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1.  Prevalence and Predictors of Posttraumatic Stress Disorder and Depression in HIV-Infected and At-Risk Rwandan Women 
Journal of Women's Health  2009;18(11):1783-1791.
During the 1994 Rwandan genocide, rape was used as a weapon of war to transmit HIV. This study measures trauma experiences of Rwandan women and identifies predictors associated with posttraumatic stress disorder (PTSD) and depressive symptoms.
The Rwandan Women's Interassociation Study and Assessment (RWISA) is a prospective observational cohort study designed to assess effectiveness and toxicity of antiretroviral therapy in HIV-infected Rwandan women. In 2005, a Rwandan-adapted Harvard Trauma Questionnaire (HTQ) and the Center for Epidemiologic Studies Depression Scale (CES-D) were used to assess genocide trauma events and prevalence of PTSD (HTQ mean >2) and depressive symptoms (CES-D ≥ 16) for 850 women (658 HIV-positive and 192 HIV-negative).
PTSD was common in HIV-positive (58%) and HIV-negative women (66%) (p = 0.05). Women with HIV had a higher prevalence of depressive symptoms than HIV-negative women (81% vs. 65%, p < 0.0001). Independent predictors for increased PTSD were experiencing more genocide-related trauma events and having more depressive symptoms. Independent predictors for increased depressive symptoms were making <$18 a month, HIV infection (and, among HIV-positive women, having lower CD4 cell counts), a history of genocidal rape, and having more PTSD symptoms.
The prevalence of PTSD and depressive symptoms is high in women in the RWISA cohort. Four of five HIV-infected women had depressive symptoms, with highest rates among women with CD4 cell counts <200. In addition to treatment with antiretroviral therapy, economic empowerment and identification and treatment of depression and PTSD may reduce morbidity and mortality among women in postconflict countries.
PMCID: PMC2828188  PMID: 19951212
2.  Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide 
Psychiatry research  2003;117(1):1-9.
The present study is the first to attempt to determine rates of panic attacks, especially ‘somatically focused’ panic attacks, panic disorder, symptoms of post-traumatic stress disorder (PTSD), and depression levels in a population of Rwandans traumatized by the 1994 genocide. The following measures were utilized: the Rwandan Panic-Disorder Survey (RPDS); the Beck Depression Inventory (BDI); the Harvard Trauma Questionnaire (HTQ); and the PTSD Checklist (PCL). Forty of 100 Rwandan widows suffered somatically focused panic attacks during the previous 4 weeks. Thirty-five (87%) of those having panic attacks suffered panic disorder, making the rate of panic disorder for the entire sample 35%. Rwandan widows with panic attacks had greater psychopathology on all measures. Somatically focused panic-attack subtypes seem to constitute a key response to trauma in the Rwandan population. Future studies of traumatized non-Western populations should carefully assess not only somatoform disorder but also somatically focused panic attacks.
PMCID: PMC2772881  PMID: 12581815
Panic disorder; Stress disorders; post-traumatic; Depression; Rwanda; Holocaust
3.  The Weight of Traumatic Stress: A Prospective Study of Posttraumatic Stress Disorder Symptoms and Weight Status in Women 
JAMA psychiatry  2014;71(1):44-51.
Posttraumatic stress disorder (PTSD) indicates a chronic stress reaction in response to trauma, and is a prevalent condition that has been identified as a possible risk factor for obesity.
To determine if women who develop PTSD symptoms are subsequently more likely to gain weight and become obese relative to either trauma exposed women who do not develop PTSD symptoms or women with no trauma and no PTSD symptoms, and if effects are independent of depression.
Design and Setting
The Nurses' Health Study II (NHS II), a prospective observational study initiated in 1989 with follow-up to 2005, using a PTSD screener to measure PTSD symptoms and when they onset.
The sub-sample of the NHSII (n= 54,224; ages 24–44 years in 1989) in whom trauma and PTSD symptoms were measured.
Main Outcome Measure(s)
Development of overweight and obesity using BMI cut-points 25.0 and 30.0kg/m2 respectively. Change in BMI during follow-up among women reporting PTSD symptom onset prior to 1989. BMI trajectory before and after PTSD symptom onset among women who developed PTSD symptoms during follow-up.
Among women with ≥ 4 PTSD symptoms prior to 1989 (cohort initiation) BMI increased more steeply (b = 0.05, SE = 0.01, p< 0.001) over the follow-up. Among women who developed PTSD symptoms after 1989, BMI trajectory did not differ by PTSD status before PTSD onset. After PTSD symptom onset, women with ≥ 4 symptoms had a faster rise in BMI (b = 0.07, SE = 0.02, p< 0.000). The onset of ≥ 4 PTSD symptoms after 1989 was also associated with increased risk of becoming overweight or obese (OR = 1.36, 95% CI: 1.19–1.56) among women who were normal weight in 1989. Effects were maintained after adjusting for depression.
Conclusions and Relevance
Experiencing PTSD symptoms is associated with increased risk of becoming overweight or obese, and PTSD symptom onset alters BMI trajectories over time. The presence of PTSD symptoms should raise clinician concerns about physical health problems that may develop and prompt closer attention to weight status.
PMCID: PMC4091890  PMID: 24258147
body weight changes; weight status; obesity; PTSD; stress; women
4.  Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case-control study 
Croatian Medical Journal  2011;52(4):505-512.
To determine the presence of disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans who suffer from combat-related posttraumatic stress disorder (PTSD).
The research included 247 veterans of the 1991-1995 war in Croatia who suffered from PTSD and were psychiatrically examined at four clinical centers in Croatia during a month in 2008. It was based on the following self-assessment instruments: The Harvard Trauma Questionnaire (HTQ): Croatian Version, the Structured Interview for Disorder of Extreme Stress (SIDES-SR), and the Mini International Neuropsychiatric Interview (MINI)
Based on the SIDES-SR results, we formed two groups of participants: the group with PTSD (N = 140) and the group with both PTSD and DESNOS (N = 107). Forty three percent of participants met the criteria for DESNOS. There was a significant difference in the intensity of posttraumatic symptoms between the group with both PTSD and DESNOS and the group with PTSD only (U = 3733.5, P = 0.001). Respondents who suffered from both PTSD and DESNOS also reported a significantly larger number of comorbid mental disorders (U = 1123.5, P = 0.049) and twice more frequently reported comorbid depression with melancholic features (OR = 2.109, P = 0.043), social phobia (OR = 2.137, P = 0.036), or panic disorder (OR = 2.208, P = 0.015).
Our results demonstrate that PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria. A greater intensity of symptoms and a more frequent comorbidity with other psychiatric disorders, especially depression, panic disorder, and social phobia require additional therapy interventions in the treatment processes.
PMCID: PMC3160697  PMID: 21853545
5.  What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? a cross-sectional community study in South Sudan 
BMC Psychiatry  2012;12:175.
Limited data exists on the association of war trauma with comorbid posttraumatic stress disorder (PTSD)-depression in the general population of low-income countries. The present study aimed to evaluate socioeconomic and trauma-related risk factors associated with PTSD, depression, and PTSD-depression comorbidity in the population of Greater Bahr el Ghazal States, South Sudan.
In this cross-sectional community study (n=1200) we applied the Harvard Trauma Questionnaire (HTQ) and MINI International Neuropsychiatric Interview (MINI) to investigate the prevalence of PTSD, depression, and PTSD-depression comorbidity. Multinomial logistic regression analyses were conducted to examine the association between these disorders, previous trauma exposure, sociodemographic, and socioeconomic factors.
PTSD only was found in 331 (28%) and depression only in 75 (6.4%) of the study population. One hundred and twelve (9.5%) of the participants had PTSD-depression comorbid diagnosis. Exposure to traumatic events and socioeconomic disadvantage were significantly associated with having PTSD or PTSD-depression comorbidity but not with depression. Participants with a comorbid condition were more likely to be socioeconomic disadvantaged, have experienced more traumatic events, and showed higher level of psychological distress than participants with PTSD or depression alone.
In individuals exposed to war trauma, attention should be given to those who may fulfill criteria for a diagnosis of both PTSD and depression.
PMCID: PMC3534332  PMID: 23083301
PTSD; Depression; Comorbidity; Tauma; Post-conflict; Socioeconomic, South Sudan
6.  Psychological Consequences of War Trauma and Postwar Social Stressors in Women in Bosnia and Herzegovina 
Croatian medical journal  2007;48(2):167-176.
To assess the consequences of psychotrauma in civilian women in Herzegovina who were exposed to prolonged and repetitive traumatic war events and postwar social stressors.
The study included a cluster sample of 367 adult women, divided into two groups. One group (n = 187) comprised women from West Mostar who were exposed to serious war and posttraumatic war events. The other group (n = 180) comprised women from urban areas in Western Herzegovina who were not directly exposed to war destruction and material losses, but experienced war indirectly, through military drafting of their family members and friends. Demographic data on the women were collected by a questionnaire created for the purpose of this study. Data on trauma exposure and posttraumatic stress disorder (PTSD) symptoms were collected by Harvard Trauma Questionnaire (HTQ) – Bosnia-Herzegovina version. General psychological symptoms were determined with Symptom Check List-90-revised (SCL-90-R). Data on postwar stressors were collected by a separate questionnaire.
In comparison with the control group, women from Western Mostar experienced significantly more traumatic events (mean ± standard deviation [SD], 3.3 ± 3.2 vs 10.1 ± 4.9, respectively, t = 15.91; P<0.001) and had more posttraumatic symptoms (12.3 ± 10.3 vs 21.2 ± 10.9, respectively, t = 8.42; P<0.001). They also had significantly higher prevalence of PTSD (4.4% vs 28.3%, respectively; χ2 = 52.56; P<0.001). The number of traumatic events experienced during the war was positively associated with postwar stressful events both in the West Mostar group (r = 0.223; P = 0.002) and control group (r = 0.276; P<0.001). Postwar stressful events contributed both to the number and intensity of PTSD symptoms and all general psychological symptoms measured with SCL-90 questionnaire, independently from the number of experienced traumatic war events.
Long-term exposure to war and postwar stressors caused serious psychological consequences in civilian women, with PTSD being only one of the disorders in the wide spectrum of posttraumatic reactions. Postwar stressors did not influence the prevalence of PTSD but they did contribute to the intensity and number of posttraumatic symptoms.
PMCID: PMC2080525  PMID: 17436381
7.  Exposures to war-related traumatic events and post-traumatic stress disorder symptoms among displaced Darfuri female university students: an exploratory study 
BMC Public Health  2012;12:603.
With the deaths of hundreds of thousands and the displacement of up to three million Darfuris, the increasingly complex and on-going war in Darfur has warranted the need to investigate war-related severity and current mental health levels amongst its civilian population. The purpose of this study is to explore the association between war-related exposures and assess post-traumatic stress disorder (PTSD) symptoms amongst a sample of Darfuri female university students at Ahfad University for Women (AUW) in Omdurman city.
An exploratory cross-sectional study among a representative sample of Darfuri female university students at AUW (N = 123) was conducted in February 2010. Using an adapted version of the Harvard Trauma Questionnaire (HTQ), war-related exposures and post-traumatic stress disorder (PTSD) symptoms were assessed. Means and standard deviations illustrated the experiential severity of war exposure dimensions and PTSD symptom sub-scales, while Pearson correlations tested for the strength of association between dimensions of war exposures and PTSD symptom sub-scales.
Approximately 42 % of the Darfuri participants reported being displaced and 54 % have experienced war-related traumatic exposures either as victims or as witnesses (M = 28, SD = 14.24, range 0 – 40 events). Also, there was a strong association between the experiential dimension of war-related trauma exposures and the full symptom of PTSD. Moreover, the refugee-specific self-perception of functioning sub-scale within the PTSD measurement scored a mean of 3.2 (SD = .56), well above the 2.0 cut-off.
This study provides evidence for a relationship between traumatic war-related exposures and symptom rates of PTSD among AUW Darfuri female students. Findings are discussed in terms of AUW counseling service improvement.
PMCID: PMC3461465  PMID: 22863107
8.  Validation of a French adaptation of the Harvard Trauma Questionnaire among torture survivors from sub-Saharan African countries 
European Journal of Psychotraumatology  2012;3:10.3402/ejpt.v3i0.19225.
To date no validated instrument in the French language exists to screen for posttraumatic stress disorder (PTSD) in survivors of torture and organized violence.
The aim of this study is to adapt and validate the Harvard Trauma Questionnaire (HTQ) to this population.
The adapted version was administered to 52 French-speaking torture survivors, originally from sub-Saharan African countries, receiving psychological treatment in specialized treatment centers. A structured clinical interview for DSM was also conducted in order to assess if they met criteria for PTSD.
Cronbach's alpha coefficient for the HTQ Part 4 was adequate (0.95). Criterion validity was evaluated using receiver operating characteristic curve analysis that generated good classification accuracy for PTSD (0.83). At the original cut-off score of 2.5, the HTQ demonstrated high sensitivity and specificity (0.87 and 0.73, respectively).
Results support the reliability and validity of the French version of the HTQ.
PMCID: PMC3517723  PMID: 23233870
Refugees; ethnic/cultural minorities; torture; cross-cultural assessment; questionnaire
9.  Treatment of a Multitraumatized Tortured Refugee Needing an Interpreter with Exposure Therapy 
Case Reports in Psychiatry  2013;2013:197323.
This paper described the application and feasibility of exposure therapy treatment (ET) for posttraumatic stress disorder (PTSD) in a multitraumatized tortured refugee with chronic PTSD and depression, in need of an interpreter. The patient received 26 one-hour sessions of ET involving exposure to his trauma-related memories. Symptoms of PTSD, depression, and anxiety were assessed at pre- and posttreatment and 3-, 6-, and 12-month followup with the Harvard Trauma Questionnaire (HTQ-R), PTSD Symptom Scale-Self Report (PSS-SR), Major depression inventory (MDI), and Beck Anxiety Inventory (BAI). Treatment led to a significant improvement across all measures of posttraumatic stress disorder, anxiety, and depression, and the improvement was maintained at the 12-month follow-up. The results from this case study provide further preliminary evidence that ET may be effective in treating multi-traumatized torture survivors who are refugees and in need of an interpreter, despite the additional stressors and symptoms complexity experienced by tortured refugees.
PMCID: PMC3580894  PMID: 23476868
10.  The psychological reactions after witnessing a killing in public in a Danish high school 
European Journal of Psychotraumatology  2013;4:10.3402/ejpt.v4i0.19826.
School killings attract immense media and public attention but psychological studies surrounding these events are rare.
To examine the prevalence of posttraumatic stress disorder (PTSD) and possible risk factors of PTSD in 320 Danish high school students (mean age 18 years) 7 months after witnessing a young man killing his former girlfriend in front of a large audience.
The students answered the Harvard Trauma Questionnaire (HTQ), the Crisis Support Scale (CSS), and the Trauma Symptom Checklist (TSC).
Prevalence of PTSD 7 months after the incident was 9.5%. Furthermore, 25% had PTSD at a subclinical level. Intimacy with the deceased girl; feeling fear, helplessness, or horror during the killing; lack of expressive ability; feeling let down by others; negative affectivity; and dissociation predicted 78% of the variance of the HTQ total scores.
It is possible to identify students who are most likely to suffer from PTSD. This knowledge could be used to intervene early on to reduce adversities.
PMCID: PMC3542399  PMID: 23316270
witnessing school killing; PTSD; social support; risk factors
11.  Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors 
European Journal of Psychotraumatology  2011;2:10.3402/ejpt.v2i0.6343.
During the Rwandan genocide of 1994, nearly one million people were killed within a period of 3 months.
The objectives of this study were to investigate the levels of trauma exposure and the rates of mental health disorders and to describe risk factors of posttraumatic stress reactions in Rwandan widows and orphans who had been exposed to the genocide.
Trained local psychologists interviewed orphans (n=206) and widows (n=194). We used the PSS-I to assess posttraumatic stress disorder (PTSD), the Hopkins Symptom Checklist to assess depression and anxiety symptoms, and the M.I.N.I. to assess risk of suicidality.
Subjects reported having been exposed to a high number of different types of traumatic events with a mean of 11 for both groups. Widows displayed more severe mental health problems than orphans: 41% of the widows (compared to 29% of the orphans) met symptom criteria for PTSD and a substantial proportion of widows suffered from clinically significant depression (48% versus 34%) and anxiety symptoms (59% versus 42%) even 13 years after the genocide. Over one-third of respondents of both groups were classified as suicidal (38% versus 39%). Regression analysis indicated that PTSD severity was predicted mainly by cumulative exposure to traumatic stressors and by poor physical health status. In contrast, the importance given to religious/spiritual beliefs and economic variables did not correlate with symptoms of PTSD.
While a significant portion of widows and orphans continues to display severe posttraumatic stress reactions, widows seem to constitute a particularly vulnerable survivor group. Our results point to the chronicity of mental health problems in this population and show that PTSD may endure over time if not addressed by clinical intervention. Possible implications of poor mental health and the need for psychological intervention are discussed.
PMCID: PMC3402134  PMID: 22893816
Posttraumatic stress disorder; depression; anxiety; genocide; Rwanda; risk factors
12.  Association of FKBP5 Polymorphisms and Childhood Abuse With Risk of Posttraumatic Stress Disorder Symptoms in Adults 
In addition to trauma exposure, other factors contribute to risk for development of posttraumatic stress disorder (PTSD) in adulthood. Both genetic and environmental factors are contributory, with child abuse providing significant risk liability.
To increase understanding of genetic and environmental risk factors as well as their interaction in the development of PTSD by gene × environment interactions of child abuse, level of non–child abuse trauma exposure, and genetic polymorphisms at the stress-related gene FKBP5.
Design, Setting, and Participants
A cross-sectional study examining genetic and psychological risk factors in 900 non psychiatric clinic patients (762 included for all genotype studies) with significant levels of childhood abuse as well as non–child abuse trauma using a verbally presented survey combined with single-nucleotide polymorphism (SNP) genotyping. Participants were primarily urban, low-income, black (>95%) men and women seeking care in the general medical care and obstetrics-gynecology clinics of an urban public hospital in Atlanta, Georgia, between 2005 and 2007.
Main Outcome Measures
Severity of adult PTSD symptomatology, measured with the modified PTSD Symptom Scale, non–child abuse (primarily adult) trauma exposure and child abuse measured using the traumatic events inventory and 8 SNPs spanning the FKBP5 locus.
Level of child abuse and non–child abuse trauma each separately predicted level of adult PTSD symptomatology (mean [SD], PTSD Symptom Scale for no child abuse, 8.03 [10.48] vs ≥2 types of abuse, 20.93 [14.32]; and for no non–child abuse trauma, 3.58 [6.27] vs ≥4 types, 16.74 [12.90]; P<.001). Although FKBP5 SNPs did not directly predict PTSD symptom outcome or interact with level of non–child abuse trauma to predict PTSD symptom severity, 4 SNPs in the FKBP5 locus significantly interacted (rs9296158, rs3800373, rs1360780, and rs9470080; minimum P=.0004) with the severity of child abuse to predict level of adult PTSD symptoms after correcting for multiple testing. This gene × environment interaction remained significant when controlling for depression severity scores, age, sex, levels of non–child abuse trauma exposure, and genetic ancestry. This genetic interaction was also paralleled by FKBP5 genotype-dependent and PTSD-dependent effects on glucocorticoid receptor sensitivity, measured by the dexamethasone suppression test.
Four SNPs of the FKBP5 gene interacted with severity of child abuse as a predictor of adult PTSD symptoms. There were no main effects of the SNPs on PTSD symptoms and no significant genetic interactions with level of non–child abuse trauma as predictor of adult PTSD symptoms, suggesting a potential gene-childhood environment interaction for adult PTSD.
PMCID: PMC2441757  PMID: 18349090
13.  A brief screening tool for assessing psychological trauma in clinical practice: development and validation of the New York PTSD Risk Score☆,☆☆ 
General hospital psychiatry  2011;33(5):489-500.
The objective was to develop a brief posttraumatic stress disorder (PTSD) screening instrument that is useful in clinical practice, similar to the Framingham Risk Score used in cardiovascular medicine.
We used data collected in New York City after the World Trade Center disaster (WTCD) and other trauma data to develop a new PTSD prediction tool — the New York PTSD Risk Score. We used diagnostic test methods to examine different clinical domains, including PTSD symptoms, trauma exposures, sleep disturbances, suicidal thoughts, depression symptoms, demographic factors and other measures to assess different PTSD prediction models.
Using receiver operating curve (ROC) and bootstrap methods, five prediction domains, including core PTSD symptoms, sleep disturbance, access to care status, depression symptoms and trauma history, and five demographic variables, including gender, age, education, race and ethnicity, were identified. For the best prediction model, the area under the ROC curve (AUC) was 0.880 for the Primary Care PTSD Screen alone (specificity=82.2%, sensitivity=93.7%). Adding care status, sleep disturbance, depression and trauma exposure increased the AUC to 0.943 (specificity=85.7%, sensitivity=93.1%), a significant ROC improvement (P < .0001). Adding demographic variables increased the AUC to 0.945, which was not significant (P=.250). To externally validate these models, we applied the WTCD results to 705 pain patients treated at a multispecialty group practice and to 225 trauma patients treated at a Level I Trauma Center. These results validated those from the original WTCD development and validation samples.
The New York PTSD Risk Score is a multifactor prediction tool that includes the Primary Care PTSD Screen, depression symptoms, access to care, sleep disturbance, trauma history and demographic variables and appears to be effective in predicting PTSD among patients seen in healthcare settings. This prediction tool is simple to administer and appears to outperform other screening measures.
PMCID: PMC3557518  PMID: 21777981
Posttraumatic stress disorder; Psychological Trauma; Diagnostic testing; Patient screening; Area under receiver operating characteristic (ROC) curve
14.  CBT for Vietnamese Refugees With Treatment-Resistant PTSD and Panic Attacks: A Pilot Study 
Journal of traumatic stress  2004;17(5):429-433.
We examined the feasibility, acceptability, and therapeutic efficacy of a culturally adapted cognitive–behavior therapy (CBT) for twelve Vietnamese refugees with treatment-resistant posttraumatic stress disorder (PTSD) and panic attacks. These patients were treated in two separate cohorts of six with staggered onset of treatment. Repeated measures Group × Time ANOVAs and between-group comparisons indicated significant improvements, with large effect sizes (Cohen’s d) for all outcome measures: Harvard Trauma Questionnaire (HTQ; d = 2.5); Anxiety Sensitivity Index (ASI; d = 4.3); Hopkins Symptom Checklist-25 (HSCL-25), anxiety subscale (d = 2.2); and Hopkins Symptom Checklist-25, depression subscale (d = 2.0) scores. Likewise, the severity of (culturally related) headache-and orthostasis-cued panic attacks improved significantly across treatment
PMCID: PMC2748790  PMID: 15633922
posttraumatic stress disorder; panic attacks; cognitive; behavior therapy; Vietnamese refugees
15.  Transgenerational consequences of PTSD: risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide 
Understanding how parental Posttraumatic Stress Disorder (PTSD) may or may not affect the development and mental health in the offspring is particularly important in conflict regions, where trauma-related illness is endemic. In Rwanda, organised atrocities and the genocide against the Tutsi of 1994 have left a significant fraction of the population with chronic PTSD. The aim of the present investigation was to establish whether PTSD in mothers is associated with symptoms of depression, anxiety, and aggressive and antisocial behaviour in their children.
A community sample of 125 Rwandan mothers who experienced the genocide of 1994 and their 12-year-old children were interviewed. Using a structured interview, symptoms of maternal PTSD and children’s depression, anxiety, and aggressive and antisocial behaviour were assessed by trained and on-site supervised local B.A. psychologists. The interview also included a detailed checklist of event types related to family violence.
In showing that a maternal PTSD was not associated with child’s psychopathology, the results contradict the assumption of straight “trans-generational trauma transmission”. Instead, a child’s exposure to maternal family violence posed a significant risk factor for a negative mental health outcome. Furthermore, it was not maternal PTSD-symptoms but mother’s exposure to family violence during her own childhood that was associated with the magnitude of adversities that a child experiences at home.
Contrary to a simple model of a trans-generational transmission of trauma, neither maternal PTSD nor maternal traumatic experiences were directly associated with symptoms of anxiety, depression, or antisocial and aggressive behaviour in the children. Instead, the present results suggest a relationship between parental child rearing practices and children’s mental health. Furthermore, the study details the “cycle of violence”, showing a significant link between maternal violence against a child and its mother’s experience of childhood maltreatment.
PMCID: PMC3978019  PMID: 24690436
16.  Rwanda – lasting imprints of a genocide: trauma, mental health and psychosocial conditions in survivors, former prisoners and their children 
The 1994 genocide of the Tutsi in Rwanda left about one million people dead in a period of only three months. The present study aimed to examine the level of trauma exposure, psychopathology, and risk factors for posttraumatic stress disorder (PTSD) in survivors and former prisoners accused of participation in the genocide as well as in their respective descendants.
A community-based survey was conducted in four sectors of the Muhanga district in the Southern Province of Rwanda from May to July 2010. Genocide survivors (n = 90), former prisoners (n = 83) and their respective descendants were interviewed by trained local psychologists. The PTSD Symptom Scale Interview (PSS-I) was used to assess PTSD, the Hopkins Symptom Checklist (HSCL-25) to assess symptoms of depression and anxiety and the relevant section of the M.I.N.I. to assess the risk for suicidality.
Survivors reported that they had experienced on average twelve different traumatic event types in comparison to ten different types of traumatic stressors in the group of former prisoners. According to the PSS-I, the worst events reported by survivors were mainly linked to witnessing violence throughout the period of the genocide, whereas former prisoners emphasized being physically attacked, referring to their time spent in refugee camps or to their imprisonment. In the parent generation, when compared to former prisoners, survivors indicated being more affected by depressive symptoms (M = 20.7 (SD = 7.8) versus M = 19.0 (SD = 6.4), U = 2993, p < .05) and anxiety symptoms (M = 17.2 (SD = 7.6) versus M = 15.4 (SD = 7.8), U = 2951, p < .05) but not with regard to the PTSD diagnosis (25% versus 22%, χ2(1,171) = .182, p = .669).
A regression analysis of the data of the parent generation revealed that the exposure to traumatic stressors, the level of physical illness and the level of social integration were predictors for the symptom severity of PTSD, whereas economic status, age and gender were not. Descendants of genocide survivors presented with more symptoms than descendants of former prisoners with regard to all assessed mental disorders.
Our study demonstrated particular long-term consequences of massive organized violence, such as war and genocide, on mental health and psychosocial conditions. Differences between families of survivors and families of former prisoners accused for participation in the Rwandan genocide are reflected in the mental health of the next generation.
PMCID: PMC3620568  PMID: 23531331
Rwanda; PTSD; Anxiety; Depression; Risk factors; Genocide survivors; Former prisoners; Descendants
17.  Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study 
BMC Women's Health  2013;13:52.
Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.
This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student’s t-test were used to compare data between groups.
The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.
Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support.
PMCID: PMC3879178  PMID: 24364878
Induced abortion; Posttraumatic stress disorder; Anxiety disorders; Mental health
18.  Maternal post-traumatic stress disorder, depression and alcohol dependence and child behaviour outcomes in mother–child dyads infected with HIV: a longitudinal study 
BMJ Open  2013;3(12):e003638.
HIV and psychiatric disorders are prevalent and often concurrent. Childbearing women are at an increased risk for both HIV and psychiatric disorders, specifically depression and post-traumatic stress disorder (PTSD). Poor mental health in the peripartum period has adverse effects on infant development and behaviour. Few studies have investigated the relationship between maternal PTSD and child behaviour outcomes in an HIV vertically infected sample. The aim of this study was to investigate whether maternal postpartum trauma exposure and PTSD were risk factors for child behaviour problems. In addition, maternal depression, alcohol abuse and functional disability were explored as cofactors.
The study was conducted in Cape Town, South Africa.
70 mother–child dyads infected with HIV were selected from a group of participants recruited from community health centres.
The study followed a longitudinal design. Five measures were used to assess maternal trauma exposure, PTSD, depression, alcohol abuse and functional disability at 12 months postpartum: Life Events Checklist (LEC), Harvard Trauma Scale (HTS), Alcohol Use Disorders Identification Test (AUDIT), Center for Epidemiological Studies Depression (CESD) Scale and the Sheehan Disability Scale (SDS). Child behaviour was assessed at 42 months with the Child Behaviour Checklist (CBCL).
The rate of maternal disorder was high with 50% scoring above the cut-off for depression, 22.9% for PTSD and 7% for alcohol abuse. Half of the children scored within the clinical range for problematic behaviour. Children of mothers with depression were significantly more likely to display total behaviour problems than children of mothers without depression. Maternal PTSD had the greatest explanatory power for child behaviour problems, although it did not significantly predict child outcomes.
This study highlights the importance of identifying and managing maternal PTSD and depression in mothers of children infected with HIV. The relationship between maternal PTSD and child behaviour warrants further investigation.
PMCID: PMC3863126  PMID: 24334155
Maternal mental health; Child behaviour and development; Posttraumatic Stress Disorder; Depression; Alcohol abuse; HIV/AIDS
19.  Posttraumatic stress disorder across two generations: concordance and mechanisms in a population-based sample 
Biological psychiatry  2012;72(6):505-511.
Research conducted using small samples of persons exposed to extreme stressors has documented an association between parental and offspring posttraumatic stress disorder (PTSD), but it is unknown whether this association exists in the general population and whether trauma exposure mediates this association. We sought to determine whether mothers’ posttraumatic stress symptoms were associated with PTSD in their young adult children and whether this association was mediated by higher trauma exposure in children of women with PTSD.
Using data from a cohort of mothers (n=6924) and a cohort of their children (n=8453), we calculated risk ratios (RR) for child’s PTSD and examined mediation by trauma exposure.
Mother’s lifetime posttraumatic stress symptoms were associated with child’s PTSD in dose-response fashion (mother’s 1 to 3 symptoms, child’s RR=1.2; mother’s 4-5 symptoms, RR=1.3; mother’s 6-7 symptoms, RR=1.6, compared to children of mothers with no symptoms, p<0.001 for each). Mother’s lifetime symptoms were also associated with child’s trauma exposure in dose-response fashion. Elevated exposure to trauma substantially mediated elevated risk for PTSD in children of women with symptoms (mediation proportion, 74%, p<0.001).
Intergenerational association of PTSD is clearly present in a large population-based sample. Children of women who had PTSD were more likely than children of women without PTSD to experience traumatic events; this suggests, in part, why the disorder is associated across generations. Health care providers who treat mothers with PTSD should be aware of the higher risk for trauma exposure and PTSD in their children.
PMCID: PMC3412195  PMID: 22521146
Posttraumatic stress disorder; trauma; childhood abuse; epidemiology; family studies; violence
20.  PTSD symptom severity is associated with increased recruitment of top-down attentional control in a trauma-exposed sample☆ 
NeuroImage : Clinical  2014;7:19-27.
Recent neuroimaging work suggests that increased amygdala responses to emotional stimuli and dysfunction within regions mediating top down attentional control (dorsomedial frontal, lateral frontal and parietal cortices) may be associated with the emergence of anxiety disorders, including posttraumatic stress disorder (PTSD). This report examines amygdala responsiveness to emotional stimuli and the recruitment of top down attention systems as a function of task demands in a population of U.S. military service members who had recently returned from combat deployment in Afghanistan/Iraq. Given current interest in dimensional aspects of pathophysiology, it is worthwhile examining patients who, while not meeting full PTSD criteria, show clinically significant functional impairment.
Fifty-seven participants with sub-threshold levels of PTSD symptoms completed the affective Stroop task while undergoing fMRI. Participants with PTSD or depression at baseline were excluded.
Greater PTSD symptom severity scores were associated with increased amygdala activation to emotional, particularly positive, stimuli relative to neutral stimuli. Furthermore, greater PTSD symptom severity was associated with increased superior/middle frontal cortex response during task conditions relative to passive viewing conditions. In addition, greater PTSD symptom severity scores were associated with: (i) increased activation in the dorsolateral prefrontal, lateral frontal, inferior parietal cortices and dorsomedial frontal cortex/dorsal anterior cingulate cortex (dmFC/dACC) in response to emotional relative to neutral stimuli; and (ii) increased functional connectivity during emotional trials, particularly positive trials, relative to neutral trials between the right amygdala and dmFC/dACC, left caudate/anterior insula cortex, right lentiform nucleus/caudate, bilateral inferior parietal cortex and left middle temporal cortex.
We suggest that these data may reflect two phenomena associated with increased PTSD symptomatology in combat-exposed, but PTSD negative, armed services members. First, these data indicate increased emotional responsiveness by: (i) the positive relationship between PTSD symptom severity and amygdala responsiveness to emotional relative to neutral stimuli; (ii) greater BOLD response as a function of PTSD symptom severity in regions implicated in emotion (striatum) and representation (occipital and temporal cortices) during emotional relative to neutral conditions; and (iii) increased connectivity between the amygdala and regions implicated in emotion (insula/caudate) and representation (middle temporal cortex) as a function of PTSD symptom severity during emotional relative to neutral trials. Second, these data indicate a greater need for the recruitment of regions implicated in top down attention as indicated by (i) greater BOLD response in superior/middle frontal gyrus as a function of PTSD symptom severity in task relative to view conditions; (ii) greater BOLD response in dmFC/dACC, lateral frontal and inferior parietal cortices as a function of PTSD symptom severity in emotional relative to neutral conditions and (iii) greater functional connectivity between the amygdala and inferior parietal cortex as a function of PTSD symptom severity during emotional relative to neutral conditions.
•Greater PTSD symptoms associated with increased amygdala activation to emotional stimuli•PTSD symptoms associated with greater top down attention response in task and emotion conditions•PTSD symptoms were associated with slower reaction times.•Increased top down attention recruitment may compensate for heightened emotional responses.
PMCID: PMC4299952  PMID: 25610763
Post-traumatic stress disorder; Emotion attention; Amygdala; Top down attention
21.  Screening for Posttraumatic Stress Disorder in VA Primary Care Patients with Depression Symptoms 
Journal of General Internal Medicine  2007;22(9):1321-1324.
Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression.
The objective was to evaluate a 4-item screen for PTSD in patients with depression.
Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard.
Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics.
The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used.
Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point “(>50)”, the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38.
Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.
PMCID: PMC2219778  PMID: 17634781
posttraumatic stress disorder; depression; screening; primary care; veterans
22.  Sleep disturbances and PTSD: a perpetual circle? 
European Journal of Psychotraumatology  2012;3:10.3402/ejpt.v3i0.19142.
Sleep facilitates the consolidation of fear extinction memory. Nightmares and insomnia are hallmark symptoms of posttraumatic stress disorder (PTSD), possibly interfering with fear extinction and compromising recovery. A perpetual circle may develop when sleep disturbances increase the risk for PTSD and vice versa. To date, therapeutic options for alleviating sleep disturbances in PTSD are limited.
We conducted three studies to examine the relationship between sleep and posttraumatic symptoms: (1) a prospective longitudinal cohort study examining the impact of pre-deployment insomnia symptoms and nightmares on the development of PTSD; (2) a cross-sectional study examining subjective sleep measures, polysomnography, endocrinological parameters, and memory in veterans with PTSD, veterans without PTSD, and healthy controls (HCs); (3) a randomized controlled trial (RCT) (n=14) comparing the effect of prazosin and placebo on sleep disturbances in veterans with PTSD. In addition to these studies, we systematically reviewed the literature on treatment options for sleep disturbances in PTSD.
Pre-deployment nightmares predicted PTSD symptoms at 6 months post-deployment; however, insomnia symptoms did not. Furthermore, in patients with PTSD, a correlation between the apnea index and PTSD severity was observed, while obstructive sleep apnea syndrome was not more prevalent. We observed a significant increase in awakenings during sleep in patients with PTSD, which were positively correlated with adrenocorticotropic hormone (ACTH) levels, negatively correlated with growth hormone (GH) secretion, and the subjective perception of sleep depth. Also, heart rate was significantly increased in PTSD patients. Interestingly, plasma levels of GH during the night were decreased in PTSD. Furthermore, GH secretion and awakenings were independent predictors for delayed recall, which was lower in PTSD. In our RCT, prazosin was not associated with improvement of any subjective and objective sleep parameters. Only a few RCTs have been published. They show promising results for atypical antipsychotics and prazosin, the latter especially on nightmare reduction.
Disturbed sleep due to nightmares increases the risk for PTSD. PTSD in turn leads to increased sleep fragmentation, decreased GH secretion, and frequent nightmares, which may again compromise fear extinction, synaptic plasticity, and recovery. This suggests that disturbed sleep is a precipitating and perpetuating factor in PTSD symptomatology, creating a perpetual circle. This dissertation suggests that activity of the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system (SNS) is involved in disturbed sleep in patients with PTSD.
PMCID: PMC3464455  PMID: 23050070
PTSD; sleep; nightmares; polysomnography; cortisol; growth hormone; memory; noradrenalin
23.  Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan 
BMC Psychiatry  2014;14:6.
The negative effect of exposure to traumatic events on mental health is well known. Most studies of the effects of trauma on mental health in war-affected populations have focused on post-traumatic stress disorder (PTSD) and depression. Although some studies confirm the existence of anxiety symptoms in war-affected populations, the extent to which exposure to traumatic events is independently associated with anxiety diagnoses (other than PTSD) has received less attention. The study aimed to determine whether having an anxiety diagnosis, other than PTSD, was associated with experiencing traumatic events in a post-conflict setting, across genders and after controlling for demographic and socio-economic variables.
In this cross-sectional community study (n = 1200), we applied the Harvard Trauma Questionnaire (HTQ) to investigate the extent of trauma exposure and PTSD. The Mini-International Neuropsychiatric Interview (MINI) was used to investigate the prevalence of anxiety disorders: generalized anxiety disorder (GAD), panic disorder (PD), social phobia, obsessive-compulsive disorder (OCD), and agoraphobia. Multinomial logistic regression analyses were conducted to examine the association between these disorders, previous trauma exposure, and socio-economic factors.
The participants were 56.4% male and 43.6% female. The age ranged between 18 and 73 years old (Mean 34.63, SD = 12.03). The estimated rates of GAD-only and PD-only (without comorbidity with PTSD) were 5.5% and 3.1%, respectively. Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban setting, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. There were gender differences in the pattern of risk factors for having PTSD, GAD or PD.
In individuals with a history of war-related trauma exposure, attention should be given to symptoms of GAD and PD, in addition to PTSD symptoms.
PMCID: PMC3893536  PMID: 24410951
PTSD; Anxiety disorders; Trauma exposure; Post-conflict; South Sudan
24.  The relationship between organized violence, family violence and mental health: findings from a community-based survey in Muhanga, Southern Rwanda 
European Journal of Psychotraumatology  2013;4:10.3402/ejpt.v4i0.21329.
The relationship between organized violence and family violence, and their cumulative effect on mental health in post-conflict regions remains poorly understood.
The aim of the present study was to establish prevalence rates and predictors of family violence in post-conflict Rwanda. And to examine whether higher levels of war-related violence and its socio-economic consequences would result in higher levels of violence within families and whether this would be related to an increase of psychological distress in descendants.
One hundred and eighty-eight parent–child pairs from four sectors of the district Muhanga, Southern Province of Rwanda, were randomly selected for participation in the study. Trained local psychologists administered structured diagnostic interviews. A posttraumatic stress disorder (PTSD) diagnosis was established using the PTSD Symptom Scale Interview (PSS-I) and child maltreatment was assessed by means of the Childhood Trauma Questionnaire (CTQ). Additionally, the Hopkins Symptom Checklist (HSCL-25) assessed symptoms of depression and anxiety in descendants.
Prevalence rates of child abuse and neglect among descendants were below 10%. Ordinal regression analyses revealed that the level of child maltreatment in descendants was predicted by female sex, poverty, loss of the mother, exposure to war and genocide as well as parents’ level of PTSD and reported child maltreatment. Poor physical health, exposure to war and genocide, parental PTSD symptoms, and reported childhood trauma were significantly associated with depressive and anxious symptoms, while only exposure to war and genocide and poor physical health predicted the level of PTSD.
The results indicate that cumulative stress such as exposure to organized violence and family violence in Rwandan descendants poses a risk factor for the development of depressive and anxious symptoms. Besides the support for families to cope with stress, awareness-raising initiatives challenging the current discourse of discipline toward children in schools or at home need to be fostered.
PMCID: PMC3828565  PMID: 24244834
Child maltreatment; psychopathology; genocide; descendants; Rwanda; intergenerational; cycle of violence
25.  Predicting Future PTSD using a Modified New York Risk Score: Implications for Patient Screening and Management 
Minerva psichiatrica  2012;53(1):47-59.
We previously developed a posttraumatic stress disorder (PTSD) screening instrument – the New York PTSD Risk Score – that was effective in predicting PTSD. In the present study, we assessed a 12-month prospective version of this risk score, which is important for patient management, follow-up, and for emergency medicine.
Using data collected in a study of New York City adults after the World Trade Center Disaster (WTCD), we developed a new PTSD prediction tool. Using diagnostic test methods, including receiver operating curve (ROC) and bootstrap procedures, we examined different prediction variables to assess PTSD status 12 months after initial assessment among 1,681 trauma-exposed adults.
While our original PTSD screener worked well in the short term, it was not specifically developed to predict long-term PTSD. In the current study, we found that the Primary Care PTSD Screener (PCPS), when combined with psychosocial predictors from the original NY Risk Score, including depression, trauma exposure, sleep disturbance, and healthcare access, increased the area under the ROC curve (AUC) from 0.707 to 0.774, a significant improvement (p<0.0001). When additional risk-factor variables were added, including negative life events, handedness, self-esteem, and pain status, the AUC increased to 0.819, also a significant improvement (p=0.001). Adding Latino and foreign status to the model further increased the AUC to 0.839 (p=0.007).
A prospective version of the New York PTSD Risk Score appears to be effective in predicting PTSD status 12 months after initial assessment among trauma-exposed adults. Further research is advised to further validate and expand these findings.
PMCID: PMC3298362  PMID: 22408285
Posttraumatic stress disorder; Psychological Trauma; Diagnostic screening; Emergency Medicine

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