Posttraumatic stress disorder a greater risk in rich countries

By New Zealand Defence Force from Wellington New ZealandOne would think that people with few friends and living in poverty are more at risk for PTSD than those with a strong support network and many resources.

And that’s true.

However, it is a different story when you look at the country-, rather than the individual level. Countries with more resources, such as the USA and the Netherlands, have higher levels of PTSD than countries with fewer resources (e.g. Colombia, South Africa).

This is the key finding of our latest study, which has just been published in the British Journal of Psychiatry. For the analyses, we made use of international data on trauma exposure, PTSD and country vulnerability. They had been collected in 24 different studies, published between 2005 and 2014.

The information on exposure and PTSD came from one, well-established and (evidently) widely used measure, the Composite International Diagnostic Interview. The country resources, or vulnerability, information came from the annual World Risk Report. It includes a mix of country characteristics, such as number of hospital beds, malnutrition, and gross domestic product per capita.

Both trauma exposure and vulnerability were major determinants of PTSD, but the latter in an unexpected way. While a higher percentage of trauma exposure in the country related to higher levels of PTSD, more vulnerability was associated with less PTSD.

Michel Dückers, the lead author of the study, calls it the “vulnerability paradox”. Continue reading

Getting rid of the Ghost People

child soldierPatrick became a child soldier at the age of 13. He was abducted by Ugandan rebels, who kept him for 3 years.

Schultz and Weisaeth (2015) describe Patrick’s story, his mental health problems, and his treatment, a local cleansing ritual. They conclude that the ritual is safe, effective, and perhaps even more powerful than Western-style therapy. That sounds fascinating and important, right?

In interviews Patrick told about his experiences, including an attack on a convoy:

“Everybody was screaming…The road was all red from the blood… My body was shaking, but I managed to appear calm. If not they would have killed me. The next day I experienced the Ghost People for the first time. I could see them get chopped up and sliced apart with axes. I saw the same scenes over and over again.”

The Ghost People only showed up when Patrick was alone, and scared him enormously. He also suffered from concentration problems and sleeping difficulties. He was clinically depressed and had moderate to severe PTSD.

When his nightmares were occurring twice a week and he saw the Ghost People every day – about 8 years after the convoy attack –, he stated that his life was ruined. He wanted to do a cleansing ritual. Continue reading

Why demographics – including sexual orientation – matter in PTSD research

A while ago I started Paper in a Day to get young trauma researchers together. It has been engaging and productive (if you’re interested, the upcoming ISTSS conference will feature one). In a recent edition, four clever minds – Drs Averill, Eubanks Fleming, Holens and Larsen – have thought through research gaps in the PTSD literature. They published a commentary and I wanted to share their thoughts here. They reflect on one of the biggest areas of trauma research, the experiences of military personnel:

As the wars in Afghanistan and Iraq continue, and military service members continue to return home from these two conflicts, more research has been conducted to examine rates of PTSD among these service members (known in the US as OEF/OIF Veterans i.e. Veterans of Operation Enduring Freedom/Operation Iraqi Freedom). This research is important so that we have an understanding of the need for healthcare in newer returning Veterans (which may differ from previous generations). In reviewing some of these articles, many of which are quite well-designed, we noticed a need for some further study to understand the nuances of who develops PTSD and why.

In particular, it would be useful to examine how PTSD prevalence in US OEF/OIF Veterans depends on 1) Veterans Affairs services use (with a particular focus on non-VA users), 2) relationship status, and 3) sexual orientation. Continue reading

Is a trauma focus truly needed in PTSD treatment?

???????????????????????????????????????????????????????????????????????????????????????Last month Joris Haagen shared Part 1 of a saga around the question whether a trauma focus is truly necessary in trauma treatment. Based on a meta-analysis, Benish, Wampold and their colleagues concluded that the answer is No. Their analysis, and in particular the selection of studies, was heavily criticized by Ehlers et al. However, Wampold was not easily defeated and offered a riposte…Over to Joris:

Wampold et al. (2010) argue that their classification criteria are in fact more objective than previous meta-analyses and that the content of supportive therapies in research studies does not match supportive therapy as given in daily practice. For example, no therapist would normally dissuade their client from discussing traumatic experiences as is often the case in experimental studies. Wampold et al. also note that supportive interventions are difficult to capture in a single category because their content varies.

They further state that the distinction that Ehlers et al. make between trauma-focused and non-trauma-focused therapy is not clear-cut. TF-CBT has for instance considerable overlap with stress inoculation therapy (SIT) despite SIT not being considered trauma-focused. A neuro-feedback study is categorized as trauma-focused exposure, even though patients have no possibility to discuss traumatic content. Hypnotherapy and psychodynamic therapy are categorized as non-trauma-focused although both allow for – and even encourage – discussion of traumatic memories. As such, Wampold et al. stood by their view that the available research did not demonstrate the difference between trauma-focused and non-trauma-focused therapy.

Both groups display – at first glance – fundamentally different positions. Continue reading

Do we let patients suffer needlessly?

Joris HaagenPTSD treatment guidelines invariably point to trauma-focused therapy, such as trauma-focused cognitive behavioral therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR) as preferred interventions. Is the trauma focus justified? Researcher and psychologist Joris Haagen tells the story of a heated academic debate…

An article by Benish, Imel and Wampold (2008) challenged our belief in the necessity of a trauma focus. According to the authors it does not matter which psychological intervention we employ and whether it is trauma-focused or not. Could this mean that traumatized patients needlessly suffer from therapeutic exposure to horrific memories? The article was the start of a fiery debate between prominent researchers.

Let’s start with the initial article itself. Dr. Benish et al. published a meta-analysis with data from 15 studies and 958 patients in PTSD treatment. The aims of their meta-analysis were most unusual; whereas the last decades were dedicated to the discovery of the most effective therapies, based on the assumption that the effectiveness varies between interventions, Benish et al. assumed and tested the reverse: all therapeutically-intended interventions are equally efficacious. Continue reading