Assessment of dissociation in Bosnian treatment-seeking refugees in Denmark

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations

BACKGROUND

The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups.

METHODS

Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway.

RESULTS

The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction.

CONCLUSIONS

Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.

The Past, the Present, and the Future: A Qualitative Study Exploring How Refugees' Experience of Time Influences Their Mental Health and Well-Being

The experience of time has a decisive influence on refugees' well-being and suffering in all phases of their flight experiences. Basic safety is connected both developmentally and in present life with a feeling of continuity and predictability. Refugees often experience disruption of this basic sense of time in their home country due to war, persecution, and often severe traumatization, during flight, due to unpredictable and dangerous circumstances in the hands of smugglers, and after flight, due to unpredictable circumstances in asylum centers, e.g., extended waiting time and idleness. These context-dependent disruptions of normal experiences of time may lead to disturbances in mental life and extreme difficulties in organizing one's daily life. This article is based on narrative interviews with 78 asylum seekers and refugees in asylum centers in Norway, exploring their experiences before, during, and after flight. The distinction between abstract, chronological time, and concrete time connecting situational experiences (daily activities, such as daily rhythm of sleep and wakefulness) proved important for understanding how the experiences became mentally disturbing and how people tried to cope with this experience more or often less successfully. Prominent findings were loss of future directedness, a feeling of being imprisoned or trapped, disempowerment, passivity and development of a negative view of self, memory disturbances with difficulty of placing oneself in time and space, disruptions of relations, and a feeling of loss of developmental possibilities. Some had developed resilient strategies, such as imagining the flight as a holiday trip, to cope with the challenges, but most participants felt deeply disempowered and often disorientated. The analysis pointed clearly to a profound context dependent time-disrupting aspect of the refugee experience. An insecure and undefined present made participants unable to visualize their future and integrate the future in their experience of the present. This was connected with the inherent passivity and undefined waiting in the centers and camps, and with previous near encounters with annihilation and death. A response was often withdrawal into passivity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray

Post-traumatic stress disorder (PTSD), a diagnosis that may follow the experience of trauma, has multiple symptomatic phenotypes. Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid- and opioid-mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower-level midbrain and extended brainstem systems.

Is there a complex relation between social anxiety disorder, childhood traumatic experiences and dissociation?

BACKGROUND

A possible relationship has been suggested between social anxiety and dissociation. Traumatic experiences, especially childhood abuse, play an important role in the aetiology of dissociation.

AIM

This study assesses childhood trauma history, dissociative symptoms, and dissociative disorder comorbidity in patients with social anxiety disorder (SAD).

METHOD

The 94 psychotropic drug-naive patients participating in the study had to meet DSM-IV criteria for SAD. Participants were assessed using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), the Dissociation Questionnaire (DIS-Q), the Liebowitz Social Anxiety Scale (LSAS), and the Childhood Trauma Questionnaire (CTQ). Patients were divided into two groups using the DIS-Q, and the two groups were compared.

RESULTS

The evaluation found evidence of at least one dissociative disorder in 31.91% of participating patients. The most prevalent disorders were dissociative disorder not otherwise specified (DDNOS), dissociative amnesia, and depersonalization disorders. Average scores on LSAS and fear and avoidance sub-scale averages were significantly higher among the high DIS-Q group (p < .05). In a logistic regression taking average LSAS scores as the dependent variable, the five independent variables DIS-Q, CTQ-53 total score, emotional abuse, sexual abuse, and emotional neglect were associated with average LSAS scores among patients with SAD (p < .05).

CONCLUSIONS

It is concluded that, on detecting SAD symptoms during hospitalization, the clinician should not neglect underlying dissociative processes and traumatic experiences among these patients.

Treatment of traumatised refugees with basic body awareness therapy versus mixed physical activity as add-on treatment: Study protocol of a randomised controlled trial

Background

Treatment of traumatised refugees is one of the fields within psychiatry, which has received little scientific attention. Evidence based treatment and knowledge on the efficiency of the treatment for this complex patient group is therefore scarce. This leads to uncertainty as to which treatment should be offered and potentially lowers the quality of life for the patients.

Chronic pain is very common among traumatised refugees and it is believed to maintain the mental symptoms of trauma. Hence, treating chronic pain is believed to be of high clinical value for this patient group.

In clinical studies, physical activity has shown a positive effect on psychiatric illnesses such as depression and anxiety and for patients with chronic pain. However, scientific knowledge about physical activity as part of the treatment for traumatised refugees is very limited and no guidelines exist on this topic.

Methods/design

This study will include approximately 310 patients, randomised into three groups. All three groups receive psychiatric treatment as usual for the duration of 6–7 months, consisting of consultations with a medical doctor including pharmacological treatment and manual-based Cognitive Behavioural Therapy. The first group only receives treatment as usual while the second and the third groups receive either Basic-Body Awareness Therapy or mixed physical activity as add-on treatments. Each physical activity is provided for an individual 1-hour consultation per week, for the duration of 20 weeks. The study is being conducted at the Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup in the Capital Region of Denmark.

The primary endpoint of the study is symptoms of Post Traumatic Stress Disorder; the secondary endpoints are depression and anxiety as well as quality of life, functional capacity, coping with pain, body awareness and physical fitness.

Discussion

This study will examine the effect of physical activity for traumatised refugees. This has not yet been done in a randomised controlled setting on such a large scale before. Hereby the study will contribute to important knowledge that is expected to be used in future clinical guidelines and reference programs.

Trial registration

ClinicalTrials.gov NCT01955538. Date of registration: 18 September 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0974-9) contains supplementary material, which is available to authorized users.

Facing Violence - A Global Challenge

Violence has been shown to be a global challenge resulting in long-lasting social, medical, and mental health sequelae. In this article, we focus on massive social violence, such as war and civil war. Social suffering and mental health problems related to violence as a global public health problem can be tackled only with a holistic approach that addresses the specific region, culture and group and the limited resources available in most countries. Research that can give a reliable assessment of complex long-term outcomes is still largely missing, and can be seen as a major and complex challenge for future study.