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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.
Abstract
Objective
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.
Methods
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).
Results
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.
Conclusions
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.
doi:10.1089/jwh.2009.1367
PMCID: PMC2828188  PMID: 19951212
2.  Prevalence of shingles and its association with PTSD among HIV-infected women in Rwanda 
BMJ Open  2015;5(3):e005506.
Objective
To examine the prevalence of reported shingles in the last 6 months and its association with post-traumatic stress disorder (PTSD), depression and severity of HIV disease in Rwandan women with HIV.
Settings
This cross-sectional study was conducted as part of the Rwanda Women's Interassociation Study and Assessment (RWISA), an observational cohort study designed to assess the impact of HIV and residual factors from experiencing rape in the 1994 genocide in Rwandan women. Participants were recruited through grassroots women's associations of people living with HIV infection and clinical care sites for HIV infection. Most participants (58.5%, n=405/692) had PTSD.
Participants
This cross-sectional analysis was conducted in 710 HIV-infected women enrolled in RWISA. Inclusion criteria were: age >15 years, informed consent, HIV test, ability to complete the interview in the local language, travel to and from the research site and participate in a baseline outpatient visit, and being naive to antiretroviral therapy at enrolment.
Primary and secondary outcome measures
The outcome of interest was self-reported shingles in the past 6 months. The exposure was PTSD defined using the cross-culturally validated Harvard Trauma Questionnaire.
Results
Overall prevalence of reported shingles in the past 6 months was 12.5% (n=89/710). There was an inverse relationship between shingles prevalence and immunological status: 7.6%, 12.3% and 16.7% of women with CD4 >350, 200–350 and <200 cells/µL, respectively, reported singles (p=0.01). In multivariate analysis, PTSD (aOR 1.7; 95% CI 1.02 to 2.89) and low CD4 (aOR 2.4; 95% CI 1.23 to 4.81) were independently associated with reported shingles in the past 6 months.
Conclusions
Our study found a significant independent relationship between PTSD and reported shingles, suggesting that PTSD may be associated with immune compromise that can result in herpes zoster reactivation. Further study is needed. It also confirmed previous findings of a strong relationship between shingles and greater immunosuppression in women with HIV infection.
doi:10.1136/bmjopen-2014-005506
PMCID: PMC4360726  PMID: 25748413
HIV/AIDS; Shingles; PTSD; Depression
3.  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
4.  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.
Importance
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.
Objective
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.
Participants
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.
Results
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.
doi:10.1001/jamapsychiatry.2013.2798
PMCID: PMC4091890  PMID: 24258147
body weight changes; weight status; obesity; PTSD; stress; women
5.  Posttraumatic stress in intensive care unit survivors – a prospective study 
Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21%) had symptom levels indicating subclinical PTSD. Female, five illness factors: coma time, mechanical ventilation, sedation, benzodiazepine, pain relieving medication, and four psychological factors: symptoms of acute stress (T1), fear of death and/or feeling completely helpless and powerless in relation to the accident and/or ICU (T1), SOC (T1) and more external locus of control (T1) correlated significantly with PTSD symptoms at T2. In the linear regression analysis, female, length of sedation, dissociation (T1), hypervigilance (T1), and external locus of control predicted 58% of the variation of PTSD. Conclusions: High levels of PTSD symptoms occurred in 19.2% of respondents in six months following traumatic injury requiring ICU admission. Screening for the variables gender, length of sedation, dissociation, hypervigilance, and locus of control after ICU admission following traumatic injuries may help to predict who will develop PTSD.
doi:10.1080/21642850.2014.943760
PMCID: PMC4346029  PMID: 25750824
posttraumatic stress; intensive care; trauma; ICU survivors
6.  Specific Trauma Subtypes Improve the Predictive Validity of the Harvard Trauma Questionnaire in Iraqi Refugees 
Background
Trauma exposure contributes to poor mental health among refugees, and exposure often is measured using a cumulative index of items from the Harvard Trauma Questionnaire (HTQ). Few studies, however, have asked whether trauma subtypes derived from the HTQ could be superior to this cumulative index in predicting mental health outcomes.
Methods
A community sample of recently arrived Iraqi refugees (N = 298) completed the HTQ and measures of posttraumatic stress disorder (PTSD) and depression symptoms.
Results
Principal components analysis of HTQ items revealed a 5-component subtype model of trauma that accounted for more item variance than a 1-component solution. These trauma subtypes also accounted for more variance in PTSD and depression symptoms (12% and 10%, respectively) than did the cumulative trauma index (7% and 3%, respectively).
Discussion
Trauma subtypes provided more information than cumulative trauma in the prediction of negative mental health outcomes. Therefore, use of these subtypes may enhance the utility of the HTQ when assessing at-risk populations.
doi:10.1007/s10903-014-9995-9
PMCID: PMC4138298  PMID: 24549491
refugees; posttraumatic stress disorder; depression; trauma
7.  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.
Aim
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).
Methods
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)
Results
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).
Conclusion
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.
doi:10.3325/cmj.2011.52.505
PMCID: PMC3160697  PMID: 21853545
8.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
In individuals exposed to war trauma, attention should be given to those who may fulfill criteria for a diagnosis of both PTSD and depression.
doi:10.1186/1471-244X-12-175
PMCID: PMC3534332  PMID: 23083301
PTSD; Depression; Comorbidity; Tauma; Post-conflict; Socioeconomic, South Sudan
9.  Psychological Consequences of War Trauma and Postwar Social Stressors in Women in Bosnia and Herzegovina 
Croatian medical journal  2007;48(2):167-176.
Aim
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.
Methods
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.
Results
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.
Conclusion
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
10.  Posttraumatic stress disorder among refugees: Measurement invariance of Harvard Trauma Questionnaire scores across global regions and response patterns 
Psychological assessment  2015;27(4):1160-1170.
Despite the central role of posttraumatic stress disorder (PTSD) in international humanitarian aid work, there has been little examination of the measurement invariance of PTSD measures across culturally defined refugee subgroups. This leaves mental health workers in disaster settings with little to support inferences made using the results of standard clinical assessment tools, such as the severity of symptoms and prevalence rates. We examined measurement invariance in scores from the most widely used PTSD measure in refugee populations, the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992), in a multinational and multilingual sample of asylum seekers from 81 countries of origin in 11 global regions. Clustering HTQ responses to justify grouping regional groups by response patterns resulted in three groups for testing measurement invariance: West Africans, Himalayans, and all others. Comparing log-likelihood ratios showed that while configural invariance seemed to hold, metric and scalar invariance did not. These findings call into question the common practice of using standard cut-off scores on PTSD measures across culturally dissimilar refugee populations. In addition, high correlation between factors suggests that the construct validity of scores from North American and European measures of PTSD may not hold globally.
doi:10.1037/pas0000115
PMCID: PMC4615261  PMID: 25894706
posttraumatic stress disorder; culture; refugees; measurement invariance; Harvard Trauma Questionnaire
11.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2458-12-603
PMCID: PMC3461465  PMID: 22863107
12.  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.
Background
To date no validated instrument in the French language exists to screen for posttraumatic stress disorder (PTSD) in survivors of torture and organized violence.
Objective
The aim of this study is to adapt and validate the Harvard Trauma Questionnaire (HTQ) to this population.
Method
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.
Results
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).
Conclusion
Results support the reliability and validity of the French version of the HTQ.
doi:10.3402/ejpt.v3i0.19225
PMCID: PMC3517723  PMID: 23233870
Refugees; ethnic/cultural minorities; torture; cross-cultural assessment; questionnaire
13.  Mental health care in post-genocide Rwanda: evaluation of a program specializing in posttraumatic stress disorder and substance abuse 
Background
Following the genocide, millions of Rwandans are likely living with posttraumatic stress disorder (PTSD). Le Centre Psychothérapeutique Icyizere provides the only specialized treatment for PTSD in the Rwandan healthcare system.
Methods
Demographics, diagnosis, treatment, outcomes, and scores on assessments of functioning and PTSD were recorded from clinical charts of all patients receiving care between October 2013 and 2014. Descriptive statistics and within-group t tests comparing functional impairment and PTSD symptoms at intake to discharge and follow-up were calculated.
Results
A total of 719 patients (55.08% male) received care. Patients were more educated, more likely to live in the capital, and less likely to be married than the general population. Patients reported high desire for, and strong satisfaction with, care. Most patients (55.60%) were still in care by the end of the program evaluation. Functioning improved from intake to discharge (p < 0.001), and improvements were sustained at follow-up (p < 0.001). Most adults were diagnosed with psychotic disorders, substance use disorders, or depression. Only 20 patients were diagnosed with PTSD, and symptoms were improved at discharge (p = 0.003).
Conclusions
This program evaluation demonstrated the utility of a low-resource information management system to provide clarity about the patient population and outcomes. Results suggest that services are effective and sustainable, although people with PTSD were not the primary recipients of care. Disparities in care by diagnosis, education, marital status, and geography are discussed. Results have contributed to changes in service delivery and care and efforts to increase access to care.
doi:10.1017/gmh.2016.12
PMCID: PMC5012309  PMID: 27610238
Genocide; mental health services; mental illness; policy and systems; program evaluation; Rwanda
14.  Psychosocial predictors of treatment outcome for trauma-affected refugees 
European Journal of Psychotraumatology  2016;7:10.3402/ejpt.v7.30907.
Background
The effects of treatment in trials with trauma-affected refugees vary considerably not only between studies but also between patients within a single study. However, we know little about why some patients benefit more from treatment, as few studies have analysed predictors of treatment outcome.
Objective
The objective of the study was to examine possible psychosocial predictors of treatment outcome for trauma-affected refugees.
Method
The participants were 195 adult refugees with posttraumatic stress disorder (PTSD) who were enrolled in a 6- to 7-month treatment programme at the Competence Centre for Transcultural Psychiatry (CTP), Denmark. The CTP Predictor Index used in the study included 15 different possible outcome predictors concerning the patients’ past, chronicity of mental health problems, pain, treatment motivation, prerequisites for engaging in psychotherapy, and social situation. The primary outcome measure was PTSD symptoms measured on the Harvard Trauma Questionnaire (HTQ). Other outcome measures included the Hopkins Symptom Check List-25, the WHO-5 Well-being Index, Sheehan Disability Scale, Hamilton Depression and Anxiety Scales, the somatisation scale of the Symptoms Checklist-90, Global Assessment of Functioning scales, and pain rated on visual analogue scales. The relations between treatment outcomes and the total score as well as subscores of the CTP Predictor Index were analysed.
Results
Overall, the total score of the CTP Predictor Index was significantly correlated to pre- to post treatment score changes on the majority of the ratings mentioned above. While employment status was the only single item significantly correlated to HTQ-score changes, a number of single items from the CTP Predictor Index correlated significantly with changes in depression and anxiety symptoms, but the size of the correlation coefficients were modest.
Conclusions
The total score of the CTP Predictor Index correlated significantly with outcomes on most of the rating scales, but correlations were modest in size, possibly due to the number of different factors influencing treatment outcome.
Highlights of the article
The study investigated the relation between the CTP Predictor Index including 15 different possible predictors and outcome on a range of different rating scales.
The total score of the index correlated significantly to score changes on the majority of the ratings.
Employment status was the only single item from the index that was significantly correlated to changes in posttraumatic stress disorder symptoms.
A number of single items correlated significantly with changes in depression and anxiety symptoms.
doi:10.3402/ejpt.v7.30907
PMCID: PMC4889772  PMID: 27251179
Refugee; trauma; treatment; stress disorders; posttraumatic; depression
15.  Rates and predictors of mental stress in Rwanda: investigating the impact of gender, persecution, readiness to reconcile and religiosity via a structural equation model 
Background
As a consequence of the 1994 Rwandan genocide, prevalences of mental disorders are elevated in Rwanda. More knowledge about determinants of mental stress can help to improve mental health services and treatment in the east-central African country. The present study aimed to investigate actual rates of mental stress (posttraumatic stress disorder, syndromal depression and syndromal anxiety) in Rwanda and to examine if gender, persecution during the genocide, readiness to reconcile as well as importance given to religiosity and quality of religiosity are predictors of mental stress.
Methods
The study comprised a community sample of N = 200 Rwandans from Rwanda’s capital Kigali, who experienced the Rwandan genocide. By conducting structured interviews, ten local Master level psychologists examined types of potentially lifetime traumatic events, symptoms of posttraumatic stress disorder (PTSD), depression and anxiety, readiness to reconcile and religiosity. Applying non-recursive structural equation modeling (SEM), the associations between gender, persecution, readiness to reconcile, religiosity and mental stress were investigated.
Results
Respondents had experienced an average number of 11.38 types of potentially lifetime traumatic events. Of the total sample, 11% met diagnostic criteria for PTSD, 19% presented with syndromal depression and 23% with syndromal anxiety. Female sex, persecution and readiness to reconcile were significant predictors of mental stress. Twofold association was found between centrality of religion (which captures the importance given to religiosity) and mental stress, showing, that higher mental stress provokes a higher centrality and that higher centrality reduces mental stress. The variables positive and negative religious functioning (which determine the quality of religiosity) respectively had an indirect negative and positive effect on mental stress.
Conclusions
Study results provide evidence that rates of mental stress are still elevated in Rwanda and that female sex, persecution, readiness to reconcile, centrality and religious functioning are predictors of mental stress. Seventeen years after the genocide, there remains a large gap between the need for and provision of mental health services in Rwanda. Results underline the importance of improving the respective infrastructure, with a focus on the requirements of women and persons, who were persecuted during the genocide. They further highlight that the consideration of readiness to reconcile, centrality and religious functioning in therapeutic interventions can aid mental health in Rwanda.
doi:10.1186/1752-4458-8-37
PMCID: PMC4414000  PMID: 25926870
Rwanda; Genocide; Mental stress; Reconciliation; Religiosity
16.  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.
doi:10.1155/2013/197323
PMCID: PMC3580894  PMID: 23476868
17.  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.
Background
School killings attract immense media and public attention but psychological studies surrounding these events are rare.
Objective
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.
Method
The students answered the Harvard Trauma Questionnaire (HTQ), the Crisis Support Scale (CSS), and the Trauma Symptom Checklist (TSC).
Results
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.
Conclusion
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.
doi:10.3402/ejpt.v4i0.19826
PMCID: PMC3542399  PMID: 23316270
witnessing school killing; PTSD; social support; risk factors
18.  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.
Background
During the Rwandan genocide of 1994, nearly one million people were killed within a period of 3 months.
Objective
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.
Design
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.
Results
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.
Conclusions
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.
doi:10.3402/ejpt.v2i0.6343
PMCID: PMC3402134  PMID: 22893816
Posttraumatic stress disorder; depression; anxiety; genocide; Rwanda; risk factors
19.  Posttraumatic Stress Disorder and Incidence of Type 2 Diabetes Mellitus in a Sample of Women 
JAMA psychiatry  2015;72(3):203-210.
IMPORTANCE
Posttraumatic stress disorder (PTSD) is a common, debilitating mental disorder that has been associated with type 2 diabetes mellitus (T2D) and its risk factors, including obesity, in cross-sectional studies. If PTSD increases risk of incident T2D, enhanced surveillance in high-risk populations may be warranted.
OBJECTIVE
To conduct one of the first longitudinal studies of PTSD and incidence of T2D in a civilian sample of women.
DESIGN, SETTING, AND PARTICIPANTS
The Nurses’ Health Study II, a US longitudinal cohort of women (N = 49 739). We examined the association between PTSD symptoms and T2D incidence over a 22-year follow-up period.
MAIN OUTCOMES AND MEASURES
Type 2 diabetes, self-reported and confirmed with self-report of diagnostic test results, symptoms, and medications, a method previously validated by physician medical record review. Posttraumatic stress disorder was assessed by the Short Screening Scale for DSM-IV PTSD. We examined longitudinal assessments of body mass index, smoking, alcohol intake, diet quality, physical activity, and antidepressant use as mediators of possible increased risk of T2D for women with PTSD. The study hypothesis was formulated prior to PTSD ascertainment.
RESULTS
Symptoms of PTSD were associated in a dose-response fashion with T2D incidence (1-3 symptoms: hazard ratio, 1.4 [95% CI, 1.2-1.6]; 4 or 5 symptoms; hazard ratio, 1.5 [95% CI, 1.3-1.7]; 6 or 7 symptoms: hazard ratio, 1.8 [95% CI, 1.5-2.1]). Antidepressant use and a higher body mass index associated with PTSD accounted for nearly half of the increased risk of T2D for women with PTSD. Smoking, diet quality, alcohol intake, and physical activity did not further account for increased risk of T2D for women with PTSD.
CONCLUSIONS AND RELEVANCE
Women with the highest number of PTSD symptoms had a nearly 2-fold increased risk of T2D over follow-up than women with no trauma exposure. Health professionals treating women with PTSD should be aware that these patients are at risk of increased body mass index and T2D. Comprehensive PTSD treatment should be expanded to address the health behaviors that contribute to obesity and chronic disease in affected populations.
doi:10.1001/jamapsychiatry.2014.2632
PMCID: PMC4522929  PMID: 25565410
20.  Association of FKBP5 Polymorphisms and Childhood Abuse With Risk of Posttraumatic Stress Disorder Symptoms in Adults 
Context
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.
Objective
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.
Results
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.
Conclusions
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.
doi:10.1001/jama.299.11.1291
PMCID: PMC2441757  PMID: 18349090
21.  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
doi:10.1023/B:JOTS.0000048956.03529.fa
PMCID: PMC2748790  PMID: 15633922
posttraumatic stress disorder; panic attacks; cognitive; behavior therapy; Vietnamese refugees
22.  Transgenerational consequences of PTSD: risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1752-4458-8-12
PMCID: PMC3978019  PMID: 24690436
23.  Rwanda – lasting imprints of a genocide: trauma, mental health and psychosocial conditions in survivors, former prisoners and their children 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1752-1505-7-6
PMCID: PMC3620568  PMID: 23531331
Rwanda; PTSD; Anxiety; Depression; Risk factors; Genocide survivors; Former prisoners; Descendants
24.  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.
Objective
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1016/j.genhosppsych.2011.06.001
PMCID: PMC3557518  PMID: 21777981
Posttraumatic stress disorder; Psychological Trauma; Diagnostic testing; Patient screening; Area under receiver operating characteristic (ROC) curve
25.  Posttraumatic stress disorder symptoms and food addiction in women, by timing and type of trauma exposure 
JAMA psychiatry  2014;71(11):1271-1278.
Importance
Posttraumatic stress disorder (PTSD) appears to increase obesity risk, but the pathways by which PTSD leads to weight gain are not known. Identification of the links between PTSD and obesogenic eating behaviors is necessary to clarify this pathway and inform development of obesity prevention strategies in PTSD-affected populations.
Study objective
To determine whether women with PTSD symptoms are more likely to report food addiction, a measure of perceived dependence on food, than women without PTSD symptoms. To determine whether age at PTSD symptom onset and type of trauma influence the PTSD food addiction association.
Design, setting, and participants
Cross-sectional analysis of 49,408 participants in the Nurses’ Health Study II (NHSII), a cohort comprised of female nurses who were aged 25–42 at 1989 recruitment from 14 US states.
Exposure and outcome measures
The NHSII ascertained lifetime trauma exposure and PTSD symptoms in 2008 and current food addiction in 2009. Food addiction was defined as ≥3 clinically significant symptoms on a modified version of the Yale Food Addiction Scale. Confounder-adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated using modified Poisson regression.
Results
Roughly 80% of the study sample reported some type of trauma exposure, with 66% of the trauma-exposed reporting at least 1 lifetime PTSD symptom. Eight percent of the cohort met the criteria for food addiction. The prevalence of food addiction increased with number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6–7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (PR=2.68; 95% CI: 2.41, 2.97). PTSD symptoms were more strongly related to food addiction when symptom onset occurred at an earlier age. The PTSD food addiction association did not differ substantially by trauma type.
Conclusions and relevance
PTSD symptoms were associated with increased food addiction prevalence in this cohort of women. Strategies to reduce obesity associated with PTSD may require psychological and behavioral interventions that address dependence on food and/or use of food to cope with distress.
doi:10.1001/jamapsychiatry.2014.1208
PMCID: PMC4341890  PMID: 25230359

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