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Gjerstad SF, Nordin L, Poulsen S, Spadaro EFA, Palic S. How is trauma-focused therapy experienced by adults with PTSD? A systematic review of qualitative studies. BMC Psychol 2024; 12:135. [PMID: 38459602 PMCID: PMC10924413 DOI: 10.1186/s40359-024-01588-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/12/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Trauma-focused therapies (TFTs) are first-line treatments for posttraumatic stress disorder (PTSD). However, TFTs are under-utilised, partly due to clinicians' and patients' fear that TFT is too challenging or harmful. We review the qualitative studies on how adults with PTSD experience TFTs to enhance the understanding of user perspectives, therapeutic processes, and outcomes. METHODS PubMed, PsychINFO and PTSDPubs were searched between October 1st and November 30th, 2021. Study quality assessments were undertaken, and studies were analysed using a descriptive-interpretative approach. Nine studies were included. RESULTS The analysis resulted in the identification of four key domains, representing a temporal sequence of TFT stages: Overcoming ambivalence towards TFT, Experience of treatment elements, Motivation for dropout/retention, and Perceived changes post-treatment. CONCLUSION Although many participants reported high levels of distress and considered dropping out, only a minority did eventually drop out and most patients expressed that the hardships in therapy were necessary for PTSD improvement. Establishing a safe therapeutic environment and working with the ambivalence towards treatment was essential for retention. This review serves a dual purpose, to shed light on diverse TFT experiences found to be important for treatment satisfaction, and to elucidate common treatment patterns. The results can be used in preparing patients for therapy and in training TFT therapists. Studies had moderate to high quality, and more studies of experiences of TFT non-responders and dropouts in a non-veteran population are needed to further our understanding of the utility and limitations of TFTs.
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Affiliation(s)
- Solveig Flem Gjerstad
- Department of Psychology, University of Copenhagen, 2A Oester Farimagsgade, 1353, Copenhagen, Denmark
- Clinical Department of Eating Disorders, Mental Health Centre Ballerup, Mental Health Services in the Capitol Region of Denmark, Copenhagen, Denmark
| | - Linda Nordin
- DIGNITY- Danish Institute Against Torture, Copenhagen, Denmark
- Department of Psychology, Lund University, Lund, Sweden
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, 2A Oester Farimagsgade, 1353, Copenhagen, Denmark.
| | | | - Sabina Palic
- DIGNITY- Danish Institute Against Torture, Copenhagen, Denmark
- Department for Treatment of Borderline Personality Disorder and Self-Harm, Psychiatric Centre Glostrup, Mental Health Services in the Capitol Region of Denmark, Copenhagen, Denmark
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Thøgersen MH, Bager L, Bangsgaard SG, Palic S, Auning-Hansen M, Møller SB, Larsen KB, Tækker L, Jensen BS, Bothe S, Nordin L. The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees. Int J Environ Res Public Health 2023; 20:6611. [PMID: 37623194 PMCID: PMC10454926 DOI: 10.3390/ijerph20166611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/20/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.
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Affiliation(s)
- Marie Høgh Thøgersen
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
| | - Line Bager
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
- National Center for Register-Based Research, Aarhus University, 8210 Aarhus, Denmark
| | - Sofie Grimshave Bangsgaard
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
| | - Sabina Palic
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
| | | | - Stine Bjerrum Møller
- The Clinics for Trauma and Torture Survivors (ATT), 7100 Vejle, Denmark;
- Department of Psychology, University of Southern Denmark, 5230 Odense, Denmark
| | | | - Louise Tækker
- Privat Treatment Center for Traumatized Refugees and Their Families, (OASIS), 1164 Copenhagen, Denmark;
| | | | - Søren Bothe
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
| | - Linda Nordin
- The Danish Institute Against Torture (DIGNITY), 2100 Copenhagen, Denmark; (L.B.); (S.G.B.); (S.P.); (S.B.); (L.N.)
- Department of Psychology, Lund University, 22100 Lund, Sweden
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Bernardsdóttir B, Sandahl H, Carlsson J, Mortensen EL, Palic S. Psychotherapy readiness domains as predictors of psychotherapy outcome in trauma-affected refugees. J Affect Disord 2023; 325:248-255. [PMID: 36586606 DOI: 10.1016/j.jad.2022.12.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Little is known about predictors of psychotherapy outcome in trauma-affected refugees. Knowledge on outcome predictors can help clinicians identify patients prior to treatment who are not likely to benefit from standardized psychotherapy and take additional measures to adjust treatment to the individual patient. Given the dynamic nature of psychotherapy readiness domains, they represent potential targets to be worked with in therapy in order to improve outcomes. METHODS Psychotherapy readiness domains (locus of control, cognitive functioning, motivation for therapy, and personality functioning) were examined as potential predictors of psychotherapy outcome in trauma-affected refugees. Secondary analyses were conducted on data from a pragmatic randomized controlled trial. Study participants (N = 190) were refugees with PTSD who received flexible manual-based Cognitive Behavioral Therapy (CBT) at a psychiatric outpatient clinic in Denmark. Psychotherapy readiness domains were assessed via semi-structured interviews at the beginning of psychotherapy. Outcome variables were pre-post change in PTSD symptomology and global level of functioning. RESULTS Multiple regression analyses revealed that higher motivation for psychotherapy predicted improvement in PTSD symptomology and global level of functioning. Moreover, higher cognitive functioning predicted improvement in global level of functioning. LIMITATIONS The predictor rating scales need further psychometric evaluations in cross-cultural contexts. CONCLUSIONS These findings highlight the importance of considering motivation in psychotherapy offered to trauma-affected refugees. Further research is needed to identify potential barriers to motivation in this diverse patient population and to determine whether motivational interventions can lead to improved treatment outcomes.
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Affiliation(s)
- Berglind Bernardsdóttir
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Mental Health Services in the Capital Region of Denmark, Ballerup, Denmark.
| | - Hinuga Sandahl
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Mental Health Services in the Capital Region of Denmark, Ballerup, Denmark
| | - Jessica Carlsson
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Mental Health Services in the Capital Region of Denmark, Ballerup, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Sabina Palic
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup, Mental Health Services in the Capital Region of Denmark, Ballerup, Denmark
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Bager L, Laursen TM, Palic S, Nordin L, Høgh Thøgersen M. Adverse childhood experiences among children of parents who are refugees affected by trauma in Denmark: a register-based cohort study. The Lancet Public Health 2022; 7:e825-e833. [DOI: 10.1016/s2468-2667(22)00194-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 12/17/2022] Open
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Sonne C, Mortensen EL, Silove D, Palic S, Carlsson J. Predictors of treatment outcomes for trauma-affected refugees - results from two randomised trials. J Affect Disord 2021; 282:194-202. [PMID: 33418367 DOI: 10.1016/j.jad.2020.12.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/15/2020] [Accepted: 12/22/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Treatment effects in trials with trauma-affected refugees vary considerably between studies, but the variability in outcome between individual patients is often overlooked. Consequently, we know little about why some patients benefit more from treatment than others. The aim of the study was therefore to identify predictors of treatment outcome for refugees with Posttraumatic Stress Disorder (PTSD). METHODS Data was derived from two randomised trials including 321 refugees, who had all participated in a 6-7 months bio-psycho-social treatment programme. Outcome measures were the Harvard Trauma Questionnaire (PTSD, self-rating), Hopkins Symptom Checklist-25 (depression and anxiety, self-rating) and Hamilton Depression and Anxiety rating scales (observer-ratings). Using hierarchical regressions models, associations were analysed between pre- to post treatment score changes (dependent variable) and a range of variables including sociodemographics, pre-migration trauma, post-migratory stressors, baseline symptom scores and level of functioning. RESULTS A high baseline score (=more symptoms) and a high level of functioning were found to be associated with improvement on all ratings. Additionally, the following variables were associated with symptom improvement on at least one outcome measure: short time in host country, full time occupation, young age and status as family reunified (in contrast to refugee status). Being Muslim was inversely correlated with improvement. LIMITATIONS Translated self-ratings were used, which could impact reliability. CONCLUSION These results call for screening and early interventions for arriving refugees. For clinical populations, level of functioning should be included in assessments of refugees, to possibly begin stratifying samples to different interventions based on their likelihood of responding.
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Affiliation(s)
- Charlotte Sonne
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Maglevaenget 21, 2750 Ballerup, Denmark.
| | - Erik Lykke Mortensen
- Institute of Public Health and Center for Healthy Aging, University of Copenhagen, Denmark
| | - Derrick Silove
- School of Psychiatry, University of New South Wales, Australia
| | - Sabina Palic
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Maglevaenget 21, 2750 Ballerup, Denmark
| | - Jessica Carlsson
- University of Copenhagen/Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Denmark
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Rathke H, Poulsen S, Carlsson J, Palic S. PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression. Psychiatry Res 2020; 287:112898. [PMID: 32179211 DOI: 10.1016/j.psychres.2020.112898] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 01/17/2023]
Abstract
This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.
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Affiliation(s)
- Hannah Rathke
- Competence Center for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Maglevænget 21, Ballerup 2750, Denmark.
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, Copenhagen K 1353, Denmark
| | - Jessica Carlsson
- Competence Center for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Maglevænget 21, Ballerup 2750, Denmark
| | - Sabina Palic
- Competence Center for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region, Maglevænget 21, Ballerup 2750, Denmark
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Brochmann HD, Calundan JHN, Carlsson J, Poulsen S, Sonne C, Palic S. Utility of group treatment for trauma‐affected refugees in specialised outpatient clinics in Denmark: A mixed methods study of practitioners’ experiences. Couns Psychother Res 2019. [DOI: 10.1002/capr.12208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Helle Dølvik Brochmann
- Sjøvegan Outpatient Psychiatric Clinic for Children and AdolescentsDivision of Psychiatric care and substance abuse treatmentUniversity Hospital of North Norway Sjøvegan Norway
| | | | - Jessica Carlsson
- Competence Centre for Transcultural PsychiatryMental Health Centre Ballerup Ballerup Denmark
| | - Stig Poulsen
- Department of PsychologyUniversity of Copenhagen Copenhagen Denmark
| | - Charlotte Sonne
- Competence Centre for Transcultural PsychiatryMental Health Centre Ballerup Ballerup Denmark
| | - Sabina Palic
- Competence Centre for Transcultural PsychiatryMental Health Centre Ballerup Ballerup Denmark
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Fried EI, Eidhof MB, Palic S, Costantini G, Huisman-van Dijk HM, Bockting CLH, Engelhard I, Armour C, Nielsen ABS, Karstoft KI. Replicability and Generalizability of Posttraumatic Stress Disorder (PTSD) Networks: A Cross-Cultural Multisite Study of PTSD Symptoms in Four Trauma Patient Samples. Clin Psychol Sci 2018; 6:335-351. [PMID: 29881651 PMCID: PMC5974702 DOI: 10.1177/2167702617745092] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The growing literature conceptualizing mental disorders like posttraumatic stress disorder (PTSD) as networks of interacting symptoms faces three key challenges. Prior studies predominantly used (a) small samples with low power for precise estimation, (b) nonclinical samples, and (c) single samples. This renders network structures in clinical data, and the extent to which networks replicate across data sets, unknown. To overcome these limitations, the present cross-cultural multisite study estimated regularized partial correlation networks of 16 PTSD symptoms across four data sets of traumatized patients receiving treatment for PTSD (total N = 2,782). Despite differences in culture, trauma type, and severity of the samples, considerable similarities emerged, with moderate to high correlations between symptom profiles (0.43-0.82), network structures (0.62-0.74), and centrality estimates (0.63-0.75). We discuss the importance of future replicability efforts to improve clinical psychological science and provide code, model output, and correlation matrices to make the results of this article fully reproducible.
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Affiliation(s)
- Eiko I. Fried
- Department of Psychology, University of
Amsterdam, Amsterdam, The Netherlands
| | | | - Sabina Palic
- Competence Center for Transcultural
Psychiatry, Mental Health Center Ballerup, Copenhagen, Denmark
| | | | | | - Claudi L. H. Bockting
- Arq Psychotrauma Expert Group
Diemen/Oegstgeest, The Netherlands
- Department of Clinical Psychology,
Utrecht University, The Netherlands
| | - Iris Engelhard
- Altrecht Academic Anxiety Centre,
Utrecht, The Netherlands
- Department of Clinical Psychology,
Utrecht University, The Netherlands
| | - Cherie Armour
- Psychology Research Institute, Ulster
University, Coleraine Campus, Northern Ireland
| | - Anni B. S. Nielsen
- Research and Knowledge Center, The
Danish Veteran Center, Ringsted, Denmark
- The Research Unit and Section of General
Practice, Institute of Public Health, University of Copenhagen, Denmark
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Palic S, Zerach G, Shevlin M, Zeligman Z, Elklit A, Solomon Z. Evidence of complex posttraumatic stress disorder (CPTSD) across populations with prolonged trauma of varying interpersonal intensity and ages of exposure. Psychiatry Res 2016; 246:692-699. [PMID: 27839826 DOI: 10.1016/j.psychres.2016.10.062] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/15/2022]
Abstract
The ICD-11 proposes different types of prolonged trauma as risk factors for complex PTSD (CPTSD). However, CPTSD's construct validity has only been examined in childhood abuse, and single trauma exposure samples. Thus, the extent to which CPTSD applies to other repeatedly traumatized populations is unknown. This study examined ICD-11's PTSD and CPTSD across populations with prolonged trauma of varying interpersonal intensity and ages of exposure, including: 1) childhood sexual abuse, 2) adulthood trauma of severe interpersonal intensity (refugees and ex-prisoners of war), and 3) adulthood trauma of mild interpersonal intensity (military veterans, and mental health workers). In support of the proposal, latent class analysis (N = 820) identified, a 4-class solution representing "PTSD", "CPTSD", and "non-pathological" classes, but also an "Anxiety symptoms" class, and an alternative 5-class solution, with a "Dissociative PTSD-subtype" class. ICD-11's CPTSD was not exclusively associated with childhood abuse, but also with exposure to adulthood trauma of severe interpersonal intensity. Furthermore, all types of prolonged trauma were equally associated with the "Anxiety symptoms" class. Finally, of all the classes, the "CPTSD" class was associated with the highest frequency of work-related functional impairment, indicating an association between the severity of prolonged trauma exposure and the level of posttraumatic residues.
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Affiliation(s)
- Sabina Palic
- National Centre of Psychotraumatology, University of Southern Denmark, Odense, Denmark; Competence Center for Transcultural Psychiatry, Psychiatric Center Ballerup, The Mental Health Services of the Capital Region of Denmark, Copenhagen, Denmark
| | - Gadi Zerach
- Department of Behavioral Sciences, Ariel University, Ariel, Israel
| | - Mark Shevlin
- University of Ulster, Derry, Northern Ireland, UK
| | | | - Ask Elklit
- National Centre of Psychotraumatology, University of Southern Denmark, Odense, Denmark
| | - Zahava Solomon
- Center of Excellence for Mass Trauma Research, Tel Aviv University, Israel
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Palic S, Kappel ML, Makransky G. Rasch Validation and Cross-Validation of the Health of Nation Outcome Scales for Monitoring of Psychiatric Disability in Traumatized Refugees in Western Psychiatric Care. Assessment 2016. [DOI: 10.1177/1073191115594690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are no validated measures of psychiatric disability for traumatized refugees in Western psychiatric care. This is a serious shortcoming as it precludes monitoring of global treatment outcomes in this group, as well as appropriate matching of treatment needs to the disability levels. Using Rasch analysis, we evaluated the psychometrics of the Health of Nation Outcome Scales (HoNOS) in pretreatment data of consecutive refugee patients ( N = 448) from a Danish psychiatric clinic. Then, we carried out a cross-validation of the pretreatment HoNOS model on posttreatment data from the same group. A revised 10-item HoNOS fit the Rasch model at pretreatment and also showed excellent fit within the cross-validation data. Culture, gender, and need for translation did not exert serious bias on the measure’s performance. The results establish good monitoring properties of the 10-item HoNOS as the first validated measure of psychiatric disability for traumatized refugees in Western psychiatric care.
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Abstract
BACKGROUND Dissociative experiences are common in traumatized individuals, and can sometimes be mistaken for psychosis. It is difficult to identify pathological dissociation in the treatment of traumatized refugees, because there is a lack of systematic clinical descriptions of dissociative phenomena in refugees. Furthermore, we are currently unaware of how dissociation measures perform in this clinical group. AIMS To describe the phenomenology of dissociative symptoms in Bosnian treatment-seeking refugees in Denmark. METHOD As a part of a larger study, dissociation was assessed systematically in 86 Bosnian treatment-seeking refugees using a semi-structured clinical interview (Structured Interview for Disorders of Extreme Stress-dissociation subscale; SIDES-D) and a self-report scale (Dissociative Experiences Scale; DES). RESULTS The SIDES-D indicated twice as high prevalence of pathological dissociation as the DES. According to the DES, 30% of the refugees had pathological dissociation 15 years after their resettlement. On the SIDES-D, depersonalization and derealization experiences were the most common. Also, questions about depersonalization and derealization at times elicited reporting of visual and perceptual hallucinations, which were unrelated to traumatic re-experiencing. Questions about personality alteration elicited spontaneous reports of a phenomenon of "split" pre- and post-war identity in the refugee group. Whether this in fact is a dissociative phenomenon, characteristic of severe traumatization in adulthood, needs further examination. CONCLUSIONS Knowledge of dissociative symptoms in traumatized refugees is important in clinical settings to prevent misclassification and to better target psychotherapeutic interventions. Much development in the measurement of dissociation in refugees is needed.
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Affiliation(s)
- Sabina Palic
- Sabina Palic, M.Sc., Psychology, Danish National Centre for Psychotraumatology, University of Southern Denmark , Odense , Denmark
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Palic S, Kappel ML, Nielsen MS, Carlsson J, Bech P. Comparison of psychiatric disability on the health of nation outcome scales (HoNOS) in resettled traumatized refugee outpatients and Danish inpatients. BMC Psychiatry 2014; 14:330. [PMID: 25519423 PMCID: PMC4272564 DOI: 10.1186/s12888-014-0330-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 11/10/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Currently, the mental health issues of traumatized refugees are mainly documented in terms of posttraumatic stress disorder, depression, and anxiety. Importantly, there are no reports of the level of psychiatric disability in treatment seeking traumatized refugees resettled in the West. Insufficient acknowledgment of the collective load of bio-psycho-social problems in this patient group hinders effective psychiatric and social service utilization outside the specialized clinics for traumatized refugees. METHODS The level of psychiatric disability in traumatized refugees from Danish specialized clinics (N = 448) is documented using routine monitoring data from pre- and post-treatment on the Health of Nation Outcome Scales (HoNOS). Furthermore, the HoNOS ratings are compared with routine monitoring data from Danish inpatients with different diagnoses (N = 10.911). RESULTS The routinely collected data indicated that despite their outpatient status, traumatized refugees had higher levels of psychiatric disability at pre-treatment compared to most inpatients. Moreover, the traumatized refugees had a HoNOS profile characterized by an overall high problem level in various psychiatric and social domains. The rate of pre- to post-treatment improvement on the HoNOS was smaller for the traumatized refugees than it was for the psychiatric inpatients. CONCLUSIONS The level, and the versatile profile, of psychiatric disability on the HoNOS point to complex bio-psycho-social problems in resettled treatment seeking traumatized refugees. Thus, a broader assessment of symptoms and better cooperation between psychiatric, health care, and social systems is necessary in order to meet the treatment needs of this group.
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Affiliation(s)
- Sabina Palic
- National Centre for Psychotraumatology, University of Southern Denmark, Odense, Denmark.
| | - Michelle Lind Kappel
- Clinic for PTSD and Transcultural Psychiatry (CPTP), Aarhus University Hospital, Aarhus, Denmark.
| | - Monica Stougaard Nielsen
- Clinic for PTSD and Transcultural Psychiatry (CPTP), Aarhus University Hospital, Aarhus, Denmark.
| | - Jessica Carlsson
- Competence Center for Transcultural Psychiatry Denmark, Psychiatric Center Ballerup, The Mental Health Services of the Capital Region of Denmark, Copenhagen, Denmark.
| | - Per Bech
- Psychiatric Research Unit, Psychiatric Center North Zealand, Hillerød, Denmark.
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Elklit A, Christiansen DM, Palic S, Karsberg S, Eriksen SB. Impact of traumatic events on posttraumatic stress disorder among Danish survivors of sexual abuse in childhood. J Child Sex Abus 2014; 23:918-934. [PMID: 25256036 DOI: 10.1080/10538712.2014.964440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Childhood sexual abuse can be extremely traumatic and lead to lifelong symptomatology. The present study examined the impact of several demographic, abuse, and psychosocial variables on posttraumatic stress disorder severity among a consecutive sample of treatment-seeking, adult child sexual abuse survivors (N = 480). The child sexual abuse sample was characterized by severe trauma exposure, insecure attachment, and significant traumatization, with an estimated 77% suffering from posttraumatic stress disorder, more than twice the level of the comparison group. Regression analyses revealed risk factors associated with the development of posttraumatic stress disorder in which the strongest predictors being additional traumas, negative affectivity, and somatization. The findings add to existing research confirming the stressful nature of child sexual abuse and the variables that contribute to the development and severity of posttraumatic stress disorder.
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Affiliation(s)
- Ask Elklit
- a University of Southern Denmark , Odense , Denmark
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Abstract
The objectives of the present study were to examine the prevalence of posttraumatic stress disorder (PTSD) and to identify predicative risk factors for PTSD in bereaved people after a terminal illness. Fifty-four persons (mean age 60 years) participated in the study. Demographic, peritraumatic, and psychosocial factors were assessed in order to identify variables that affected PTSD severity. Six months after the loss, 21.6 % of the subjects had PTSD, an 8.6 % decrease from PTSD measured one month after the loss. Intake of medicine after the loss, place of death, not having a close intimate, negative affectivity, and the A2 criterion predicted 65 % of PTSD severity. A considerable number of the bereaved were still at great risk for developing PTSD six months after loss.
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Affiliation(s)
- Tina E. Kristensen
- National Centre for Psychotraumatology, University of Southern Denmark, Campusvej, Denmark
| | - Ask Elklit
- National Centre for Psychotraumatology, University of Southern Denmark, Campusvej, Denmark
| | - Karen-Inge Karstoft
- National Centre for Psychotraumatology, University of Southern Denmark, Campusvej, Denmark
| | - Sabina Palic
- National Centre for Psychotraumatology, University of Southern Denmark, Campusvej, Denmark
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Elklit A, Østergård Kjær K, Lasgaard M, Palic S. Social support, coping and posttraumatic stress symptoms in young refugees. Torture 2012; 22:11-23. [PMID: 23086002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Young refugees from the former Yugoslavia commonly testify to having been exposed to multiple, traumatic experiences, which may contribute to the development of serious mental health problems such as posttraumatic stress disorder (PTSD), anxiety, and depression. Using selfreport scales the present study investigated the prevalence of PTSD as well as factors associated with PTSD in a group of 119 Bosnian refugee youths (mean age 18.5). The group was special in that they had no right to seek asylum in the host country for the first couple of years of their stay. It is suspected that this circumstance had an effect on their wellbeing. Between 35-43% of the youth were found to be in the clinical range for a PTSD diagnosis. Female gender, problem-focused, and avoidant coping strategies, were significant predictors of PTSD. The protective effects of social support were, however, not observed for this group. There is a need for more studies, which address the factors that mediate and moderate effects of social support and effectiveness of different coping strategies in refugee youth dealing with different circumstances of the refugee experience.
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Affiliation(s)
- Ask Elklit
- National Center for Psychotraumatology, University of Southern Denmark
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Palic S, Elklit A. Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique. J Affect Disord 2011; 131:8-23. [PMID: 20708804 DOI: 10.1016/j.jad.2010.07.005] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Refugees with posttraumatic stress disorder (PTSD) often present with complicated traumatic symptoms, prolonged and repeated exposure to traumatic events, acculturation, and social problems. A consensus about suitability of psychosocial treatments for refugees does not exist. Never the less there is a need to review the state of knowledge about effective treatments for traumatized refugees, to help guide the practitioners in their choice of treatment methods. METHODS A systematic review of treatment outcome studies was carried out. RESULTS Twenty-five studies were reviewed. The majority were treatment studies of different forms of cognitive-behavioral therapy (CBT). The rest were reports of outcomes of alternative treatments and a small group of studies of multidisciplinary treatments. LIMITATIONS The amount of grey literature not covered by the review could not be estimated precisely. Included studies are methodologically diverse and consist of different refugee populations. This makes a broad interpretation of the treatment results only tentative. CONCLUSIONS Very large effect sizes were obtained in some of the CBT studies, indicating a broad suitability of CBT in the treatment of core symptoms of PTSD in adult refugees. Empirical evidence also points to the possibility that the maladaptive traumatic reactions in refugees can take shape of more complex reactions than those strictly specified in the diagnostic category of PTSD. Effectiveness of CBT treatments has as yet not been tested on the whole range of symptoms in these complex cases. There are few studies of treatments alternative to CBT and they are less methodologically rigorous than the CBT studies.
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Affiliation(s)
- Sabina Palic
- National Centre for Psychotraumatology, University of Southern Denmark, Denmark.
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Hansen M, Andersen TE, Armour C, Elklit A, Palic S, Mackrill T. PTSD-8: A Short PTSD Inventory. Clin Pract Epidemiol Ment Health 2010; 6:101-8. [PMID: 21253461 PMCID: PMC3023946 DOI: 10.2174/1745017901006010101] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 06/25/2010] [Accepted: 06/29/2010] [Indexed: 11/22/2022]
Abstract
Traumatic events pose great challenges on mental health services in scarcity of specialist trauma clinicians and services. Simple short screening instruments for detecting adverse psychological responses are needed. Several brief screening instruments have been developed. However, some are limited, especially in relation to reflecting the posttraumatic stress disorder (PTSD) diagnosis. Recently, several studies have challenged pre-existing ideas about PTSD’s latent structure. Factor analytic research currently supports two four factor models. One particular model contains a dysphoria factor which has been associated with depression and anxiety. The symptoms in this factor have been hailed as less specific to PTSD. The scope of this article is therefore to present a short screening instrument, based on this research; Posttraumatic Stress Disorder (PTSD) – 8 items. The PTSD-8 is shown to have good psychometric properties in three independent samples of whiplash patients (n=1710), rape victims (n=305), and disaster victims (n=516). Good test-rest reliability is also shown in a pilot study of young adults from families with alcohol problems (n=56).
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Affiliation(s)
- Maj Hansen
- National Center for Psychotraumatology, University of Southern Denmark
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Palic S, Elklit A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture 2009; 19:248-270. [PMID: 20065543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A group of highly traumatized refugees n = 26 with diverse cultural backgrounds in a Danish Clinic for Traumatized Refugees (CTR) was assessed for symptoms of post-traumatic stress disorder and other aspects of general functioning. Patients were assessed at intake, after the end of treatment and six months later. The results point to very high symptom levels and a large need for treatment in this population. Psychiatric symptoms and their correlates were assessed with the Harvard Trauma Questionnaire (HTQ), the Trauma Symptom Checklist-23 (TSC-23), the Global Assessment of Function (GAF), and the Crisis Support Scale (CSS). The Trail Making Test A & B (TMT) was used as a screening instrument for acquired brain damage, with promising results. Indications of effectiveness from 16-18 weeks of multidisciplinary treatment (physiotherapy, pharmacotherapy, psychotherapy, and social counseling) were supported with small to medium effect sizes on most outcome measures. The results are discussed in terms of clinical implications and future treatment, assessment, and research needs.
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Affiliation(s)
- Sabina Palic
- Institute of Psychology, Aarhus University, Denmark
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