in populations with substance use disorders (SUDs). However, APS also frequently develop in the course of Post-Traumatic Stress Disorder (PTSD). This study explores how the prevalence of APS differs between adolescent patients with only SUD, SUD with a history of traumatic experiences (TEs), and with SUD and self-reported PTSD.Methods: We recruited n = 120 treatment-seeking adolescents at a German outpatient clinic for adolescents with SUD. All participants filled out questionnaires assessing APS (PQ-16, YSR schizoid scale), trauma history, PTSD symptoms (both UCLA PTSD Index), and SUD severity (DUDIT) next to an extensive substance use interview. We performed a multivariate analysis of co-variance with the four PQ-16 scales and the YSR scale as outcomes and PTSD status as predictor. Additionally, we performed five linear regressions predicting each PQ-16 score and YSR score based on tobacco, alcohol, cannabis, ecstasy, amphetamine, and methamphetamine use.Results: Participants with co-occurring SUD and self-reported PTSD showed significantly higher APS prevalence rates (PQ-16 score, p = .00002), more disturbed thought content (p = .000004), more perceptual disturbances (p = .002), more negative symptoms (p = .004) and more thought problems (p = .001) compared to adolescents with SUD and a history of trauma and adolescents with only SUD. Past-year substance use was not predictive for APS prevalence (F(75) = 0.42; p = .86; R² = .04).Conclusion: Our data suggests that the occurrence of APS in adolescents with SUD is better explained by co-occurring self-reported PTSD than by substance use frequency or substance class. This finding might indicate that APS might be reduced through treating PTSD or focusing on TEs in SUD therapy.

Exploring the associations between social support and symptoms of posttraumatic stress disorder among Malaysian and Australian trauma survivors

Background: Social support is an important feature in understanding posttraumatic stress disorder (PTSD) and its treatment. Non-clinical research has identified distinct profiles of culturally appropriate social support. Despite this, little research has examined cultural influences on social support in the context of PTSD.Objective: This study examined cultural differences in the associations between social support and symptoms of PTSD.Method: The study employed a cross-sectional design. Australian (n = 91) and Malaysian (n = 91) trauma survivors completed an online survey assessing PTSD symptomatology and social support (explicit and implicit social support, perceived helpfulness of support provider, attitudes towards professional help-seeking). A quasi-experimental paradigm assessed the influence of mutual (i.e. the sharing of support between relationship partners) and non-mutual support (i.e. where one person constantly receives support, while the other person constantly provides support) on negative emotion and subjective distress.Results: First, explicit social support was negatively associated with PTSD symptoms for the Australian group but not the Malaysian group. Second, perceived helpfulness of support from family was negatively associated with PTSD symptoms for the Malaysian group but not the Australian group. Third, the Malaysian group reported significantly greater distress for non-mutual support and significantly fewer negative emotions and distress for mutual support than the Australian group. Fourth, the Malaysian group reported that they were significantly more open to acknowledging psychological problems and the possibility of seeking professional help for these problems than the Australian group.Conclusions: As the PTSD social support literature continues to evolve, it is essential that cultural influences are considered given the important theoretical and clinical implications.

Widening the scope: defining and treating moral injury in diverse populations

Moral injury is an emerging concept that captures the psychosocial consequences of involvement in and exposure to morally transgressive events. In the past decade, research on moral injury has grown exponentially. In this special collection we review papers on moral injury published in the European Journal of Psychotraumatology from its inception until December 2022, that have a primary focus on moral injury as evidenced by the words 'moral injury' in the title or abstract. We included 19 papers on quantitative (n = 9) and qualitative (n = 5) studies of different populations including (former) military personnel (n = 9), healthcare workers (n = 4) and refugees (n = 2). Most papers (n = 15) focused on the occurrence of potentially morally injurious experiences (PMIEs), moral injury and associated factors, while four papers primarily concerned treatment. Together, the papers offer a fascinating overview of aspects of moral injury in different populations. Research is clearly widening from military personnel to other populations such as healthcare workers and refugees. Focal points included the impact of PMIEs involving children, the association of PMIEs and personal childhood victimisation, the prevalence of betrayal trauma, and the relationship between moral injury and empathy. As for treatment, points of interest included new treatment initiatives as well as findings that PMIE exposure does not impede help-seeking behaviour and response to PTSD treatment. We further discuss the wide range of phenomena that fall under moral injury definitions, the limited diversity of the moral injury literature, and the clinical utility of the moral injury construct. From conceptualisation to clinical utility and treatment, the concept of moral injury matures. Whether or not moral injury becomes a formal diagnosis, the need to examine tailored interventions to alleviate moral injury is clear.

Sensory modulation and trauma-related symptoms during rocket attacks

BACKGROUND

War is a highly traumatogenic experience that may result in trauma-related symptoms during exposure. Although most individuals exhibit recovery after the trauma ends, symptomatology during exposure may serve as an initial indicator underlying symptomatology at the posttraumatic phase, hence the imperative to identify risk factors for trauma-related symptoms during the peritraumatic phase. While research has uncovered several factors associated with peritraumatic distress, such as age, gender, history of mental disorder, perceived threat, and perceived social support, the role of sensory modulation has not been explored.

METHOD

To address this gap, 488 Israeli citizens were assessed using an online survey for sensory modulation and trauma-related symptoms during rocket attacks.

RESULTS

Analyses revealed that while the association between high sensory responsiveness and elevated levels of specific trauma-related symptoms is somewhat weak (0.19<r<.0.22), it serves as a major risk factor for developing trauma-related symptoms during the peritraumatic phase in general. Specifically, the risk for elevated symptoms was doubled (OR = 2.11) for each increase in the high sensory-responsiveness score, after controlling for age, gender, history of mental disorder, perceived threat, and perceived social support.

LIMITATIONS

This study relied on convenience sampling and a cross-sectional design.

CONCLUSIONS

The present findings suggest that sensory modulation evaluation may serve as an important screening tool for identifying individuals who are vulnerable to trauma-related symptoms during the peritraumatic phase, and that implementing sensory modulation strategies as part of preventative interventions for PTSD might be effective.

Effects of prenatal exposure to the 1944-45 Dutch famine and glucocorticoid receptor polymorphisms on later life PTSD susceptibility

Background: Exposure to adversity in utero is thought to increase susceptibility to develop posttraumatic stress disorder (PTSD) following later life trauma, due to neurobiological programming effects during critical developmental periods. It remains unknown whether effects of prenatal adversity on PTSD susceptibility are modulated by genetic variations in neurobiological pathways implicated in PTSD susceptibility.Objective: We investigated whether genetic variation in the glucocorticoid receptor (GR) modulated effects of prenatal famine exposure on late adulthood PTSD symptom severity after trauma exposure in childhood and mid-to-late adulthood.Method: We included N = 439 term-born singleton adults (mean age: 72 years, 54.2% women) from the Dutch Famine Birth Cohort, born around the time of the Dutch Famine of 1944/1945, divided into exposure and control groups based on timing of the famine during gestation. Participants filled out self-report questionnaires on childhood (Childhood Trauma Questionnaire) and mid-to-late adulthood (Life Events Checklist for DSM-5) trauma, and current PTSD symptom severity (PTSD Checklist for DSM-5). GR haplotypes were determined from four functional GR single nucleotide polymorphisms (ER22/23EK, N363S, BclI and exon 9β) in previously collected DNA. Linear regression analyses were performed to investigate associations of GR haplotype and prenatal famine exposure in conjunction with later life trauma on PTSD symptom severity.Results: We observed a significant three-way interaction between the GR Bcll haplotype, famine exposure during early gestation, and adulthood trauma exposure on PTSD symptom severity in late adulthood. Only participants exposed to famine during early gestation without the GR Bcll haplotype showed a significantly stronger positive association between adulthood trauma and PTSD symptom severity than non-exposed participants, indicating increased PTSD susceptibility.Conclusions: Our results illustrate the importance of integrated approaches considering genetics and environmental contexts throughout various life periods, including the rarely investigated prenatal environment, to elucidate how PTSD susceptibility evolves throughout life.HIGHLIGHTS Adversity during pregnancy is thought to increase offspring's PTSD risk following later life trauma, but exact neurobiological mechanisms underlying this process remain unknown.We found that effects of prenatal famine exposure on PTSD symptom severity were influenced by genetic variation in the glucocorticoid receptor, which signals effects of the stress hormone cortisol.Integrated approaches considering genetics and environmental contexts throughout both early and later life are important to understand how PTSD risk evolves throughout life.

Warning signals? An explorative study of distant recollections of the moments before a disaster

Background: How do we remember what happened shortly before a traumatic experience? There has been little focus on the temporal context of trauma memories, but a few studies suggest that aspects of what happened in the moments prior to a traumatic experience may be selectively enhanced and prioritized in memory.Objective: The main aim of this study was to investigate the occurrence, nature, and content of voluntary memories about what happened shortly before a disaster. The participants were individuals who had survived a fire on the passenger ferry Scandinavian Star 26 years earlier.Methods: Data collection took the form of face-to-face interviews. The analysis was carried out in two steps. First, all the narratives from participants who were aged 7 years or older at the time of the fire (N = 86) were coded in terms of the presence of detailed descriptions of what happened before the fire. Next, the narratives that included detailed descriptions of the moments before (N = 28) were included in a thematic analysis, focusing on coding the mode and the content.Results: More than one-third of the participants reported detailed accounts of what happened in the hours, minutes, or seconds before the fire. These memories included detailed descriptions of sensory impressions, dialogues, actions, and thoughts. Two themes stood out in the thematic analysis: (1) unusual observations and danger cues; and (2) counterfactual thoughts.Conclusion: The finding that specific details from the moments before a traumatic event may be vividly recalled indicates that peripheral details of traumatic events can be prioritized in memory. Such details may be interpreted as warning signals. Future research should examine whether such memories might stimulate long-standing thoughts of the world as being dangerous, and hence carry the threat forward in time.

Neuroscientific account of Guilt- and Shame-Driven PTSD phenotypes

Background: Guilt and Shame, two core self-related emotions, often emerge following trauma and play an important role in the development and maintenance of post-traumatic stress disorder (PTSD). Importantly, Guilt and Shame exhibit specific focal and non-specific global impacts of trauma on self-perception, respectively.Objective and Methods: Integrating psychological theories with neuroscientific knowledge, we suggest a scheme of two diverging clinical phenotypes of PTSD, associated with distinct self-related processes and differential functionality of relevant neural networks.Proposal: The Guilt-driven phenotype is characterized by preoccupation with negative self-attributes of one's actions in the traumatic event. It involves altered functionality of both the salience network (SN) and the default-mode network (DMN), associated with heightened interoceptive signalling and ruminative introspection which may lead to hyperarousal and intrusive symptoms, respectively. On the contrary, the Shame-driven phenotype is characterized by global, identity-related negative self-attributions. It involves altered functionality of both the SN and the DMN, associated with blunted interoceptive signalling and diminished introspection which may result in withdrawal and anhedonia symptoms together with dissociative experiences, respectively.Conclusion: The proposed PTSD phenotypes may inform neuropsychological therapeutic interventions (e.g. self-focused psychotherapy and neuromodulation) aiming to restore the function of large-scale self-related neural processing.

Sleep and day-to-day PTSD symptom variability: an ecological momentary assessment and actigraphy monitored study in trauma-exposed young adults

BACKGROUND

Disrupted sleep and post-traumatic stress disorder (PTSD) are bi-directionally linked and have been found to mutually reinforce each other on a day-to-day basis. However, most of the previous research has focused on subjective measures of sleep only.

OBJECTIVE

Here, we investigated the temporal relationship between sleep and PTSD symptoms using both subjective (sleep diary) and objective measures of sleep (actigraphy).

METHODS

Forty-one non-treatment seeking, trauma exposed young adults (age M = 24.68, SD = 8.15) with a range of PTSD symptom severities (PTSS, 0-53 on PCL-5) were recruited. Participants completed two surveys per day over four weeks to measure day-time PTSD symptoms (i.e. PTSS and number of intrusions) and night-time sleep subjectively, while wearing an actigraphy watch to measure sleep objectively.

RESULTS

Linear mixed models revealed that subjectively reported sleep disruptions were associated with elevated next-day PTSS and increasing number of intrusive memories both within and between participants. Similar results were found for daytime PTSD symptoms on night-time sleep. However, these associations were not found using objective sleep data. Exploratory moderator analyses including sex (male vs. female) found that these associations differed in strength between sexes but were generally in the same direction.

DISCUSSION

These results were in line with our hypothesis with regards to the sleep diary (subjective sleep), but not actigraphy (objective sleep). Several factors which have implications on both PTSD and sleep, such as the COVID-19 pandemic and/ or sleep-state misperception, may be potential reasons behind those discrepancies. However, this study had limited power and needs to be replicated in larger samples. Nonetheless, these results add to the current literature about the bi-directional relationship between sleep and PTSD and have clinical implications for treatment strategies.

Refugee visa insecurity disrupts the brain's default mode network

BACKGROUND

Research has largely focused on the psychological consequences of refugee trauma exposure, but refugees living with visa insecurity face an uncertain future that also adversely affects psychological functioning and self-determination.

OBJECTIVE

This study aimed to examine how refugee visa insecurity affects the functional brain.

METHOD

We measured resting state brain activity via fMRI in 47 refugees with insecure visas (i.e. temporary visa status) and 52 refugees with secure visas (i.e. permanent visa status) residing in Australia, matched on key demographic, trauma exposure and psychopathology. Data analysis comprised independent components analysis to identify active networks and dynamic functional causal modelling tested visa security group differences in network connectivity.

RESULTS

We found that visa insecurity specifically affected sub-systems within the default mode network (DMN) - an intrinsic network subserving self-referential processes and mental simulations about the future. The insecure visa group showed less spectral power in the low frequency band in the anterior ventromedial DMN, and reduced activity in the posterior frontal DMN, compared to the secure visa group. Using functional dynamic causal modelling, we observed positive coupling between the anterior and posterior midline DMN hubs in the secure visa group, while the insecure visa group displayed negative coupling that correlated with self-reported fear of future deportation.

CONCLUSIONS

Living with visa-related uncertainty appears to undermine synchrony between anterior-posterior midline components of the DMN responsible for governing the construction of the self and making mental representations of the future. This could represent a neural signature of refugee visa insecurity, which is marked by a perception of living in limbo and a truncated sense of the future.

The associations between metabolic profiles and sexual and physical abuse in depressed adolescent psychiatric outpatients: an exploratory pilot study

Background: Sexual and physical abuse have been associated with long-term systemic alterations such as low-grade inflammation and changes in brain morphology that may be reflected in the metabolome. However, data on the metabolic consequences of sexual and physical abuse remain scarce.Objective: This pilot study sought to investigate changes in the metabolite profile related to sexual and physical abuse in depressed adolescent psychiatric outpatients.Method: The study included 76 patients aged 14-18 years, whose serum samples were analysed with a targeted metabolite profiling methodology. We estimated the associations between metabolite concentrations and the Trauma and Distress Scale (TADS) Sexual and Physical Abuse factor scores using three linear regression models (one unadjusted and two adjusted) per metabolite and trauma type pair. Additional variables in the two adjusted models were 1) the lifestyle indicators body mass index, tobacco use, and alcohol use, and 2) depression scores and the chronicity of depression.Results: TADS Sexual Abuse scores associated positively with homogentisic acid, as well as cystathionine, and negatively with choline in linear regression analysis, whereas TADS Physical Abuse scores associated negatively with AMP, choline, γ-glutamyl cysteine and succinate, and positively with D-glucuronic acid.Conclusions: This pilot study did not include a healthy control group for comparison and the cohort was relatively small. Nevertheless, we observed alterations in metabolites related to one-carbon metabolism, mitochondrial dysfunction, oxidative stress, and inflammation in depressed patients with a history of sexual or physical abuse.

Postpartum post-traumatic stress symptoms during the COVID-19 period: exposure and fear as mediating factors

Background: Post-traumatic stress symptoms (PTSS) following childbirth are common within a stressful environment and are mitigated by social support. During the COVID-19 pandemic, an increase in such symptoms has been reported. The current study aims to longitudinally model the influence of general and pandemic-specific risk and protective factors on the temporal unfolding of symptoms among postpartum women.Methods: Participants were 226 women following a liveborn, term birth during the first lockdown in Israel. Participants completed questionnaires 10 weeks (T1) and 6 months (T2) after delivery. PATH analyses included predictors of symptoms in T1: demographics, exposure to traumatic events, medical complications during delivery or pregnancy, exposure to COVID-19-related events and their subjective impact, fear of COVID-19, and social support. Predictors of symptoms in T2 were: T1 predictors, both as direct effects and mediated by T1 PTSS, as well as predictors measured again in T2.Results: Results showed the suggested model fit the data. The effect of COVID-19-related fear and subjective impact at T1 on symptoms at T2 were fully mediated by PTSS in T1, as were the effects of marriage and high social support at T1. COVID-19-related fear at T2 positively predicted symptoms at T2, while social support at T2 had the opposite effect. Medical complications during pregnancy negatively predicted symptoms in T2 only.Discussion: Persistent fear appears to be a risk factor and supports a consistent buffer in postpartum PTSS during the COVID-19 pandemic. Medical complications during pregnancy served as a protective factor, possibly due to habituation to medical settings.

Associations between trauma and substance use among healthcare workers and public safety personnel during the SARS-CoV-2 (COVID-19) pandemic: the mediating roles of dissociation and emotion dysregulation

BACKGROUND

Given the highly stressful environment surrounding the SARS-CoV-2 pandemic, healthcare workers (HCW) and public safety personnel (PSP) are at an elevated risk for adverse psychological outcomes, including posttraumatic stress disorder (PTSD) and alcohol/substance use problems. As such, the study aimed to identify associations between PTSD severity, related dissociation and emotion dysregulation symptoms, and alcohol/substance use problems among HCWs and PSP.

METHODS

A subset of data (N = 498; HCWs = 299; PSP = 199) was extracted from a larger study examining psychological variables among Canadian HCWs and PSP during the pandemic. Structural equation modelling assessed associations between PTSD symptoms and alcohol/substance use-related problems with dissociation and emotion dysregulation as mediators.

RESULTS

Among HCWs, dissociation fully mediated the relation between PTSD and alcohol-related problems (indirect effect β = .133, p = .03) and emotion dysregulation partially mediated the relation between PTSD and substance-related problems (indirect effect β = .151, p = .046). In PSP, emotion dysregulation fully mediated the relation between PTSD and alcohol-related problems (indirect effects β = .184, p = .005). For substance-related problems among PSP, neither emotion dysregulation nor dissociation (ps >.05) had any effects.

CONCLUSION

To our knowledge, this is the first study examining associations between PTSD severity and alcohol/substance use-related problems via mediating impacts of emotion dysregulation and dissociation among HCWs and PSP during the SARS-CoV-2 pandemic. These findings highlight dissociation and emotion dysregulation as important therapeutic targets for structured interventions aimed at reducing the burden of PTSD and/or SUD among Canadian HCWs or PSP suffering from the adverse mental health impacts of the SARS-CoV-2 pandemic.

Complementary and integrative interventions for PTSD

ABSTRACTTo treat the impact of trauma, most current evidence supports the use of trauma-focused psychotherapy as the first line approach. However, millions of individuals exposed to trauma worldwide seek Complementary and Integrative Health (CIH) therapies in hopes of achieving wellness above and beyond reducing symptoms. But what is the evidence for CIH interventions? What are potential pitfalls? Given the growing popularity of and strong interest in CIH, EJPT is featuring research on these approaches in this special issue. The papers range from common interventions such as mindfulness to the use of service dogs and scuba diving to alleviate trauma related symptoms. A featured editorial highlights the importance of defining when, where, and how placebo responses work. Nonspecific elements of treatment such as positive expectations, therapeutic rituals, healing symbols, and social interactions are identified as factors influencing treatment response and scientists looking to add to the CIH evidence base are encouraged to consider the impact and methodological challenges these elements present. CIH interventions more specifically recognize and harness some of these factors in addition to intervention-specific factors such as attention or emotion regulation along with focus on overall wellbeing. The body of work in this special issue supports the emerging evidence for meditative and relaxation-based interventions and illustrates a creative but nascent state of the field. Cross-intervention mechanisms that may play a role in achieving wellness, such as arousal reduction, emotion regulation, posttraumatic growth, and positive affect are highlighted. The trauma field would benefit from accumulation of evidence for promising CIH interventions, evaluation of potential mechanisms, and examination of health and wellbeing outcomes. With the paucity of high-quality trials, it would be premature to recommend CIH interventions as first-line treatments. However, the emerging literature on CIH continues to advance our understanding of what works and how these interventions exert their effects.

Validation of the Danish PTSD Checklist for DSM-5 in trauma-exposed chronic pain patients using the Clinician-Administered PTSD Scale for DSM-5

Background: Validation of post-traumatic stress disorder (PTSD) screening tools across various populations to ensure accurate PTSD estimates is important. Because of the high symptom overlap between PTSD and pain, it is particularly important to validate PTSD screening tools in trauma-exposed chronic pain patients.Objective: The present study is the first seeking to validate the PTSD Checklist for DSM-5 (PCL-5) in a sample of trauma-exposed, treatment-seeking chronic pain patients.Method: The validation and optimal scoring of the PCL-5 were investigated using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in chronic pain patients exposed to traffic or work-related traumas (n = 84). Construct validity was investigated using confirmatory factor analyses testing six competing DSM-5 models in a sample of mixed trauma-exposed chronic pain patients (n = 566), and a subsample of chronic pain patients exposed to traffic or work-related trauma only (n = 202). Furthermore, concurrent validity and discriminant validity were investigated using correlation analysis.Results: The results showed moderate (κ = .46) diagnostic consistency between the PCL-5 and the CAPS-5 using the DSM-5 symptom cluster criteria, and the overall accuracy of the scale (area under the curve = .79) was highly acceptable. Furthermore, the Danish PCL-5 showed excellent construct validity both in the full sample and in the subsample of traffic and work-related accidents, with superior fit of the seven-factor hybrid model. Excellent concurrent validity and discriminant validity were also established in the full sample.Conclusion: The PCL-5 appears to have satisfactory psychometric properties in trauma-exposed, treatment-seeking chronic pain patients.

Sleep impairments in refugees diagnosed with post-traumatic stress disorder: a polysomnographic and self-report study

Background: Post-traumatic stress disorder (PTSD) is the clinical manifestation of traumatic events and is associated with sleep disturbances. Sleep disturbances, if left untreated, may perpetuate or even worsen symptoms of PTSD. Previous studies of other PTSD populations show a higher incidence of sleep impairments and sleep disorders compared to healthy controls (HCs); however, this has never been investigated in trauma-affected refugees diagnosed with PTSD.Objectives: To examine subjective sleep quality, measure sleep architecture, and identify latent sleep disorders in refugees diagnosed with PTSD compared to HCs.Method: This comparative study included 20 trauma-affected refugees diagnosed with PTSD and 20 HC matched on age, sex, and body mass index. All participants completed self-report questionnaires assessing sleep quality, insomnia severity, and disturbing nocturnal behaviour, and all took part in a one-night polysomnography (PSG) assessment.Results: Patients reported significantly poorer subjective sleep quality, sleep latency, sleep duration, and sleep efficiency compared to HCs. Subjective reports on hours spent in bed were not significantly different between patients and HCs. Patients reported significantly higher nightmare frequency and severity compared to HCs. PSG measures showed that patients had significantly reduced sleep efficiency, more awakenings, and longer REM sleep latency, and spent more time awake, whereas there was no significant differences regarding total time in bed, total sleep time, or sleep latency. The prevalence of sleep disorders was equal between groups.Conclusions: The study identified significant impairments in several sleep domains, with a preponderance of disturbed regulation of sleep resulting in awakenings. These results indicate a need for more focus on hyperarousal and nightmares as key elements of disturbed sleep in PTSD. Furthermore, the study identified a discrepancy between subjective and objective measures concerning total sleep time, raising questions regarding the causes of 'sleep state misperception'.Trial registration: ClinicalTrials.gov identifier: NCT03535636..Trial registration: Sleep Impairments in Refugees Diagnosed with PTSD (PSG-PTSD). URL: https://clinicaltrials.gov/ct2/show/NCT03535636. ClinicalTrials.gov NCT03535636. Date of registration: 24/05/2018.

The Other made visible: creative methods, inner figures and agents of change when working through early childhood trauma in adulthood

Jung used creative methods such as picture-making and active imagination to work with complexes and in particular trauma and dissociation. A clinical example of a 60-year-old woman demonstrates the benefits of using creative methods to work with issues linked to early life, such as somatic intrusions of early childhood trauma. Significant inner figures were delineated, including the original figure associated with the infantile dissociative split. The figures illustrated Jung's complex theory by making visible the nonverbal inner states that were initially feared and experienced as Other. Within an analytic relationship that included a working through, an innate creative process unfolded that permitted inner figures to become agents of change within her psyche. This paper highlights the value of Jung's complex theory and the use of creative methods when working with dissociation, regression and unformulated infantile states, even when the analysand is in the later stages of adulthood.

Expanding the Traumatic Stress Framework to Incorporate a Socioecological Family Systems Perspective

Over the past few decades, there has been a growing interest among systemic researchers and clinicians to address issues related to psychological traumatic stress. Yet, research in this area has largely focused on intrapersonal and physiological processes in conceptualizing traumatic stress and its various outcomes. Despite the usefulness of intrapersonally focused models of traumatic stress, this approach has its limitations. Emerging evidence indicates that both proximal contexts, such as family, and distal socioecological contexts, such as political and environmental systems, can have a profound effect on traumatic stress risk, presentation, and recovery. In the present article, we review and synthesize emerging research on traumatic stress and integrate findings from intrapersonally and systemically focused models of traumatic stress. We propose and present evidence for what we term the dynamic socioecological framework of traumatic stress, a heuristic framework for conceptualizing the interactions between different forms of traumatic stress. This framework puts forward the dimensions of traumatic stress typology, severity, and timing, underscoring how traumatic stress risk, presentation, and recovery are highly dependent upon the systems in which people are embedded. We conclude with a discussion of the research and clinical implications of this conceptual framework.

Facilitating the emergence of hidden dissociative identity disorder: finding the lost maiden Medusa

This paper uses the myth of Medusa as a containing narrative to explore the aetiology, recognition and treatment of emergent dissociative identity disorder or DID, in apparently high-functioning people. Both the 'hiding' nature of DID, and disbelief in therapists are identified as impediments to recognition of the disorder, despite the high prevalence of DID. The paper describes the impact on psycho-neurobiological development of both disorganized attachment and group sexual abuse at a young age, both typically present for DID survivors, leading to multiple ego centres in the psyche. DID is perceived as a creative protective mechanism against knowing, that also seals the abuse survivor into a lifetime of fractured self-experience, and exile from relational depth with others. Two case studies illuminate a key feature of DID, the existence of lost but ever-present child selves/alters, and how these may present within the therapeutic relationship. The author supports the facilitation by the analyst of self-diagnosis and describes how careful attunement to inner turmoil and confusion, can act as a containing mirror within which to discern the individual needs of a multiplicity of selves/alters, leading to increased self-agency, internal co-consciousness and the ability to function more authentically with others.

The symbolic and non-symbolic aspect of image: clinical and cultural reflections

It is fundamental for analytical psychology to understand images symbolically. However, Jung was aware of the non-symbolic and direct appearance of image in synchronistic visions and dreams. Therefore, there are two aspects of the non-symbolic: literal and synchronistic. Firstly, the pathology of the non-symbolic was explored in psychosomatic syndromes, trauma, borderline syndromes and autism spectrum disorder (ASD). Then the historical and cultural considerations show that dreams were shared and understood directly and non-symbolically in Japanese medieval times. Historically, the symbolic aspect emerged through the loss of this directness and is characteristic for the modern, western, and adult consciousness. However, the increasing prevalence of ASD and ambiguity between reality and virtual reality show that the contemporary world is again dominated by directness and the non-symbolic, which can be called 'postmodern consciousness'.

Enhancing Caregiving in Traumatized Families: An Attachment-Centered Approach to Working with Parent Groups

This paper outlines a model of attachment-centered group interventions to enhance caregiving among parents suffering from early trauma and/or social hardship. Groups are understood as an essential source of experiences that may restore traumatized adults' relational security, and enhance their parenting capacities, in face of biographical and contextual factors that compromise caregiving. The model is especially suited for intervention within social service/child protection contexts and with families that struggle to establish trusting alliances with professionals and institutions. Proposed intervention strategies are oriented toward making the group function as an attachment figure that meets parents' attachment and exploration needs and enhances parental sensitivity. Group therapists facilitate two sets of group processes: on the one hand, a sense of togetherness, emotional containment, protection and comfort (related to attachment needs); on the other hand, the development of parental mentalization, the revision of parental representations of the child, and the consolidation of parenting competence (related to exploration needs). A theoretical rationale for working with parent groups from an attachment-centered perspective, the basic intervention principles and specific strategies of the model are presented and illustrated.

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.

Dreams and COVID-19

This work originates from reflections on the observation of recurring themes in dreams of patients in psychoanalytic treatment during the most restrictive lockdown period in Italy (March - May 2020). The authors focus on the peculiar dialogic state between consciousness and the unconscious that arose following a collective event such as that of the pandemic, which determined the activation of complex personal nuclei, compensatory effects of the unconscious psyche and new perspective functions. These latter aspects are interpreted with reference to the contributions of Erich Neumann, bringing a new psychological vision of the relationship between Man and Nature in relation to catastrophic events.

COVID-19, precarity and loneliness

In this paper I discuss Jungian psychological work of the trauma and loss experienced in reaction to COVID-19 with a man who represents a clinical composite. The issues of precarity, a concept used by the philosopher Judith Butler, are combined with the notions of lack and absence of French psychoanalyst André Green. The psychological and societal situation of precarity aroused the man's childhood issues that were long repressed. The loneliness, isolation and death from COVID-19 mirrored his personal and the collective responses to the disaster from this global pandemic. He felt on the edge of collapse as what he knew of his world crashed and he found himself unable to cope. The subsequent Jungian work taking place through the virtual computer screen was taxing and restorative simultaneously for both analyst and analysand.

Processing trauma in psychoanalysis in 'real' time and in dreams: the convergence of past, present and future during COVID-19

In the current collective unrest, we and our analysands are living in real time and need vantage points from which to make meaning, as subjective experience of time is collapsing. For many analysands, the past is being relived in the present, with no imaginable future. During the time of COVID‐19, dreams are providing a valuable mechanism in working with atemporal emotional trauma, previously uncontextualized. Dream metaphor can provide a transitional space to move around in within the analytic framework. This paper explores a variety of dreams from individual analysands demonstrating different ways of conceptualizing personal and collective experience, bridging between the past, present, and future. Parallels between feeling states related to the current condition and unprocessed implicit memories from the past will be examined, as a vehicle for processing past trauma. Dreams expressing current states of dread for an unimaginable future, as well compensatory dreams showing a hopeful vision of the future will be considered.

Displacement as trauma and trauma as displacement in the experience of refugees

This paper investigates the relations between displacement, home, trauma and the self in the experience of refugees, which has become an issue of unexpected and far-reaching proportions in recent times. It questions to what extent and under what conditions displacement in the world may be traumatic and how trauma may be considered the effect of an inner displacement. Refugees' lives are marked by forced migration that is related to a certain suffering due to the changes in their family, relational, social and cultural lives. The paper explores the extent to which these changes can represent a break so significant as to be traumatic. It outlines the way in which traumatic experiences can produce an inner displacement and reorganization of one's mental life that leads to a focus on traumatic complexes. Under the most severe traumatic conditions, this can be understood as a displacement of the central axis of Self, in which the ego complex yields its position to other complexes, with a deep change in the organization and functioning of self. The experience of refugees highlights the way in which we live in a matrix of conscious and unconscious links between inner and outer worlds that need deeper and simultaneous consideration to understand their implications and mutual resonances for the psyche. Clinical cases of refugees will illustrate some aspects of these interconnections.

Dissociative Collusion: Reconnecting Clients with Histories of Trauma in Couple Therapy

This paper introduces the concept of "dissociative collusion" as a helpful theoretical and clinical tool for understanding and working with clients with histories of trauma in couple therapy. The paper describes ways to diagnose and treat dissociative collusion based on the integration of an object relations approach, a relational approach, and a narrative approach. Dissociative collusion, a unique version of the well-documented "couple collusion," describes relational unconscious dynamics where split-off aspects of one or both partners are mutually dissociated in a complementary fashion that becomes a part of the shared unconscious and is reenacted in destructive ways. The dissociative collusion concept is especially relevant to couple therapists who work with clients with histories of trauma, who frequently use dissociation as a primary defense mechanism. We suggest that the challenge and goal for couple therapy with this population are to help them reconnect and better oscillate between dissociated self-other configurations. A case of couple therapy of a wife who had been a victim of childhood sexual abuse and her husband who displayed frequent use of dissociative defenses is presented.

'I do not know where it comes from, I am suspicious of some childhood trauma' association of trauma with psychosis according to the experience of those affected

BACKGROUND

Trauma-related symptoms are often experienced after a first psychotic episode.

OBJECTIVE

In this study, we conduct a qualitative analysis of referred traumatic experiences of outpatients diagnosed with psychotic disorders.

METHOD

Focus groups were formed and in-depth interviews conducted with 30 participants, focusing on their experience with the disorder and the health care received. Given the frequency with which trauma and psychosis have been associated in the scientific literature, the nature of this relation is addressed as a secondary objective, via a qualitative analysis.

RESULTS

Analysis revealed two main themes in the patients' discourse. On many occasions, traumatic experiences were related to the development of the disorder. Although most participants referred to traumatic experiences during childhood, episodes during adult life were also reported, which may have triggered the disorder. The second theme was that of the interlocking relationship between the psychotic experience and certain coercive practices undergone during the provision of health care for psychosis, and the traumatic effects thus generated.

CONCLUSIONS

The participants considered both themes to be highly important. Accordingly, these issues should be carefully assessed and managed in order to provide appropriate person-centred care.

Traumatic and stressful life events in hoarding: the role of loss and deprivation

BACKGROUND

Although past research shows hoarding to be associated with stressful life events involving loss and/or deprivation, the temporal relationship between the onset of symptoms and these events is not completely clear.

OBJECTIVES

In a cross-sectional online study, we examined the relationship between the number of events involving loss or deprivation before/simultaneously vs. after the onset of hoarding and various hoarding-related beliefs, such as emotional attachment to possessions, and symptom severity. Further, we examined whether perceived social support moderated the influence of these events on emotional attachment to objects.

METHODS

One hundred seventeen subjects with hoarding problems responded to a series of instruments to assess the history and timing of traumatic and stressful loss and/or deprivation in relation to the onset of hoarding, and self-report tools evaluating the severity of hoarding, beliefs/motivations, depression, anxiety, general distress, and perceived social support.

RESULTS

The number of events involving loss or deprivation occurring before hoarding was related to increased emotional attachment to possessions, whereas events happening after the onset of hoarding were related to increased concerns about memory as drivers of hoarding symptoms. Events happening before hoarding did not interact with perceived social support to influence emotional attachment to objects.

CONCLUSIONS

The timing of traumatic and stressful life events related to loss and deprivation is associated with different hoarding phenotypes, including beliefs/motivations for hoarding. If confirmed by longitudinal studies, these findings may be relevant for therapeutic and preventive measures.

Gender differences in a wide range of trauma symptoms after victimization and accidental traumas: a cross-sectional study in a clinical setting

BACKGROUND

There are large gender differences in PTSD prevalence. Gender differences in a wide range of trauma symptoms including disturbances in self-organization have not been extensively researched.

OBJECTIVE

To explore gender differences in a wide range of trauma symptoms by comparing victimization trauma (VT) with accidental trauma (AT).

METHOD

A cross-sectional study of 110 traumatized patients attending a mental health outpatient clinic in Oslo, Norway (38.2% men, Mage = 40.4, 40% ethnic Norwegians). The trauma was categorized as VT or AT based on the Life Events Checklist. The Structured Clinical Interview for DSM-IV-PTSD-module and Structured Interview for Disorders of Extreme Stress Not-Otherwise-Specified (DESNOS) assessed a wide range of trauma symptoms. First, we examined gender differences within the trauma categories, then MANCOVA for an adjusted two-by-two between-groups analysis.

RESULTS

Among VT patients, men reported more symptoms of alteration of negative self-perception (p = .02, ES = 0.50) and alteration in systems of meaning (p < .01, ES = 1.04). Within the AT group, women reported more symptoms of affect and impulses (p = .01, ES = 0.94). The VT-AT difference was significantly higher in men in intrusion (p < .01, η² = 0.04), affect and impulses (p < .01, η² = 0.12), negative self-perception (p < .01, η² = 0.11), difficulty in relations (p = .01, η² = 0.10) and alterations in systems of meaning (p = .01, η² = 0.14). Conclusion: Comparing the VT-AT differences between the genders, men with VT had relatively more symptoms of intrusion, self-organization, identity, ideology/meaning, cognition, and relations difficulties. Effect sizes were moderate to large. Men may be relatively more vulnerable to VT than AT, while women may be more equally affected by VT and AT. Acknowledging possible gender differences in a wider range of trauma symptoms depending on trauma category may have clinical benefits.

Is only one cognitive technique also effective? Results from a randomized controlled trial of two different versions of an internet-based cognitive behavioural intervention for post-traumatic stress disorder in Arabic-speaking countries

BACKGROUND

Internet-based cognitive-behavioural interventions seem to be effective for the treatment of posttraumatic stress disorder (PTSD) in Arabic-speaking countries in the MENA region. However, due to high prevalence rates of trauma-related mental disorders in this region, it is important to scale up existing Internet-based interventions in order to increase the number of clients.

OBJECTIVE

The aim of the study was to examine whether a brief Internet-based intervention with one cognitive technique (TF-short, 6 assignments) results in the same PTSD symptom change and lower dropouts compared to a longer intervention with two cognitive techniques (TF-reg, 10 assignments).

METHOD

A total of 224 Arab participants (67.4% female; M = 25.3 years old) with PTSD were randomly assigned to Internet-based CBT with either a TF-reg protocol (n = 110) or a TF-short protocol (n = 114). Symptoms of PTSD and secondary outcomes (anxiety, depression, somatic complaints, quality of life) were self-assessed online at baseline and post-treatment. Treatment-associated changes were estimated using multigroup latent difference score models.

RESULTS

The overall PTSD score assessed with the PDS decreased by about 15 points in both conditions. The between-group differences (TF-reg vs. TF-short) at post-assessment were non-significant, Δ = 0.29, p = .896, d = 0.02, 95% CI [-0.30, 0.34]. Like the primary outcome, all within-group changes for the secondary outcomes throughout the intervention were statistically significant and all between-group effects were non-significant. Overall, the dropout rates did not differ between the two conditions, χ2 (1/N = 175) = 0.83, p = .364.

CONCLUSIONS

The findings suggest that the shorter condition results in the same symptom change and dropout rate as the longer condition. This highlights the potential of shorter, more scalable Internet-based interventions in socially restricted and (post-)conflict societies.

CLINICALTRIALSGOV ID

NCT01508377.

Age-related similarities and differences in networks of acute trauma-related stress symptoms in younger and older preschool children

BACKGROUND

Prior research on trauma-exposed preschool children has found various levels of trauma-related stress symptoms depending on age, which might be explained by developmental factors.

OBJECTIVE

This study uses network analysis to extend prior research and compare symptom presentation in younger and older preschoolers in the acute phase (first 4 weeks) following a potentially traumatic event.

METHOD

Parent-reported trauma-related acute stress symptoms were assessed using the Pediatric Emotional Distress Scale - Early Screener via www.kidtrauma.com. First, the overall symptom severity and symptom levels were compared between younger (1-3 years) and older (4-6 years) preschoolers. Further, two Gaussian graphical models of stress symptoms in younger (n = 242; M_age = 2.3 years; SD_age = 0.6 years) and older preschoolers (n = 299; M_age = 4.8 years; SD_age = 0.7 years) were modelled and compared.

RESULTS

Overall symptom severity did not differ between the groups. Symptom levels for developmental regression and avoidance of talking about the event were higher in older preschoolers. The network structures of the younger and the older preschoolers were largely similar. Highly central symptoms in both networks were trauma-unrelated fear and anger. The connections between fear of reminders and clinginess and trauma-unrelated fear and clinginess were stronger in the older preschoolers' network. The connections between worry and sadness and withdrawal; fear of reminders and creation of games, stories, and pictures; and whininess and clinginess were all stronger in the younger preschoolers' network.

CONCLUSIONS

Trauma-related stress symptomatology of younger and older preschoolers may not differ greatly in the acute phase. Trauma-unrelated fear and anger seem to be central symptoms in both groups. However, examining symptom-level associations across age groups revealed differential connections that might arise from developmental differences. If replicated in longitudinal and within-subject studies, these findings could help tailor interventions for trauma-exposed preschoolers in the acute phase.

Investigating the frequency of intrusive memories after 24 hours using a visuospatial interference intervention: a follow-up and extension

BACKGROUND

There is a need for effective, low-cost, readily available measures for reducing trauma symptoms so that people exposed to potentially traumatic events can receive help more quickly. A previous study reported that performing an intervention including a visuospatial task shortly after a reminder of a series of unpleasant film clips seen 24 hours earlier reduced the number of intrusive memories over the following week.

OBJECTIVE

This study reports a follow-up and extension of the earlier promising finding. The prediction was that participants performing the visuospatial task immediately after the reminder would report fewer intrusions compared to three other groups who 1) performed no task, and novel conditions who 2) performed the task before the reminder, and 3) performed the task 90 minutes after the reminder.

METHOD

A trauma-analogue method was used, where students (N = 200) watched a series of short films with unpleasant material. Over the following week, they were asked to write down any intrusive memories they experienced in a diary. On the second day they returned to the lab and saw static reminders of the films. They were then randomly allocated to condition, recorded intrusive memories over the following days and returned to the lab for final testing on Day 8.

RESULTS

A total of 49 participants did not report any intrusions and were excluded from the analyses. Two more participants were excluded as outliers, leaving a final sample of n = 149. Despite using largely the same materials as the original study there were no significant differences in the number of intrusive memories between the four groups post intervention.

CONCLUSIONS

Possible explanations include the effect not being as robust as expected, a low number of intrusions across groups, baseline differences in attention, and minor but potentially important differences in procedure between this and the original study.

The association between COVID-19 related stressors and mental health in refugees living in Australia

BACKGROUND

Refugees may be particularly vulnerable to the adverse effects of the COVID-19 pandemic on mental health due to their traumatic pasts and the challenges of the postmigration environment.

OBJECTIVE

To evaluate the prevalence of COVID-19 related stressors and their relationship to key mental health and functioning outcomes in a resettled refugee sample.

METHOD

N = 656 refugees and asylum seekers living in Australia completed a survey in June 2020 to index their mental health (posttraumatic stress disorder (PTSD), depression, health anxiety and disability) and COVID-19 experiences. The relationship between COVID-19 stressors and mental health was examined using a series of hierarchical linear regression models while controlling for other key demographic factors.

RESULTS

Refugees' most prevalent stressors related to worries of being infected by COVID-19 or the risk COVID-19 posed to others, which predicted health anxiety and PTSD. Social-related difficulties predicted depression and disability symptoms. Accessing and trusting information from authorities were the least prevalent stressors and were not significantly associated with mental health outcomes; neither was accessing basic supplies and financial support. Fears relating to the future such as concerns about visa application processes predicted health anxiety and disability. Crucially, the strongest predictor of all mental health outcomes was COVID-19 serving as a reminder of difficult past events.

CONCLUSIONS

Refugees may be uniquely affected by COVID-19 because the pandemic serves as a reminder of their past conflict and persecution trauma. It is critical that mental health strategies accommodate the specific needs of refugees during the COVID-19 pandemic.

Effectiveness of animal-assisted interventions for children and adults with post-traumatic stress disorder symptoms: a systematic review and meta-analysis

Background: Animal-assisted interventions (AAI) are increasingly applied for people with post-traumatic stress disorder (PTSD) symptoms albeit its effectiveness is unclear.Objectives: To examine the effectiveness of AAI for treating PTSD symptoms.Method: We searched 11 major electronic databases for studies reporting quantitative data on effects of AAI for children and adults with PTSD symptoms. Of 22'211 records identified, we included 41 studies with 1111 participants in the systematic review comprising eight controlled studies with 469 participants in the meta-analysis. We conducted random-effects meta-analyses with all controlled studies based on standardized mean differences (SMD), and calculated standardized mean change (SMC) as effect sizes for studies with a pre-post one-group design. Two independent researchers assessed the quality of the included studies using the NIH Study Quality Assessment Tools. The primary outcome was PTSD or depression symptom severity measured via a standardized measurement at pre- and post-intervention assessments.Results: There was a small but not statistically significant superiority of AAI over standard PTSD psychotherapy (SMD = -0.26, 95% CI: -0.56 to 0.04) in reducing PTSD symptom severity while AAI was superior to waitlist (SMD = -0.82, 95% CI: -1.56 to 0.08). Getting a service dog was superior to waiting for a service dog (SMD = -0.58, 95% CI: -0.88 to -0.28). AAI led to comparable effects in reducing depression as standard PTSD psychotherapy (SMD = -0.03, CI: -0.88 to 0.83). Pre-post comparisons showed large variation for the reduction in PTSD symptom severity, with SMCs ranging from -0.38 to -1.64, and for depression symptom severity, ranging from 0.01 to -2.76. Getting a service dog lowered PTSD symptoms between -0.43 and -1.10 and depression with medium effect size of -0.74.Conclusions: The results indicate that AAI are efficacious in reducing PTSD symptomatology and depression. Future studies with robust study designs and large samples are needed for valid conclusions.