January 2018 - Volume 206 - Issue 1

  • John A. Talbott, MD
  • 0022-3018
  • 1539-736X
  • 12 issues / year
  • 1.860


Assessing and Treating Posttraumatic Stress Disorder: An Update


Psychiatric Disorders and Predictors Hereof Among Refugee Children in Early Adulthood: A Register-Based Cohort Study
Amina Barghadouch, MSc, Jessica Carlsson, MD, PhD, and Marie Norredam, PhD, DMSc

A total of 15,264 young adult refugees were matched 1:6 on age and sex with 99,313 Danish-born children. Rate ratios (RR) of having a first-time in- or outpatient hospital diagnosis with an affective (F30–39), psychotic (F29–30), neurotic (F40–48), or any psychiatric disorder (F00–99) according to ICD-10 were computed. Refugees had higher RRs of psychotic (RR: 1.81, 95% CI: 1.41–2.32) and nervous (RR: 1.28, 95% CI: 1.14–1.43) disorders compared with Danish-born children. The RRs of having an affective disorder among refugees was 0.74 (95% CI: 0.60–0.90) compared with Danish-born children. Sex, geographical origin, migrant status, household income, age at residence permission, and accompanied/unaccompanied arrival predicted psychiatric contacts among refugees.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence? Evidence From Post-Genocide Rwanda
Richard Neugebauer, PhD, MPH, Allana Forde, MPH, Kinga E. Fodor, MA, Prudence W. Fisher, PhD, J. Blake Turner, PhD, Tasha Stehling-Ariza, PhD, and Saori Yamabe, MA

We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8–19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. Posttraumatic stress symptoms (PTSS) were assessed with a symptom checklist based on DSM-IV indexed. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal.

The Role of Relocation Patterns and Psychosocial Stressors in Posttraumatic Stress Disorder and Depression Among Earthquake Survivors
Ebru Salcioglu, PhD, Sahin Ozden, MA, and Furkan Ari, BA

The psychological impact of relocation within and outside of a disaster region was examined in 541 survivors of the 2011 Van earthquake in Turkey at 16.5 months postdisaster. Anticipatory fear of future earthquakes and less sense of control over life were the strongest predictors of posttraumatic stress disorder (PTSD) and depression symptoms. Relocation within the disaster region predicted PTSD but not depression. Dissatisfaction with emotional support received from close ones was significantly associated with depression, but associated with PTSD at a marginally significant level. Survivors who experienced more intense fear during the earthquake displayed higher levels of anticipatory fear in the long term, whereas avoidance of trauma reminders and fear-evoking situations sustained anticipatory fear of future earthquakes. These findings suggest that interventions that reduce fear and avoidance behaviors would help survivors overcome traumatic stress and depressive symptoms.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers
Natacha Premand, MD, Rachel Baeriswyl-Cottin, MA, Marianne Gex-Fabry, PhD, Nikol Hiller, MA, David Framorando, MA, Ariel Eytan, MD, Panteleimon Giannakopoulos, MD, MSc, and Javier Bartolomei, MD

The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers, and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization.

Predicting the Mental Health and Functioning of Torture Survivors
Suzan J. Song, MD, MPH, PhD, Andrew Subica, PhD, Charles Kaplan, PhD, Wietse Tol, PhD, and Joop de Jong, MD, PhD

This study investigates whether sociodemographic, premigration and postmigration, and psychosocial factors predict adverse psychiatric symptoms in refugees and asylum seekers exposed to torture (N = 278). Hierarchical linear regressions revealed that female sex, older age, and unstable housing predicted greater severity of anxiety, PTSD, and depression. Cumulative exposure to multiple torture types predicted anxiety and PTSD, while mental health, basic resources, and external risks (risk of being victimized at home, community, work, school) were the strongest psychosocial predictors of anxiety, PTSD, and depression. Also, time spent in the U.S. before presenting for services significantly predicted anxiety, PTSD, and depression.

Prevalence and Predictors of Posttraumatic Stress and Depression Symptoms Among Syrian Refugees in a Refugee Camp
Ceren Acarturk, PhD, Mustafa Cetinkaya, MA, Ibrahim Senay, PhD, Birgul Gulen, MA, Tamer Aker, MD, and Devon Hinton, MD

The current study investigates the prevalence of probable PTSD and depression among adult Syrians residing in a camp (N = 781) and potential predictors. The Impact of Event Scale–Revised was used to measure PTSD and the Beck Depression Inventory depression. Probable PTSD prevalence was 83.4%, with predictors being female sex (odds ratio [OR], 4.1), previous mental health problems (OR, 4.5), life threat (OR, 3.0), and injury of a loved one (OR, 1.8). Probable depression prevalence was 37.4%, with predictors being female sex (OR, 5.1), previous mental health problems (OR, 2.9), having a loved one who was tortured (OR, 1.7), and not being satisfied at the camp (OR, 1.7). The current study reveals high rates of probable PTSD and depression among Syrian refugees, and highlights vulnerabilities such as great risk for women of having psychopathology.

Contributors to Screening Positive for Mental Illness in Lebanon's Shatila Palestinian Refugee Camp
Steven P. Segal, PhD, Vicky C. Khoury, MS, Ramy Salah, MD, and Jess Ghannam, PhD

This study evaluates contributors to the mental health status of Palestinians, Syrians, and nonrefugee residents of Lebanon's Shatila Refugee Camp. Primary health care clinic patients in Shatila were screened for mental illness between 2012 and 2013 using the K6, the Primary Care Posttraumatic Stress Disorder (PTSD), and the Modified Mini International Neuropsychiatric Interview. The sample (n = 254) included 63.4% Palestinians, 18.5% Syrians, and 18.1% nonrefugees. People lived in the camp for 21.1 years (±17), 63% had stable housing and 78% had war event exposure. Mental illness prevalence was 51.6% in total (34.8% serious mental illness [SMI] alone, 5.1% PTSD alone, 11.4% comorbid SMI/PTSD, and 0.08% comorbid psychotic spectrum disorder SMI/PTSD). For Palestinians and nonrefugees, respectively, stable housing accounted for a 79% and a 98% reduction in positive SMI screen risk. For Syrians, access to paid employment accounted for a 66% risk reduction. Stable living situations and economically productive employment for those trapped in a refugee situation seem most important for ensuring reduced mental disorder risk.

The Effects of Traumatic and Multiple Loss on Psychopathology, Disability, and Quality of Life in Iraqi Asylum Seekers in the Netherlands
Sophie M.C. Hengst, MD, Geert E. Smid, MD, PhD, and Cornelis J. Laban, MD, PhD

Respondents (N = 294) completed structured Arabic interviews. Data were analyzed using structural equation modeling. The loss of a loved one was reported by 87.6% of the sample. Traumatic and multiple losses of family members independently predicted psychopathology, taking the effects of other traumatic events, postmigration stressors, and sociodemographic characteristics into account. Effects of traumatic and multiple losses on quality of life and disability were either partially or fully mediated by psychopathology. These findings highlight the need to evaluate and treat the effects of the loss of loved ones when working with asylum seekers and refugees.

The Range and Impact of Postmigration Stressors During Treatment of Trauma-affected Refugees

A total of 116 patients completed 6 months of multidisciplinary treatment. Clinician-rated postmigration stressors were registered at each session. Outcome measures were Harvard Trauma Questionnaire and Global Assessment of Functioning, function (GAF-F) and symptom. Postmigration stressors were deemed to impact on 39.1% of treatment sessions with medical personnel. Issues related to work, finances, and family were the most frequently identified stressors. Postmigration stressors interfering with treatment were more common among male refugees, those living alone, those from Middle Eastern origin, and persons with low baseline GAF-F.


Evoked Death-Related Thoughts in the Aftermath of Terror Attack: The Associations Between Mortality Salience Effect and Adjustment Disorder
Lia Ring, MSW, Osnat Lavenda, PhD, Yaira Hamama-Raz, PhD, Menachem Ben-Ezra, PhD, Shani Pitcho-Prelorentzos, MSW, Udi Y. David, MSW, Adi Zaken, MSW, and Michal Mahat-Shamir, PhD

The current study examined whether mortality salience effect, a possible consequence of a terror attack, may serve as a significant predictor associated with each of the adjustment disorder (AjD) subscales. Using an online survey, 379 adult participants were recruited and filled out self-reported questionnaires dealing with AjD symptoms, as well as mortality salience effect. Findings revealed that mortality salience effect was a significant predictor of all AjD subscales.

The Influence of Trauma Type and Timing on PTSD Symptoms
Jeffrey Guina, MD, Ramzi W. Nahhas, PhD, Paige Sutton, MD, and Seth Farnsworth, MD§

This cross-sectional study surveyed a consecutive sample of mental health outpatients (n = 602), using regression to estimate associations between DSM-5 PTSSs and demographics, several trauma types, and age at first trauma in those with trauma (n = 367). Combat and sexual trauma were associated with worse total posttraumatic stress symptoms (PTSS) severity. Combat was significantly associated with arousal and intrusions (especially physical symptoms), sexual trauma with conscious avoidance and negative cognitions/mood (especially amnesia, an unconscious avoidance symptom), and physical assault with blame. Interpersonal traumas were the most common first traumas experienced, but age at first trauma was not significantly associated with PTSS severity.


Textbook of Disaster Psychiatry, Second Edition. Robert J. Ursano, MD, Carol S. Fullterson, PhD, Lars Weisaeth, MD, and Beverly Raphael, MD, Eds. (2017) Cambridge, United Kingdom. 364 pp. Reviewed by Pedro Ruiz, MD.


2017 Annual Acknowledgment​​

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