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Background: Chronic pain is a common comorbid complaint in traumatized refugees seeking treatment for posttraumatic stress disorder (PTSD) and depression. However, the effect of comorbid pain on treatment remains under investigated. Objective: To investigate whether pre-treatment pain (severity/interference) predicts outcomes in a multimodal treatment targeting PTSD, depression, anxiety, somatic complaints, and health-related disability in refugees exposed to torture and organized violence. Additional predictors were gender, age, and number of treatment sessions. Method: Participants were active cases at a specialist outpatient clinic for tortured refugees (n = 276; 170 men, 106 women) who were either on a treatment waitlist (mean length = 7.4 months, SD = 4.5), in treatment (mean length = 12.2 months, SD = 6.5), or who completed treatment and had (or were waiting for) a follow-up assessment. Participants completed symptom measures at referral, pre- and post-treatment, and 9-month follow-up. Multi-level mixed modelling was used to assess whether outcomes at post-treatment and 9-months were predicted by pain, gender, age, or the number of treatment sessions. Results: Treatment yielded significant pre-to-post-treatment reductions in PTSD, depression, anxiety, and number of pain locations, but no reductions in pain severity/interference, or health-related disability, except for societal participation. Gains for PTSD, depression, and societal participation were maintained at the 9-month follow-up. Higher levels of pain interference (but not severity) predicted poorer outcomes (PTSD, depression, and anxiety). Age, gender and number of treatment sessions did not predict outcomes, except for a small negative effect of (older) age on PTSD. Conclusions: A growing body of literature suggests that pain and PTSD symptoms interact in ways to increase the severity and impact of both disorders in refugee and non-refugee populations alike. The present study suggests interference fr

Panic Disorder, with or without agoraphobia (PDA or PD, respectively), is a major public health problem. After having established a PD diagnosis based on the DSM or the ICD systems, the Panic Disorder Severity Scale (PDSS) is the most widely-used interview-based instrument for assessing disorder severity. There is also a self-report version of the instrument (PDSS-SR); both exist in a Swedish translation but their psychometric properties remain untested. In a sample of 221 adults with PD/PDA recruited to a randomized controlled preference trial of cognitive-behavioural and brief panic-focused psychodynamic psychotherapy, both forms possessed excellent psychometric properties (internal consistency, test-retest reliability) and convergent validity. A single factor structure for both versions was not confirmed. In terms of clinical utility, the PDSS had very high inter-rater reliability and correspondence with PD assessed via structured diagnostic interview. Both versions were sensitive to the effects of PD-focused treatment, although subjects scored systematically lower on the self-report version.

Background: Panic Disorder with or without Agoraphobia is a commonly occurring disorder affecting 2-3% of the population in Sweden. Untreated, panic disorder is a chronic condition that significantly increases the risk for psychiatric comorbidity, morbidity and mortality, employment difficulties, and healthcare utilization. Cognitive behavioural approaches are the recommended first-line treatment for panic disorder, however many patients in routine care receive another evidence-based psychotherapy, including psychodynamic therapy. Allowing patients to choose among evidence-based approaches to panic disorder may improve outcomes and reduce overall health costs. Trials involving comparing the gold standard treatment for panic disorder to other evidence based psychotherapies are needed, and also trials which can separate patient preferences for treatment from randomization effects on outcome, disability and healthcare utilization in the longer-term. Methods/Design: A phase 2/3 doubly-randomized controlled trial carried out in routine care with 216 adults (aged 18-60 years) with a primary diagnosis of DSM-IV Panic Disorder (with or without Agoraphobia). Within each clinic, patients are randomized to self-selection, random assignment of treatment, or wait-list. Patients choose or are randomly assigned to either Panic Control Treatment or Panic Focussed Psychodynamic Psychotherapy. Primary outcomes are changes in panic symptom severity, occupational status, and sickness-related absences from work at 6, 12 and 24 months post-treatment. Secondary outcomes include changes in agoraphobic avoidance, psychiatric comorbidity, disability, and healthcare utilization. The study also employs elements of an effectiveness trial as therapist and service-related effects on outcome will be estimated. Putative change mechanisms for CBT and PF-PP are also assessed. Discussion: CBT and psychodynamic therapy are evidence-based approaches that are routinely offered to panic disorder patients

Background: Increasing survival rates for pediatric brain tumor patients creates a greater need for neuropsychologic follow-up and intervention. The aim of this study was to evaluate rates of referral by medical doctors to neuropsychologic services and patient and treatment factors that differentiated referred and non-referred patients. Methods: Data were retrieved from medical records of all pediatric brain tumor patients in Southern Sweden diagnosed between 1993 and 2004 who survived more than one year (n=132). Characteristics of the patients, the cancer, and treatment received were then compared for patients who were and were not referred for neuropsychologic examination during that period. Results: Sixty-four (48%) of the pediatric brain tumor patients were referred for neuropsychologic evaluation. These patients had significantly larger tumors, more recurrences of cancer, and increased intracranial pressure at diagnosis when compared to the non-referred group (n=68). However most of the patients in the non-referred group either had risk significant factors for cognitive impairment or were reporting impairments that would suggest a referral was warranted. Conclusions: Given the high rates of cognitive impairment found in patients with pediatric brain tumors, survivors should be referred to neuropsychologic services. In addition to improving long-term adjustment, systematic referral can provide data on cognitive impairments that may inform cost-benefit-analyses when deciding on various treatments at the point of diagnosis. Greater efforts are needed to disseminate and raise awareness about published guidelines on the long-term care of pediatric brain tumor patients.

Purpose of review: We review recent evidence regarding risk factors for childhood posttraumatic stress disorder (PTSD) and treatment outcome studies from 2010 to 2012 including dissemination studies, early intervention studies and studies involving preschool children.Recent findings: Recent large-scale epidemiological surveys confirm that PTSD occurs in a minority of children and young people exposed to trauma. Detailed follow-up studies of trauma-exposed young people have investigated factors that distinguish those who develop a chronic PTSD from those who do not, with recent studies highlighting the importance of cognitive (thoughts, beliefs and memories) and social factors. Such findings are informative in developing treatments for young people with PTSD. Recent randomized controlled trials (RCTs) confirm that trauma-focused cognitive behaviour therapy (TF-CBT) is a highly efficacious treatment for PTSD, although questions remain about effective treatment components. A small number of dissemination studies indicate that TF-CBT can be effective when delivered in school and community settings. One recent RCT shows that TF-CBT is feasible and highly beneficial for very young preschool children. Studies of early intervention show mixed findings. Summary: Various forms of theory-based TF-CBT are highly effective in the treatment of children and adolescents with PTSD. Further work is needed to replicate and extend initial promising outcomes of TF-CBT for very young children. Dissemination studies and early intervention studies show mixed findings and further work is needed.

Studies have found that the cognitive model of worry developed by Dugas, Gagnon, Ladouceur and Freeston (1998) involving Intolerance of Uncertainly (IU), Cognitive Avoidance (CA), Positive Beliefs about Worry (PB), and Negative Problem Orientation (NPO) accounts for approximately 40-50% of the variance in worry frequency in adults. A recent trial of the treatment based on this model (Dugas, Brillon, Savard et al., 2010) found it to be superior to no treatment and marginally superior to applied relaxation in adults with Generalized Anxiety Disorder (GAD). In this presentation the authors discuss the results of two studies testing the applicability of this cognitive model to children and adolescents. In the first study measures of IU, CA, PB, worry and anxiety were administered to 515 British primary and secondary school students (aged 7-19 years). A path analysis was undertaken to test whether IU acted as a higher order variable for CA and PB and whether the relationship between IU/CA/PB and anxiety was mediated by worry frequency. Significant (bivariate) correlations were observed between the measures of IU, PB, CA, worry and anxiety across the age range. However separate path models had to be fitted for children (aged 7-12 years) and adolescents (aged 13-19) with PB being dropped from the child model. CA was related to anxiety only through worry in children while IU showed direct paths to worry and anxiety in both children and adolescents. In the second study we present results from a case series where a modified version of the treatment based on the Dugas et al (1998) led to an 80% reduction in GAD diagnoses in 16 youth (aged 7-17 years) clinically referred for anxiety. Further testing and refinement of this cognitive model and its treatment may lead to further improvements in our understanding of worry in youth and its treatment. Possible modifications and refinements are discussed.