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Nonmaleficence is a key ethical value of research among vulnerable populations. Trauma-focused research typically includes detailed interviews about traumatic life events and post-traumatic symptoms. This raises concerns about causing distress and harm for the affected individuals. We aimed to determine the immediate effects of trauma-focused interviews on participants' wellbeing. We developed the brief Distress and Harm Scale (DH7) for the assessment of current symptoms of distress and urge to harm oneself or others. Using data from 332 Iraqi and Syrian children and both of their parents (N = 996), we assessed these symptoms before and after participating in trauma-focused interviews. Results showed that the mean levels of self-reported distress and harm impulses were significantly decreased among adults and children rather than increased immediately after the interviews. Once measures to safeguard cases at risk are carefully implemented in research, the potential benefits of participating in trauma-focused interviews outweigh the risk for individuals. Potential implications of the results for ethical review boards evaluating trauma-focused studies are discussed. [ABSTRACT FROM AUTHOR]

Objective: A large proportion of refugees present with psychological disorders that require psychotherapy as first-line treatment. However, even in countries with well-established psychotherapy system, refugees continue to face barriers to care. Psychotherapists' attitudes toward refugees may also impede access to psychotherapy, as it is evident that stereotypes of health professionals contribute to health care disparities. However, little is known about psychotherapists' attitudes toward refugees. Methods: In a cross-sectional online study of N = 2002 outpatient psychotherapists in Germany (Mage = 54.48 years, 73.1% female), a vignette experiment was applied to examine differences in therapists' attitudes toward refugee patients from the Middle East and non-refugee patients. Subsequently, associations between attitudes and psychotherapists' characteristics (e.g., provision of treatment for refugees) were analyzed. Results: Results showed significant differences between therapists' attitudes toward refugee and non-refugee patients ( η p 2 =.23), with more therapy-hindering attitudes toward refugee patients. Higher therapy-hindering attitudes were significantly associated with less frequent provision of psychotherapy for refugees. Conclusion: Our findings provide initial evidence that psychotherapists perceive refugee patients as deviant from the norm and that these divergent attitudes may relate to disparities in mental health care. To avoid such a process of othering, training for psychotherapists should question stereotypes toward refugees. [ABSTRACT FROM AUTHOR]

Background: In populations affected by mass disaster such as armed conflict and displacement, children are at risk of developing mental ill-health, in particular post-traumatic stress disorder (PTSD). Valid and reliable screening instruments are needed to assess the severity of PTSD symptoms among children and to identify individuals in need of treatment. Method: In the context of an ongoing war in the Middle East, we developed the KID-PIN as a semi-structured interview for PTSD symptoms that can be administered by trained paraprofessionals. To achieve a culturally and contextually appropriate instrument, the development was based on open-ended interviews with affected children and involved both local and international experts. Using the KID-PIN and instruments for constructs associated with PTSD, 332 Iraqi and Syrian displaced children were interviewed. A subset of the sample (n = 86) participated in validation interviews based on experts applying the Clinician-Administered PTSD Scale for DSM-5--Child/Adolescent Version (CAPS-CA-5). Results: The KID-PIN demonstrated excellent internal consistency (Cronbach's alpha = 0.94) with good convergent validity. Confirmatory factor analyses of the KID-PIN showed an acceptable fit with the DSM-5 and other common models; the best fit was reached with the Hybrid model. Receiver operating characteristic analyses indicated that the cut-off score of 28 or higher on the KID-PIN is the optimum cut-off for a probable PTSD diagnosis. Conclusion: The utility of the newly developed KID-PIN as a screening instrument for PTSD in children is supported by the measure's high internal consistency and good convergent and structural validity, as well as its diagnostic accuracy. [ABSTRACT FROM AUTHOR]

While the factor structure of post-traumatic stress disorder (PTSD) symptoms has been investigated among various traumatized populations in Western and high-income countries, knowledge regarding the validity of factor structure of PTSD among culturally diverse populations in low-and-middle-income countries is limited. The current study examined the factor structure and cultural invariance of PTSD in 521 Iraqi and 993 Syrian war-affected displaced people who were living in the Kurdistan Region of Iraq. Results from confirmatory factor analyses demonstrated that alternative factor models for PTSD, including a new model derived from this population (anhedonia and affect model) resulted in a better fit than the current DSM V models. Taken together, the results showed that a good fit, as well as the measurement invariance of PTSD factors, could be obtained by applying the anhedonia and hybrid model. This study provides further support for the anhedonia and hybrid model of PTSD and fills an important gap in knowledge about the validity of PTSD symptom clusters among Arab and Kurdish populations. [ABSTRACT FROM AUTHOR]

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Current theories of psychological trauma assume that posttraumatic symptoms originate from stress reactions caused by extremely adverse life experiences. Since the diagnosis of PTSD is restricted to events that involve threats to the physical or sexual integrity of a person, such as accidents and physical and sexual violence, these theories are not well suited to explain the psychopathological consequences of severe violations of one's social integrity, such as emotional abuse and bullying. However, it is evident that social threats contribute to a broad range of mental disorders and increase symptom severity in patients with posttraumatic stress disorder. The aim of the Physical and Social Trauma (PAST) framework is to extend current memory theories of psychological trauma to incorporate threats to a person's social integrity. Within this perspective, the harmful effects of events that involve social threats result from violations of core social motives such as the need for status and belonging that bring about intense affective reactions, including despair and defeat. Within associative threat structures, these emotions are tied to the stimulus characteristics of the experiences and can be re-activated in social situations. The resulting psychopathology transcends PTSD criteria and other current classifications and suggests a transdiagnostic perspective of psychological trauma. Implications for treatment and further directions for research are discussed. • Current trauma theories are not sufficient to cover reactions to emotional abuse. • Social threats evoke distinct emotional reactions including defeat and despair. • Peri-traumatic reactions are tied to assoziative memories as threat structures. • Threat structures are the core of psychopathology related to physical and social stress. [ABSTRACT FROM AUTHOR]

Background: It is likely that alcohol use and abuse increase during and after violent conflicts. The most prominent explanation of this phenomenon has been referred to as self-medication hypothesis. It predicts that psychotropic substances are consumed to deal with conflict-related psychic strains and trauma. In northern Uganda, a region that has been affected by a devastating civil war and is characterized by high levels of alcohol abuse we examined the associations between war-trauma, childhood maltreatment and problems related to alcohol use. Deducing from the self-medication hypothesis we assumed alcohol consumption moderates the relationship between trauma-exposure and psychopathology. Methods: A cross-sectional epidemiological survey targeting war-affected families in post-conflict northern Uganda included data of male (n = 304) and female (n = 365) guardians. We used standardized questionnaires in an interview format to collect data on the guardians' socio-demography, trauma-exposure, alcohol consumption and symptoms of alcohol abuse, PTSD and depression. Results: Symptoms of current alcohol use disorders were present in 46 % of the male and 1 % of the female respondents. A multiple regression model revealed the unique contributions of emotional abuse in the families of origin and trauma experienced outside the family-context in the prediction of men's alcohol-related symptoms. We found that alcohol consumption moderated the dose-effect relationship between trauma-exposure and symptoms of depression and PTSD. Significant interactions indicated that men who reported more alcohol-related problems experienced less increase in symptoms of PTSD and depression with increasing trauma-exposure. Conclusions: The gradual attenuation of the dose-effect the more alcohol-related problems were reported is consistent with the self-medication hypothesis. Hence, the functionality of alcohol consumption has to be considered when designing and implementing addiction treatment in post-conflict contexts. [ABSTRACT FROM AUTHOR]

According to current treatment guidelines for Complex PTSD (cPTSD), psychotherapy for adults with cPTSD should start with a "stabilization phase." This phase, focusing on teaching self-regulation strategies, was designed to ensure that an individual would be better able to tolerate trauma-focused treatment. The purpose of this paper is to critically evaluate the research underlying these treatment guidelines for cPTSD, and to specifically address the question as to whether a phase-based approach is needed. As reviewed in this paper, the research supporting the need for phase-based treatment for individuals with cPTSD is methodologically limited. Further, there is no rigorous research to support the views that: (1) a phase-based approach is necessary for positive treatment outcomes for adults with cPTSD, (2) front-line trauma-focused treatments have unacceptable risks or that adults with cPTSD do not respond to them, and (3) adults with cPTSD profit significantly more from trauma-focused treatments when preceded by a stabilization phase. The current treatment guidelines for cPTSD may therefore be too conservative, risking that patients are denied or delayed in receiving conventional evidence-based treatments from which they might profit. [ABSTRACT FROM AUTHOR]

Background: Trained local screeners assessed the mental-health status of male and female students in Northern Ugandan schools. The study aimed to disclose potential differences in mental health-related impairment in two groups, former child soldiers (n =354) and other war-affected youth (n=489), as well as to separate factors predicting mental suffering in learners. Methods: Participants were randomly selected. We used the Post-Traumatic Diagnostic Scale to assess symptoms of post-traumatic stress disorder (PTSD) and for potential depression the respective section of the Hopkins Symptom Checklist with a locally validated cut-off. Results: Almost all respondents had been displaced at least once in their life. 30% of girls and 50% of the boys in the study reported past abduction history. Trauma exposure was notably higher in the group of abductees. In former child soldiers, a PTSD rate of 32% was remarkably higher than that for non-abductees (12%). Especially in girls rates of potential depression were double those in the group of former abductees (17%) than in the group of non-abductees (8%). In all groups, trauma exposure increased the risk of developing PTSD. A path-analytic model for developing PTSD and potential depression revealed both previous trauma exposure as well as duration of abduction to have significant influences on trauma-related mental suffering. Findings also suggest that in Northern Ugandan schools trauma spectrum disorders are common among war-affected learners. Conclusions: Therefore, it is suggested the school context should be used to provide mental-health support structures within the education system for war-affected youth at likely risk of developing war-related mental distress. [ABSTRACT FROM AUTHOR]

In recent years, different approaches to large-scale mental health service provision for children in war-affected, mainly low- and middle-income, countries have been developed. Some school-based programs aiming at both strengthening resilience and reducing symptoms of trauma-related distress have been evaluated. In an article published in BMC Medicine, Tol and colleagues integrate their findings of the efficacy of universal school-based intervention across four countries and do not recommend classroom-based intervention as a treatment of trauma-related symptoms, since no consistent positive effects were found. On the contrary, for some children this type of universal intervention may impair recovery. Since universal school-based programs similar to the one evaluated here are widely implemented, Tol et al.’s results are highly relevant to inform the field of mental health service provision in war-affected countries [ABSTRACT FROM AUTHOR]

Abstract: Violence against women that is perpetrated by an intimate partner prevails as one of the most widespread human rights violations in virtually all societies of the world. Women in resource-poor countries, in particular those affected by recent war, appear to be at high risk of experiencing partner violence. Although there has been a longstanding assumption that organised violence at a societal level is transmitted to an interpersonal level, little is known about the link between exposure to war and familial violence. We conducted an epidemiological survey in 2010 with 2nd-grade students and their male and female guardians from nine heavily war-affected communities in Northern Uganda employing structured interviews and standardized questionnaires. The present study analysed a subsample of 235 guardian couples from seven rural communities in order to determine the prevalence and predictors of current partner violence experienced by women in the context of the past war. Study results revealed a high prevalence of ongoing partner violence experienced by female partners. In the past year, 80% of women reported at least one type of verbal/psychological abuse, 71% were exposed to at least one type of physical abuse, 52% suffered isolation and 23% fell victim to sexual violence. Findings from linear regression analyses showed that women's prior exposure to war-related traumatic events, women's re-experiencing symptoms and men's level of alcohol-related problems were associated with higher levels of partner violence against women. Differential effects of the predictor variables emerged with respect to different subtypes of partner violence. The findings suggest that partner violence against women constitutes a major problem in rural Northern Uganda. Programmes for the prevention and reduction of partner violence against women need to address high levels of hazardous drinking in men as well as women's prior traumatisation. In addition, different patterns of partner violence should be taken into account. [Copyright &y& Elsevier]

Abstract: The psychological consequences of traumatic stress may last even into old age. In persons in their 60s and 70s who had been victims of political detention and torture four decades ago, we compared the outcome of narrative exposure therapy (NET) to that of psychoeducation (PED) only. From a group of 59 former political detainees, 18 who fulfilled the full PTSD criteria according to the Composite International Diagnostic Interview (CIDI) were offered and accepted participation in the treatment study. The participants were randomly assigned to either one session of PED (n=9) or five sessions of NET (n=9). Symptoms of PTSD (CIDI) and depression (Beck Depression Inventory, BDI) were assessed prior to treatment and after a 6-month follow-up. NET but not PED produced a significant reduction in post-traumatic symptoms and depression scores. Four out of 9 of those who completed NET, compared to 8/9 of those within the PED group, still had PTSD 6 months after the treatment had ended. These results indicate that NET may lead to the alleviation of post-traumatic and depression symptoms even when the conditions persist for excessive time periods. [Copyright &y& Elsevier]

After 20 years of civil war in Northern Uganda, the continuity of violence within the family constitutes a major challenge to children's healthy development in the post-conflict era. Previous exposure to trauma and ongoing psychopathology in guardians potentially contribute to parental perpetration against children and dysfunctional interactions in the child's family ecology that increase children's risk of maltreatment. In order to investigate distal and proximal risk factors of child victimization, we first aimed to identify factors leading to more self-reported perpetration in guardians. Second, we examined factors in the child's family environment that promote child-reported experiences of maltreatment. Using a two-generational design we interviewed 368 children, 365 female guardians, and 304 male guardians from seven war-affected rural communities in Northern Uganda on the basis of standardized questionnaires. We found that the strongest predictors of self-reported aggressive parenting behaviors toward the child were guardians’ own experiences of childhood maltreatment, followed by female guardians’ victimization experiences in their intimate relationship and male guardians’ posttrautmatic stress disorder (PTSD) symptoms and alcohol-related problems. Regarding children's self-report of victimization in the family, proximal factors including violence between adults in the household and male guardians’ PTSD symptom severity level predicted higher levels of maltreatment. Distal variables such as female guardians’ history of childhood victimization and female guardians’ exposure to traumatic war events also increased children's report of maltreatment. The current findings suggest that in the context of organized violence, an intergenerational cycle of violence persists that is exacerbated by female guardians’ re-victimization experiences and male guardians’ psychopathological symptoms. [Copyright &y& Elsevier]

Abstract: Objective: There has been uncertainty about whether refugees and asylum seekers with PTSD can be treated effectively in standard psychiatric settings in industrialized countries. In this study, Narrative Exposure Therapy (NET) was compared to Treatment As Usual (TAU) in 11 general psychiatric health care units in Norway. The focus was on changes in symptom severity and in the diagnostic status for PTSD and depression. Method: Refugees and asylum seekers fulfilling the DSM-IV criteria for PTSD (N = 81) were randomized with an a-priori probability of 2:1 to either NET (N = 51) or TAU (N = 30). The patients were assessed with Clinician Administered PTSD Scale, Hamilton rating scale for depression and the MINI Neuropsychiatric Interview before treatment, and again at one and six months after the completion. Results: Both NET and TAU gave clinically relevant symptom reduction both in PTSD and in depression. NET gave significantly more symptom reduction compared to TAU as well as significantly more reduction in participants with PTSD diagnoses. No difference in treatment efficacy was found between refugees and asylum seekers. Conclusions: The study indicated that refugees and asylum seekers can be treated successfully for PTSD and depression in the general psychiatric health care system; NET appeared to be a promising treatment for both groups. ClinicalTrials.gov registry number: NCT00218959. [Copyright &y& Elsevier]

Background: The present study investigated the influence of posttraumatic stress disorder (PTSD) on early visual processing of affective stimuli in survivors of war and torture. Methods: Trauma-exposed refugees with (n = 36) and without (n = 21) PTSD as well as unexposed control subjects (n = 16) participated in a magnetoencephalography study with pictures that varied in emotional content. Results: We found evidence for a biphasic cortical response in patients with PTSD in comparison with the two control groups. In response to aversive (relative to neutral or positive) pictures, PTSD patients showed elevated cortical activity over right prefrontal areas as early as 130–160 msec after stimulus onset followed by a decrease of the affect-related response in the parieto-occipital cortex at 206–256 msec. Conclusions: The increased early activity in the right prefrontal cortex most likely represents an enhanced alarm response or the fear network toward aversive stimuli in PTSD, whereas the subsequent decreased activation in right parieto-occipital areas in response to aversive pictures seems to reflect the tendency to disengage from emotional content. This finding is consistent with the hypothesis of a vigilance-avoidance reaction pattern to threat in anxiety disorders and helps to reconcile contradicting results of over- and under-responsiveness in the sensory processing of threatening stimuli in PTSD. [ABSTRACT FROM AUTHOR]