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Background: Narrative exposure therapy (NET) is a short-term psychological treatment for post-traumatic stress disorder (PTSD) that has been investigated in various contexts among traumatized refugees and other trauma survivors. Sustained treatment results have been reported, but the methodological quality of the trials needs a more thorough examination. Objective: To evaluate the effectiveness of NET for survivors of trauma, using a quality assessment, an updated meta-analysis, and a meta-regression analysis. Method: Following a systematic literature selection, the methodological quality of the included studies was assessed; Non-controlled and controlled effect sizes (Hedges’ g) were estimated using a random effects model. Predictor analyses were performed. Non-controlled effect sizes for PTSD and depression included symptom change at post-treatment and follow-up time-points. Controlled effect sizes included post-treatment comparisons of NET with non-active and active comparators: both trauma-focused (TF) and non-trauma-focused (non-TF) interventions. Results: The selected studies showed high external validity; methodological quality was equivalent to other guideline-supported TF interventions. In 16 randomized controlled trials, involving 947 participants, large non-controlled effect sizes were found for PTSD symptoms, at post-treatment (g = 1.18, 95% confidence interval [0.87; 1.50]) and follow-up (g = 1.37 [0.96; 1.77]). For depression symptoms, medium non-controlled effect sizes were found, at post-treatment (g = 0.47 [0.23; 0.71]) and follow-up (g = 0.60 [0.26; 0.94]). Post-treatment, NET outperformed non-active comparators and non-TF active comparators for PTSD, but not the combined active comparators. For depression, NET only outperformed non-active comparators. Advancing age predicted better treatment results for PTSD and depression symptoms; a history of migration predicted smaller treatment results for depression symptoms. Conclusions:The findings of this meta-analysis suggest that patients and providers may expect sustained treatment results from NET. Controlled comparisons with other guideline-supported TF interventions are not yet available.

Background: Bereavement can precipitate different forms of psychopathology, including prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptoms. How these symptoms influence each other is unclear. The aim of this study was to examine the temporal relationship of symptoms of PGD and PTSD following bereavement. Methods: We included 204 individuals, confronted with the loss of a loved one within the past year, who completed self-report measures of PGD and PTSD and again completed these measures one year later. We conducted a cross-lagged analysis to explore cross-lagged and autoregressive relationships. Results: A significant cross-lagged relationship was found between PGD symptoms at time point 1 (T1) and PTSD symptoms at time point 2 (T2) (β− = 0.270, p

Background: Little is known about the development of Prolonged Grief Disorder (PGD) symptoms over time in adults. For clinical purposes, it would be useful to have knowledge about early indicators of a problematic grief trajectory. Objective: This study aimed to identify classes of bereaved individuals with similar trajectories of PGD symptoms and to design a provisional screening tool including symptoms predicting membership of classes with problematic grief trajectories. Method: In a Dutch sample of 166 bereaved individuals, we conducted a latent class analysis to identify classes of bereaved individuals with similar trajectories of PGD symptoms between two time points (mean of 6 and 18 months post-loss, respectively). Next, we used Receiver Operating Characteristic (ROC) analyses to examine which symptoms at baseline best predicted membership of classes with problematic grief trajectories. Results: We found four different classes: a class including individuals with persistent high PGD symptoms (class 1, 6%), a class of individuals with persistent moderate PGD symptoms (class 2, 35%), a class of individuals with slightly decreasing moderate PGD symptoms (class 3, 33%) and a class of individuals with persistent low PGD symptoms (class 4, 26%). The endorsement of symptoms ‘yearning’, ‘stunned’, ‘life is empty’ and ‘bitterness’ as present ‘often’ during the preceding month at baseline best-predicted membership of class 1 or 2. Conclusions: Two classes of individuals with problematic grief trajectories were identified. Four symptoms were found which could act as early indicators of these two classes in a provisional screening tool.

Over half a million Dutch veterans participated in almost a hundred war and peace keeping missions since 1940. During past deployments, veterans promoted peace and stability in conflict situations, endeavoured to win the hearts and minds of local communities and improved the lives of those affected in warzone circumstances. These men and women operated under harsh conditions that placed them at the vanguard of human violence and tragedy. Despite exposure to shocking and life-threatening events, combat veterans are resilient and the majority reflects positively on their deployment experiences. Some, notwithstanding, develop enduring psychological distress as a result of psychotraumatic experiences. Posttraumatic stress disorder (PTSD) is the most prevalent deployment-related psychological disorder. Veterans with PTSD are a difficult-to-treat population and psychotherapy interventions are limited in their effectiveness. Much is unknown about the workings of PTSD psychotherapy and why some veterans recover, whilst others do not respond to therapy. This dissertation identifies factors that impact and predict PTSD treatment outcome, to enable more tailored and effective interventions for veterans. The work also reflects on the workings of psychotherapy, arguing that the present dominant treatment paradigm, the medical model of psychotherapy, by itself is incomplete to understand and effectively improve therapeutic recovery. The dissertation demonstrated how predictive research can bridge the gap between science and practice to help increase the odds of recovery for veterans with PTSD. Therapeutic recovery can be predicted at three separate levels: patient, therapy, and setting. The predictors related to each level help set the stage for therapeutic recovery. Incorporating elements that predict treatment effectiveness outcome into our treatment strategies allows us to tailor our care strategies and improve the effectiveness of PTSD treatment interventions. Besides the identification of PTSD treatment effectiveness predictors, several alternative frameworks were forwarded that challenges the exclusivity of the medical model of psychotherapy in our research, practice and policies. These alternative frameworks, based on placebo effects and common factors, allow us to explore novel pathways to improve PTSD treatment effectiveness.

Traumatic stress and specifically child trauma is a ubiquitous problem, and in South Africa rates of abuse and trauma exposure are one of the highest worldwide. Considering these high figures, there is actually limited expertise available that can help us understand and effectively treat the long-term consequences of these experiences of posttraumatic stress in children. Moreover, previous studies are primarily based in a high-income context; in low and middle-income countries studies are even more scarce. This dissertation described the psychological impact of traumatic events in South Africa, analysed current barriers in mental health care through the experiences of social workers, and evaluated the potential suitability and effectiveness of a creative arts in psychotherapy intervention that was developed, implemented and evaluated in the South African context. The overall aim was to contribute to an improvement in mental health care offered to children after trauma, specifically in a context characterized by high levels of abuse, violence, crime and poverty. Results demonstrated that high levels of traumatic exposure in the South African society do indeed place the population at risk for developing posttraumatic stress disorder and other negative mental health consequences. There are several barriers to providing proper mental health care, pointing to a need for better support and training for the health care professionals and stronger collaboration within the communities between relevant stakeholders and clients to make treatments work. At the same time, opportunities were pointed out such as high levels of resilience, transdisciplinary collaboration, and using strategies that are embedded in indigenous systems such as creative arts therapy. The current knowledge-base of creative arts therapy is very limited compared to more regular approaches to treating posttraumatic disorders such as CBT and EMDR. Yet, unique advantages of creative arts therapy are that it is non-threatening, allowing for desensitization whilst restoring dignity, accommodating possible language barriers and incorporates indigenous knowledge. The potential effects of a creative arts therapy treatment (CAP) were demonstrated in a non-randomized controlled trial, comparing creative arts therapy with a low-level supportive programme without treatment. The children participating in the programme reported less posttraumatic stress symptoms after attending therapy, compared to a low-level supportive programme. Despite major challenges of implementing and evaluating this intervention in a context with ongoing violence, lack of resources and language barriers, the potential of using creative arts therapy within communities as treatment for child trauma was demonstrated. The positive findings laid a first foundation for similar work that can be followed-up and improved in future, and hopefully inspire much more work in this area.

Many adolescent refugees and asylum seekers have experienced traumatic events. They often suffer from intrusions of these events, and report avoidance behaviors, sleeping problems and hyperarousal. On top of that, they are dealing with many daily stressors caused by their new and marginal social position in the Netherlands. How do these adolescents keep up in the Dutch society? A long waiting time for a resident permit and uncertainty about the future have a negative influence on their quality of life. However, it is a misinterpretation to qualify these adolescents as passive victims. They also show remarkably high levels of (individual) resilience and even personal growth. Young refugees display, for example, positive changes in interpersonal relationships and self perception. They describe high feelings of responsibility and they are actively engaged with performing at school and participating in the new society to move on and live a meaningful life in the host country. In this dissertation, we investigated the construct of resilience in adolescent refugees and asylum seekers in the Netherlands. We integrated data from qualitative evidence, questionnaires and DNA analyses. The results demonstrate that these individual adolescents and their social context are very much interrelated. Consequently, resilience in young refugees is influenced by different variables on numerous levels (e.g., individual, family, community). Furthermore, the results showed that not all groups benefit similarly from the same (protective) factors. In the last chapter of this dissertation, we critically review the usefulness of the concept 'resilience' in research and in practical work with young refugees and asylum seekers.

Background : Asylum seekers and refugees have been claimed to be at increased risk of developing complex posttraumatic stress disorder (complex PTSD). Consequently, it has been recommended that refugees be treated with present-centred or phased treatment rather than stand-alone trauma-focused treatment. This recommendation has contributed to a clinical practice of delaying or waiving trauma-focused treatment in refugees with PTSD. Objective : The aim of this debate piece is to defend two theses: (1) that complex trauma leads to complex PTSD in a minority of refugees only and (2) that trauma-focused treatment should be offered to all refugees who seek treatment for PTSD. Methods : The first thesis is defended by comparing data on the prevalence of complex PTSD in refugees to those in other trauma-exposed populations, using studies derived from a systematic review. The second thesis is defended using conclusions of systematic reviews and a meta-analysis of the efficacy of psychotherapeutic treatment in refugees. Results : Research shows that refugees are more likely to meet a regular PTSD diagnosis or no diagnosis than a complex PTSD diagnosis and that prevalence of complex PTSD in refugees is relatively low compared to that in survivors of childhood trauma. Effect sizes for trauma-focused treatment in refugees, especially narrative exposure therapy (NET) and culturally adapted cognitive-behaviour therapy (CA-CBT), have consistently been found to be high. Conclusions : Complex PTSD in refugees should not be assumed to be present on the basis of complex traumatic experiences but should be carefully diagnosed using a validated interview. In line with treatment guidelines for PTSD, a course of trauma-focused treatment should be offered to all refugees seeking treatment for PTSD, including asylum seekers. Keywords: Posttraumatic stress; trauma; torture; prevalence; efficacy; ISTSS treatment guidelines; asylum seekers; ICD-11; narrative exposure therapy; culturally adapted cognitive-behaviour therapy (Published: 12 February 2016) Responsible Editor: Brian Hall, University of Macau, Macau (SAR), People’s Republic of China. For the abstract or full text in other languages, please see Supplementary files in the column to the right (under ‘Article Tools’) This paper is part of the Special Issue: Global mental health: trauma and adversity among populations in transition. More papers from this issue can be found at www.ejpt.net Citation: European Journal of Psychotraumatology 2016, 7 : 28687 - http://dx.doi.org/10.3402/ejpt.v7.28687

Existing tools for evaluating psychosocial interventions (un-validated self-reporting questionnaires) are not ideal for use in non-Western conflict settings. We implement a generic method of treatment evaluation, using client and counsellor feedback, in 18 projects in non-Western humanitarian settings. We discuss our findings from the perspective of validity and suggestions for future research. A retrospective analysis is executed using data gathered from psychosocial projects. Clients (n = 7,058) complete two (complaints and functioning) rating scales each session and counsellors rate the client's status at exit. The client-completed pre- and post-intervention rating scales show substantial changes. Counsellor evaluation of the clients' status shows a similar trend in improvement. All three multivariable models for each separate scale have similar associations between the scales and the investigated variables despite different cultural settings. The validity is good. Limitations are: ratings give only a general impression and clinical risk factors are not measured. Potential ceiling effects may influence change of scales. The intra and inter-rater reliability of the counsellors' rating is not assessed. The focus on client and counsellor perspectives to evaluate treatment outcome seems a strong alternative for evaluation instruments frequently used in psychosocial programming. The session client rated scales helps client and counsellor to set mutual treatment objectives and reduce drop-out risk. Further research should test the scales against a cross-cultural valid gold standard to obtain insight into their clinical relevance.

Item does not contain fulltext In contrast with traumatic experiences, there is a dearth of studies on the link between trauma symptoms, disconnected (frightened, threatening and dissociative) parenting behavior, extremely insensitive parenting behavior and child attachment. This study extends previous work on the impact of posttraumatic stress disorder (PTSD) on families by studying the unique contribution of disconnected and extremely insensitive parenting behavior on child attachment in a highly traumatized sample of 68 asylum seekers and refugees and their children (18-42 months). The results show that parental symptoms of PTSD are directly related to children's insecure attachment and disorganized attachment. The greatest proportion of the risk could be attributed to factors related to the dyad and not the family. A mediation effect of adverse parenting behavior was not confirmed. On the one hand the results indicate the need for an effective treatment of PTSD symptomatology while on the other hand the results indicate the need for clinical attention to insecure attachment relationships. 19 p.

Objective : The aim of this study was to explore perceived posttraumatic growth (PTG) and its associations with potentially traumatic events (PTEs), dispositional optimism, perceived social support, posttraumatic stress disorder (PTSD) symptoms, and satisfaction with life (SWL) among adolescent refugees and asylum seekers. Method : A cross-sectional design was employed including 111 refugees, aged 12–17, that were recruited from asylum seeker centres throughout the Netherlands. Measurements included the revised Posttraumatic Growth Inventory for Children, Children’s Impact of Event Scale, Multidimensional Scale of Perceived Social Support, The Life Orientation Test, and the Satisfaction with Life Scale. Results : Participants reported mean PTG scores (20.2) indicating an average response of some perceived change, while reporting high levels of PTSD symptoms (30.6). PTG and PTSD symptoms were not related with each other ( r =0.07, p= 0.50). PTG was positively associated with dispositional optimism ( r =0.41, p

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.

OBJECTIVE: This article reviews available qualitative studies that report young refugees' ways of dealing with adversity to address their sources of resilience. DESIGN: We searched five electronic databases. Twenty-six empirical studies were included in the review. A meta-ethnography approach was used to synthesize these qualitative studies. RESULTS: Six sources of resilience emerged: (1) social support, (2) acculturation strategies, (3) education, (4) religion, (5) avoidance, and (6) hope. These sources indicated social as well as personal factors that confer resilience in young refugees, but most of them also had counterproductive aspects. CONCLUSION: The results, from an ecological developmental perspective, stressed the interplay between protective and risk processes in the mental health of young refugees who had resettled in Western countries, and they emphasized the variability as well as the universality of resilience-promoting processes. Further research is needed to explore the cultural shape of resilience and the long-term consequences of war and migration on young refugees.

Background A longitudinal study was conducted in order to assess the impact of the Ghislenghien disaster (July 30th, 2004) on physical, mental and social health in the affected population. Objectives The present study explored the risk for the development of four types of mental health disturbances (MHD) due to exposure to different aspects of this technological disaster in comparison with data obtained from previous health surveys among the population of the same province. Methods/Design Surveys were conducted 5 months (T1) and 14 months (T2) after the disaster. Potential adult victims (≥ 15 years) were included (n=1027 and 579 at T1 and T2 respectively). The "Symptom Checklist-90-Revised" (SCL-90-R) has been used in order to compute actual prevalence rates of somatization-, depression-, anxiety- and sleeping disturbances for three defined exposure categories: direct witnesses who have seen human damage (SHD), direct witnesses who have not seen human damage (NSHD) and indirect witnesses (IW). Those prevalence rates were compared with overall rates using the inhabitants of the province of Hainaut (n=2308) as reference population. A mental health comorbidity index was computed. Relative risks were estimated using logistic regression models. Results Prevalence rates of the four MHD were much higher for the SHD than for the other exposure groups, at T1 and T2. Moreover, NSHD and IW had no increased risk to develop one of the 4 types of MHD compared to the reference population. The SHD had at T1 and T2 good 5-times a higher risk for somatization, about 4-times for depression and sleeping disorders, and 5- to 6-times for anxiety disorders respectively. Further, they suffered 13 times, respectively 17 times more from all mental disorders together. Conclusions The present study calls attention to the fact that mental health problems disturbances are significantly more prevalent and long-lasting among survivors who have directly been exposed to human damage.

BACKGROUND: This paper investigates risk factors for the development of posttraumatic stress symptoms in the different survivor groups involved in a technological disaster in Ghislenghien (Belgium). A gas explosion instantly killed five firefighters, one police officer and 18 other people. Moreover, 132 people were wounded among which many suffered severe burn injuries. METHODS: In the framework of a large health survey of people potentially involved in the disaster, data were collected from 3,448 households, of which 7,148 persons aged 15 years and older, at 5 months (T1) and at 14 months (T2) after the explosion. Hierarchical regression was used to determine the significant predictors and to assess their proportion in variance accounted for. RESULTS: The degree of exposure to the disaster was a predictor of the severity of posttraumatic stress symptoms. Peritraumatic dissociation appeared to be the most important predictor of the development of posttraumatic stress symptoms at T1. But at T2, posttraumatic stress symptoms at T1 had become the most important predictor. Dissatisfaction with social support was positively linked to development of posttraumatic stress symptoms at T1 and to the maintenance of these symptoms at T2. Survivors who received psychological help reported significant benefits. CONCLUSIONS: In harmony with the findings from studies on technological disasters, at T1 6,0% of the respondents showed sufficient symptoms to meet all criteria for a full PTSD. At T2, 6,6% still suffered from posttraumatic stress symptoms. The symptoms of the different victim categories clearly indicated the influence of the degree of exposure on the development of posttraumatic stress symptoms. Problems inherent to retrospective scientific research after a disaster are discussed.

Anger and aggression are common mental health problems after military deployment. Anger and aggression have been associated with abnormalities in subcortical and cortical levels of the brain and their connectivity. Here, we tested brain activation during the processing of emotional stimuli in military veterans with and without anger and aggression problems. Thirty military veterans with anger and aggression problems and 29 veterans without a psychiatric diagnosis (all males) participated in this study. During an fMRI scan 32 negative, 32 positive and 32 neutral pictures from the International Affective Picture System were presented in intermixed order. The Aggression group showed heightened activity in brain areas including the supplementary motor area, the cingulum and the parietal cortex, in response to stimuli, regardless of category. Furthermore, the Aggression group showed stronger connectivity between the dorsal anterior cingulate cortex (dACC) and the amygdala during the viewing of negative stimuli, and weaker connectivity between dACC and medial prefrontal cortex during the viewing of positive stimuli. Veterans with anger and aggression problems showed enhanced brain response to all stimuli during the task, irrespective of valence and they rated the pictures more likely as negative. We take this to indicate enhanced preparation for action and attention to the presentation of stimuli that could prove to be threatening. Further, group differences in functional connectivity involving the dACC reveal abnormal processing of stimuli with negative and positive valence. In sum, the results point towards a bias towards an enhanced sensitivity to perceived or potential threat in aggression. [Abstract copyright: Copyright © 2017 Elsevier Masson SAS. All rights reserved.]

Despite increased attention to the role of fathers within families, there is still a dearth of studies on the impact of trauma on father-involvement. This study investigates the quantity of father-involvement and the influence of posttraumatic stress on the quality of involvement in a refugee and asylum seeker population. Eighty refugees and asylum seekers and their young children (aged 18-42 months) were recruited. Measures included assessment of parental trauma (Harvard Trauma Questionnaire), quantity and quality of involvement (quantity of caregiving and Emotional Availability Scales), and perception of the father-child relationship (interview). The results show that fathers were less involved in caregiving tasks and play activities than mothers. No parental gender differences were found on each of the Emotional Availability Scales. Traumatic stress symptoms negatively affected the perception and the actual quality of parent-child interaction (sensitivity, structuring, nonhostility). Nevertheless, almost all fathers described their relationship with their child as good and their child as very important to them. As the quality of father-involvement is of importance to the development of the child, traumatized fathers are as much in need of clinical intervention as mothers. Despite the impact of posttraumatic stress, refugee fathers clearly are involved in the lives of their children. Mechanisms such as a deliberate withdrawal when stressed and compensation might enable affected fathers to step into the interaction when needed, raise the quality of involvement with their child, and diminish the negative impact of stress resulting from trauma and migration. Language: en

In 2009, a commercial airplane crashed near Amsterdam. This longitudinal study aims to investigate (1) the proportion of survivors of the airplane crash showing a probable posttraumatic stress disorders (PTSD) or depressive disorder, and (2) whether symptoms of PTSD and depression were predicted by trauma characteristics. Identifying these trauma characteristics is crucial for early detection and treatment. Of the 121 adult survivors, 82 participated in this study 2 months after the crash and 76 participated 9 months after the crash. Risk for PTSD and depression was measured with the self-report instruments Trauma Screening Questionnaire and Patient Health Questionnaire-2. Trauma characteristics assessed were Injury Severity Score (ISS), hospitalisation, length of hospital stay, and seating position in the plane. Two months after the crash, 32 participants (of N = 70, 46%) were at risk for PTSD and 28 (of N = 80, 32%) were at risk for depression. Nine months after the crash, 35 participants (of N = 75, 47%) were at risk for PTSD and 24 (of N = 76, 35%) were at risk for depression. There was a moderate correlation between length of hospital stay and symptoms of PTSD and depression 9 months after the crash (r = .33 and r = .45, respectively). There were no differences in seating position between participants at high risk vs. participants at low risk for PTSD or depression. Mixed design ANOVAs showed also no association between the course of symptoms of PTSD and depression 2 and 9 months after the crash and ISS or hospitalisation. This suggests that health care providers need to be aware that survivors may be at risk for PTSD or depression, regardless of the objective severity of their physical injuries.

Mental health problems following loss can manifest as heterogeneous symptomatology that may include symptoms of Prolonged Grief Disorder (PGD), Post-Traumatic Stress Disorder (PTSD), and Major Depressive Disorder (MDD). However, the co-occurrence of symptoms of these three disorders is still only partially explored. The aims of this study were to identify subgroups (i.e., classes) in a Dutch sample of bereaved individuals, based on severity and/or co-occurrence of symptoms and to identify predictors for these subgroups, taking into account all three disorders. Using data from 496 participants who filled in questionnaires assessing PGD, PTSD and MDD, we conducted latent class analyses to identify different symptom classes. Predictors of these classes were identified using one-way ANOVA, Chi Square tests and multinomial regression analysis. We found three different classes: a resilient class, a PGD class and a combined PGD/PTSD class. Violent cause of death, loss of a child, and loss of a partner were associated with membership of the combined PGD/PTSD class. This study increases our understanding of the predictability of symptomology outcome following bereavement. This is a first step towards designing assessment and intervention methods, specifically directed towards subgroups of individuals sharing characteristic symptomatology.

Dr Halvorsen quite rightly draws attention to the various definitions of clinically significant change, which all have their advantages and disadvantages. We especially agree with the comment that the threshold for clinically significant change should at least coincide with the threshold for reliable change (18.66 in our sample). However, using the threshold of 10 points, as promoted by Schnurr,1 has specific value in our study. First, the 10-point threshold has been shown to be related to changes in quality of life in several samples.2,3 Second, clinically significant change refers to both clinical improvement and deterioration. Most clinicians and researchers would agree that a deterioration of more than 10 points is clinically meaningful and undesirable. Third, treatment duration in our study was relatively short, justifying a relatively low threshold for clinically significant change. Obviously, if the threshold for clinically meaningful change is increased, the number of participants who benefit from the treatment will decrease. In our study, using the 30% rule (which is based on each participant's score at baseline rather than on the participants' mean score at baseline), the number of participants who experience clinically significant change decreases to six in both conditions. Using the two-standard-deviations rule, the number is reduced even further, to one in the EMDR condition and three in the stabilisation condition. However, the informative value of this, in our opinion, is limited. The general conclusion of our paper is that six 90-min sessions of EMDR preceded by three 60-min preparatory sessions are of limited efficacy. This conclusion is based not only on calculations of clinically significant change but also on the slopes of clinician-administered and self-reported measures and on the number of PTSD cases (which may also be subjected to different scoring rules4). An alternative conclusion would be that EMDR is not efficacious at all, but that would not be defensible given the significant decrease in self-reported PTSD severity in the EMDR sample and the significant, medium-sized differences between the EMDR condition and the non-randomised wait-list condition. What the rules for calculating clinically significant change have in common is that they are defined a priori by researchers. In reference to the discussion of our paper, it may be argued that participants themselves should be invited to define at which point they feel that they have meaningfully changed and which criteria define for them where this point lies. By listening to refugee patients' opinions and insights on what is helpful and meaningful to them, we might all be in for a surprise.

Disorders of Extreme Stress Not Otherwise Specified (DESNOS), also known as Complex posttraumatic stress disorder, was assessed in a sample (N = 472) of adult psychiatric patients with confirmed diagnoses of Borderline Personality Disorder (BPD), Somatoform Disorders (SoD), comorbid BPD + SoD, or Affective or Anxiety Disorders (Psychiatric Controls, PC). BPD + SoD patients had the most extensive childhood trauma histories and were most likely (38%) to meet DESNOS criteria, followed by BPD (26%), PC (17%), and SoD (10%), The BPD + SoD and BPD-only groups reported significantly higher levels of DESNOS symptoms than the SoD or PC groups, and did not differ from each other except for greater severity of DESNOS somatic symptoms by the BPD + SoD group. DESNOS warrants further investigation with psychiatrically impaired adults as a potential independent syndrome or as a marker identifying a subgroups of affectively or both affectively and somatically dysregulated patients diagnosed with BPD who have childhood trauma histories. (PsycINFO Database Record (c) 2012 APA, all rights reserved) Complex Posttraumatic Stress Disorder in Patients With Borderline Personality Disorder and Somatoform Disorders (PDF Download Available). Available from: http://www.researchgate.net/publication/232491929_Complex_Posttraumatic_Stress_Disorder_in_Patients_With_Borderline_Personality_Disorder_and_Somatoform_Disorders [accessed Oct 29, 2015].

This thesis describes the mental health disturbances in the wake of the Ghislenghien gas explosion (July 30th 2004) which instantly killed five firefighters, one police officer and 18 other people. Moreover, 132 people were wounded among which many suffered severe burn injuries. The Ghislenghien studies aimed at clarifying the impact of a technological disaster, both phenomenologically and empirically. On the phenomenological side, the lived experiences of a disaster survivor are used to set the stage for a discussion on the conceptual differences between mainstream (Anglo-Saxon) trauma theories and the more classical (French) psychodynamic theories. On the empirical side, the study focused on the prevalence of posttraumatic stress symptoms in adult and child survivors of a massive gas explosion, in their family members as well in family members of deceased victims. Other research questions focused on the risk factors regarding the development of posttraumatic stress symptoms and other mental health disturbances. A secondary aim was also to better understand the challenges of the type and timing of psychological help in the wake of technological disaster. Therefore, this thesis consists of a phenomenological part and an empirical part. The phenomenological part consists of three chapters which provide contextual information on the trauma inflicted by a massive explosion. The empirical part consists of four chapters providing a quantitative approach of trauma-related mental health disturbances in adults and children after a technological disaster. The phenomenological part starts with the testimony of a survivor of the Ghislenghien disaster and the interpretation of this survival in terms of both empirical (Anglo-Saxon) trauma models and the psychodynamic (French) theories The phenomenological part also examines the conceptualization of psychological trauma in contemporary French theory and the disaster-related experiences in fire and emergency services personnel. The empirical part of this manuscript is based on a longitudinal study conducted in order to assess the impact of the disaster on physical, mental and social health. The study included adults (≥ 15 years) and children (8-14 years) at risk of developing adverse health effects related to the disaster at 5 months and 14 months after the disaster. Four chapters report on this study and discuss respectively: the strengths and weaknesses of the methodology employed, the difficulties and challenges encountered during the design of the study and the risk factors of developing trauma-related symptoms and mental health disturbances. The results clearly indicate the influence of the degree of exposure, peritraumatic dissociation and dissatisfaction with social support on the development of posttraumatic stress symptoms. The risk for the development of four types of mental health disturbances (somatization, depression, anxiety and sleeping disturbances) was much higher in direct witnesses who have seen human damage than in victims who have not seen human damage. In children, risk factors for the development of posttraumatic stress reactions were related to the type of exposure to the disaster, peritraumatic dissociation during or immediately after the disaster, and dissatisfaction with the received psychological help. This epilogue discusses possible future developments for early psychophysiological stabilization of disaster victims.

Background Many refugees resettled in Western countries struggle to attain a level of psychological well-being. Heavily burdened by pre- and post-migration stressors, refugees are at considerable risk of developing posttraumatic stress disorder (PTSD). The accumulation of stressors is also what makes them, in the eyes of many clinicians, complex and difficult to treat. Although trauma-focused treatment, such as trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitisation and reprocessing therapy (EMDR), is recommended as first-line treatment for adults who suffer from PTSD, in refugees this recommendation is often contended. Instead, clinicians are advised to focus on psychosocial stabilisation as direct trauma-focused treatment is feared to be ineffective and even harmful. The contradictions between the two approaches have been subject of recent debate. Aims An eye for complexity contributes to a clarification of this debate by presenting the outcomes of several studies with refugees. The overall aim of this thesis is to contribute to an improvement of mental health care offered to treatment-seeking refugees. To this end, the thesis addresses three main research questions: What is the safety and efficacy of EMDR compared to that of stabilisation in traumatised asylum seekers and refugees? What is the applicability of the complex PTSD construct to refugees? Can traumatised asylum seekers and refugees be safely and effectively treated with trauma-focused therapy? Method These questions are answered through six studies: a systematic review of treatment outcome studies of EMDR in refugees; a pilot study of EMDR (11 sessions) versus stabilisation (11 sessions) with 20 traumatised refugees treated at a specialised institute; a randomised controlled trial of EMDR (12 hours) versus stabilisation (12 hours) in 72 refugees who suffer from PTSD; a multilevel analysis of the trial data to identify predictors for treatment response in refugees; a naturalistic study comparing the effectiveness of treatment as usual in refugees and non-refugees; and a systematic review of the prevalence of complex PTSD in refugee populations. Results In this thesis it is shown that although the acceptability, safety and efficacy of EMDR with refugees are matters of interest, very little research in this area has been done. A pilot study showed EMDR to be safe and efficacious enough with treatment-seeking refugees to warrant the conduct of a full randomised controlled trial. Consequently, in a randomised controlled trial both EMDR and stabilisation were shown to be safe and limitedly efficacious with refugees who suffer from PTSD. Two predictor studies showed that treatment-response in refugee participants appears related to depressive symptom severity and diagnosis as well as PTSD symptom severity at intake. Finally, prevalence of complex PTSD in refugees was shown to be relatively low. Conclusions Refugees may be safely treated with a short course of EMDR (9 sessions), but efficacy may be limited. Treatment response may be hampered by depressive symptoms. The construct of complex PTSD may only limitedly apply to traumatised refugees. Current research supports a recommendation of trauma-focused rather than phase-based treatment in refugees who seek treatment for PTSD, including asylum seekers.

Child maltreatment (CM) is associated with poor long-term health outcomes. However, knowledge about CM prevalence and related consequences is scarce among adults in South European countries. We examined the self-reported prevalence of five different forms of CM in a community sample of 1,200 Portuguese adults; we compared the results with similar samples from three other countries, using the same instrument. We also explored the relationship between CM and psychological symptoms. Cross-sectional data using the Childhood Trauma Questionnaire-Short Form and the Brief Symptom Inventory were analyzed. Moderate or severe CM exposure was self-reported by 14.7 % of the sample, and 67 % was exposed to more than one form of CM. Emotional neglect was the most endorsed experience, with women reporting greater emotional abuse and men reporting larger physical abuse. Physical and sexual abuse was less self-reported by Portuguese than by American or German subjects. CM exposure predicted 12.8 % of the psychological distress. Emotional abuse was the strongest predictor for psychological symptoms, namely for paranoid ideation, depression, and interpersonal sensitivity. Emotional abuse overlapped with the exposure to all other CM forms, and interacted with physical abuse, physical neglect, and emotional neglect to predict psychological distress. Low exposure to emotional abuse was directly associated with the effects of physical abuse, physical neglect, and emotional neglect to predict adult psychological distress. Verbal abuse experiences were frequently reported and had the highest correlations with adult psychological distress. Our results underline the potential hurtful effects of child emotional abuse among Portuguese adults in the community. They also highlight the need to improve prevention and intervention actions to reduce exposure and consequences of CM, particularly emotional abuse.

Exposure to mass trauma may bring about increased sensitivity to new or ongoing stressors. It is unclear whether sensitivity to stress associated with ethnic minority/immigrant status may be affected by severe exposure to mass trauma. We examined whether the loss of loved ones or home due to a disaster is associated with more persistent disaster-related distress in ethnic minorities compared with Dutch natives in the Netherlands. In residents affected by a fireworks disaster ( N = 1029), we assessed disaster-related distress after 3 weeks, 18 months, and 4 years. The effects of loss of loved ones or home and ethnic minority/immigrant status on distress were analyzed using latent growth modeling. After controlling for age, gender, education, employment, and post-disaster stressful life events, the loss of loved ones was associated with more persistent disaster-related distress in ethnic minorities compared with natives at 18 months, and the loss of home was associated with more persistent disaster-related distress in ethnic minorities compared with natives between 18 months and 4 years. Our results suggest that the loss of loved ones may increase sensitivity to stress associated with ethnic minority/immigrant status during the early phase of adaptation to a disaster. Loss of home may lead to further resource loss and thereby increase sensitivity to stress associated with ethnic minority/immigrant status in the long term. Efforts to prevent stress-related psychopathology following mass trauma should specifically target ethnic minority groups, notably refugees and asylum seekers, who often experienced multiple losses of loved ones as well as their homes.