Stress on local and international psychotherapists in the crisis region of Iraq

BACKGROUND

Local and international Psychotherapists working with war survivors are confronted with a whole variety of burdens. The close contact to their clients and the conversations about terror, flight and genocides, they are frequently subject to vicarious traumatization resulting from these events and reveal a risk of developing secondary traumatization.

METHODS

We interviewed 54 local psychotherapists and 28 psychotherapists originating from abroad who were treating survivors of ISIS terror in refugee camps organised by non-government organisations (NGOs).

RESULTS

The results show that local and non-local psychotherapists who work in a context of humanitarian crises reveal a risk of developing secondary traumatization. The results of this present study would also indicate that the secondary traumatization depends both on individual characteristics such as bonding styles and personal experiences and also on the ambient characteristics such as the degree of traumatization of the patients.

CONCLUSION

The study revealed that the local and non-local psychotherapists had a range of different pressure factors and helpful resources which indicated that better caring/support, supervision and organization are needed to enable psychotherapists to perform more effectively in war regions from the point of view of preventive healthcare.

Combining psychotherapy with craniosacral therapy for severe traumatized patients: A qualitative study from an outpatient clinic in Norway

BACKGROUND

Craniosacral therapy (CST) is an established complementary modality for several health complaints. A clinic for psychosomatics in Norway has included CST into a multimodal treatment approach for severely traumatized patients. The aim of this study was to investigate and describe the indications for the use of craniosacral therapy within trauma therapy. Specifically, to explore treatment philosophy, criteria for improvement, treatment aims, and the evaluation of the risk profile of the multimodal treatment approach.

METHODS

Semi-structured individual interviews (n = 8) and one focus group interview were conducted with the therapists at the Clinic for Psychosomatics, Hospital of Southern Norway, Kristiansand, Norway. The text data were transcribed verbatim, and the analysis of the material was conducted according to conventional and direct content analysis.

RESULTS

The therapists at the clinic applied a holistic treatment approach, based on their understanding of mind and body as one entity. To access emotions and traumata, they used a mixture of different treatment techniques. The therapists experienced patients with severe bodily symptoms as being less cognitively present and attributed this to the symptoms craving most mental resources. The craniosacral therapists' specific aims and task within the multimodal trauma therapy was to ease these physical complaints, so that cognitive and emotional resources could be utilized for therapy. The psychotherapists found that emotions and traumata were more accessible after CST. The general treatment goals were to increase symptom tolerance levels and to enable better self-care. Furthermore, the ability to transform negative behaviors and develop positive alternatives were considered to be signs of improvement.

CONCLUSION

The study participants considered that patients with complex traumas, including post-traumatic stress disorder, seemed to benefit from this multimodal treatment approach and appreciated its' holistic treatment philosophy, including craniosacral therapy. With regard to patient safety, the study participants recommended that craniosacral therapy for severely traumatized patients should only be provided in cooperation with psychotherapists, or other highly qualified health personnel working in specialized institutions.

HELP@APP: development and evaluation of a self-help app for traumatized Syrian refugees in Germany - a study protocol of a randomized controlled trial

BACKGROUND

Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps' efficacy, usability, acceptance, and economic health benefit/cost-effectiveness.

METHODS

We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18-65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated.

DISCUSSION

We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees.

TRIAL REGISTRATION

German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782 . Registered: 06th of July 2018.

[Adult ADHD and borderline personality disorder: A pilot study on differences in attachment and early traumatization]

Adult ADHD and borderline personality disorder: A pilot study on differences in attachment and early traumatization Objective: Attention-deficit/hyperactivity disorder (ADHD) in adulthood and borderline personality disorder (BPD) share commondiagnostic criteria.The present study examined how ADHD in adulthood can be distinguished from BPDregarding attachment style and traumatic experiences.

METHOD

The sample consists of N = 30 persons with 50% (n = 15) ADHD patients and 50% (n = 15) BPD patients. The patients were asked to fill out different questionnaires to investigate the criteria for specific symptoms.

RESULTS

The results show that most of the patients are insecurely attached. In addition, 80% of both the ADHD and BPD sample claimed traumatic experiences in their childhood or adolescence. Most frequently, patients reported traumatisation following emotional neglect and emotional abuse. No group-specific differences concerning traumatic experiences and the individual attachment style were determined.

CONCLUSION

The etiological factors attachment style and traumatic experiences are not suitable for differentiating ADHD in adulthood and BPD.

DNA damage in lymphocytes of patients suffering from complex traumatization

It has been shown that complex childhood traumatization (CCT) increases the risk for severe somatic and mental disorders. However, the somatic pathways linking maladaptive affect regulation and disease are not understood. Here we tested the hypothesis that traumatic stress is linked to the induction of DNA damage. We isolated peripheral lymphocytes (PBLCs) from blood of healthy donors and patients suffering from CCT. Cells were immobilised on slides and stained with anti-phosphohistone 2AX (γH2AX). The number of γH2AX foci, which are an accepted surrogate marker of DNA double-strand breaks (DSBs), was determined and set in relation to the patient characteristics. We show that CCT patients (HS) have higher levels of DSBs in PBLCs than healthy volunteers (CG) and psychiatric patients without CCT (LS) (HS: 0.88±0.46 foci/cell; LS: 0.31±0.23 foci/cell; CG: 0.15±0.10 foci/cell). The difference between HS and control group was highly significant (p<0.001). Insecure-dismissing attachment as a psychological marker was related to an increase in the γH2AX foci in all groups, but especially in the CCT patients. There was no significant correlation in the γH2AX level to potential external genotoxic influences such as smoking and alcohol consumption. In PBLCs, spontaneous occurring γH2AX foci partially colocalized with 53BP1 and pATM, supporting the notion they represent DSBs. Overall, our data indicate that complex traumatization is a source of genotoxic stress that can cause systemic DNA damage, pointing to the importance of emotional early life experiences for the genetically determined health status in later life periods. The finding of CCT to be interrelated to genomic instability opens new opportunities for a deeper understanding of the link between emotional stress, DNA damage and somatic disorders.

Case Study Quasi-Qualitative Analysis of Peer Group Supervision of a Child Trauma Recovery Program in Occupied Palestine

This case study explores the impact of peer group supervision (PGS) for counselors delivering Teaching Recovery Techniques (TRT), a group psycho-social program for traumatized adolescents. Interviews were conducted with seven school counselors, from villages near East Jerusalem in occupied Palestine; a skilled supervisor; and an international trainer. A quasi-qualitative analysis was conducted to quantify responses and themes along with a measure of inter-rater reliability. Participants reported that even in a context of military violence, PGS provided a reflective process inclusive of formative, normative and restorative functions. Locally available PGS was viewed as essential within a geographically fragmented context. Counselors' reported PGS led to a trusting environment in contrast to military practices and gender norms. War stressors and lack of Training of Trainers led to low counselor confidence in training others in TRT. PGS and Trainer of Trainers were recommended as core aspects of program delivery and to support training of colleagues.

Emotional dysregulation and trauma predicting psychopathy dimensions in female and male juvenile offenders

BACKGROUND

Psychopathy is a specific syndrome that predicts future violent and aggressive behavior in adults. Studies in youth and adults have demonstrated a strong association between early traumatic incidents and later dissocial behavior. Moreover, the impact of personality pathology and emotional dysregulation on aggressive and violent behavior is well established. However, few studies have addressed the relationship between early traumatization and psychopathic traits in adolescents.

METHOD

The present study examined associations between both general dimensions of personality pathology and early traumatic experiences and the dimensions of psychopathy in 170 male and 171 female adolescent detainees.

RESULTS

Analyses revealed associations between physical abuse, emotional dysregulation and psychopathic traits in delinquent boys but not in delinquent girls.

CONCLUSION

Hypothesized relationships between trauma, personality pathology could only be confirmed in the lifestyle and antisocial, but not in the core affective and interpersonal facets of psychopathy.

An integrative model linking traumatization, cortisol dysregulation and posttraumatic stress disorder: Insight from recent hair cortisol findings

Abundant evidence suggests links between trauma exposure, altered secretion of the glucocorticoid cortisol and the development/maintenance of posttraumatic stress disorder (PTSD), albeit with some inconsistency in findings. Further insight into the complex relations underlying this process may be derived from an increasing number of studies using hair cortisol analysis, a novel assessment strategy assumed to retrospectively capture long-term integrated cortisol secretion. Here, we evaluate the utility of hair cortisol analysis as a method in trauma/PTSD research and review current findings in this context. We compare hair cortisol data on the complex links between trauma, cortisol dysregulation and PTSD against the main findings obtained using traditional cortisol assessment methods. Finally, we integrate these data into a model which proposes that traumatization leads to dose and time-dependent changes in long-term cortisol output (initial post-traumatic increase, subsequent chronic attenuation) and that such dysregulation may partly mediate the link between traumatic load and the risk of PTSD development upon additional trauma exposure ("building block effect").

[Trauma and psychological distress in dermatological patients]

BACKGROUND

Although seldom diagnosed, post-traumatic stress disorder (PTSD) has a high prevalence in primary and tertiary care. In a consecutive cross-sectional study, the prevalence of traumatic experiences and the severity of post-traumatic symptoms as well as specific characteristics of traumatized patients in the context of the dermatological treatment were examined.

PATIENTS AND METHODS

Standardized questionnaires for assessing general psychopathology (Brief Symptom Inventory, BSI), coping with dermatological diseases (Adjustment to Chronic Skin Diseases Questionnaire, MHF) and diagnosis of trauma (Essen Trauma-Inventory, ETI) were used in 221 patients with different skin diseases.

RESULTS

In total, 85.1 % of the patients reported at least one potentially traumatic event in their lives, whereby psychometrically in 8.6 % of the cases the diagnostic criteria for a PTSD were met. Patients with suspected PTSD were more impacted by psychopathology, had more problems in coping with their skin diseases and attributed mental stress as having a greater influence on their skin disease than nontraumatized patients or traumatized patients without suspected PTSD. In addition, cumulative traumatization also leads to increased trauma symptomatology and greater difficulties in coping with skin diseases.

CONCLUSION

The results emphasize the impact of a comorbid PTSD on a patient's ability to cope with skin diseases and underline the need for the inclusion of the differential diagnosis PTSD in dermatological treatment settings.

Hair cortisol concentrations and cortisol stress reactivity predict PTSD symptom increase after trauma exposure during military deployment

BACKGROUND

Previous evidence on endocrine risk markers for posttraumatic stress disorder (PTSD) has been inconclusive. Here, we report results of the first prospective study to investigate whether long-term hair cortisol levels and experimentally-induced cortisol stress reactivity are predictive of the development of PTSD symptomatology in response to trauma during military deployment.

METHODS

Male soldiers were examined before deployment to Afghanistan and at a 12-month post-deployment follow-up using dimensional measures for psychopathological symptoms. The predictive value of baseline (i) hair cortisol concentrations (HCC, N=90) and (ii) salivary cortisol stress reactivity (measured by the Trier Social Stress Test, N=80) for the development of PTSD symptomatology after being exposed to new-onset traumatic events was analyzed.

RESULTS

Baseline cortisol activity significantly predicted PTSD symptom change from baseline to follow-up upon trauma exposure. Specifically, our results consistently revealed that lower HCC and lower cortisol stress reactivity were predictive of a greater increase in PTSD symptomatology in soldiers who had experienced new-onset traumatic events (explaining 5% and 10.3% of variance, respectively). Longitudinal analyses revealed an increase in HCC from baseline to follow-up and a trend for a negative relationship between HCC changes and the number of new-onset traumatic events. Additional pre-deployment analyses revealed that trauma history was reflected in lower HCC (at trend level) and that HCC were negatively related to stressful load.

CONCLUSIONS

Our data indicate that attenuated cortisol secretion is a risk marker for subsequent development of PTSD symptomatology upon trauma exposure. Future studies are needed to confirm our findings in other samples.

Psychological traumatization and adverse life events in patients with organic and functional vestibular symptoms

OBJECTIVE

. A relationship has frequently been found between a history of traumatization and the existence of somatoform symptoms. The objective of this study was to examine whether this relationship is also observed for functional, i.e. medically not sufficiently explained, vestibular symptoms (FVS). We tested whether patients with FVS and organically explained vestibular symptoms (OVS) differ with regard to frequencies of previous traumatic experiences and posttraumatic stress symptoms. We also explored whether the impact of previous trauma was associated with characteristics of vestibular symptoms and handicap.

METHODS

. Patients with a diagnosis of OVS (N=185) or FVS (N=158) completed questionnaires about potentially traumatizing experiences (e.g., Childhood Trauma Questionnaire, Impact of Events Scale) and vertigo-related symptoms and handicap (Vertigo Symptom Scale, Vertigo Handicap Questionnaire).

RESULTS

. We found no differences between the two patient groups with regard to number or impact of traumatic life events. However, regression analyses across groups revealed that, regardless of their diagnosis, prior traumatic experiences and the presence of posttraumatic stress symptoms including avoidance and intrusion predicted to some extent higher overall balance symptoms and autonomic symptoms of vertigo-related anxiety.

CONCLUSION

. Exposure to trauma and symptoms of posttraumatic stress can contribute to symptom severity and handicap experienced by patients with vestibular symptoms irrespective of their original cause, most likely serving as predisposing, modulating or perpetuating factors.

Poly-traumatization and harmful behaviors in a sample of emergency department Psychiatric Intake Response Center youth

The purpose of this study is to examine risk factors for poly-traumatization, and the impact of poly-traumatization on harmful behaviors (suicidal, self-harm, and violent), among a group of pediatric patients presenting at an emergency department's psychiatric intake response center. We employed a retrospective medical chart review in a children's hospital for a 2-year span (N=260). The study employed 2 statistical analyses. The first analysis used multinomial logistic regression to model the odds of harmful behaviors comparing increasing numbers of co-occurring traumatization types. The second analysis employed latent class modeling techniques in three ways to (a) define different poly-traumatization populations, (b) examine the relationship between predictors and class assignment, and (c) examine the relationship between class assignment and harmful behavioral outcomes. About 62% of the sample presented with at least 1 traumatization type and about 50% one harmful behavior type. Compared to those with 1, 2, or 3 traumatization types, patients with 4 or more traumatization types have higher odds of harmful behaviors. The latent class analysis revealed 2 populations: High serious victimization and minimal traumatization. History of family mental health issues was the only significant predictor of class membership. Class membership was associated with all of the harmful behavioral outcome categories. These findings support consideration of poly-traumatization as a risk factor for the high occurrence of harmful behaviors in this sample of pediatric psychiatric patients and that history of family mental health issues may contribute to the high co-occurrence of poly-traumatization.

Investigating the psychological impact of bank robbery: a cohort study

Despite numerous annual bank robberies worldwide, research in the psychological sequelae of bank robberies is sparse and characterized by several limitations. To overcome these limitations we investigated the psychological impact of bank robbery in a cohort study by comparing general levels of traumatization and somatization in employees never exposed to robbery and employees exposed to robbery at different degrees and time-points, while controlling for selected risk factors of posttraumatic distress. Multivariate regression analyses showed that only the acute directly exposed robbery group which had a significantly higher score on general traumatization and somatization compared to the control group whilst controlling for other factors. In conclusion, bank robbery exposure appears to be especially associated with psychological distress in the acute phase and in victims present during the robbery. After the acute phase, other factors appear more important in predicting general traumatization and somatization in bank employees compared to exposure to robbery.