Associations between sleep problems and posttraumatic stress symptoms, social functioning, and quality of life in refugees with posttraumatic stress disorder.

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems, leading to impairments in social functioning and quality of life. Refugees are at high risk for sleep problems due to stressful life circumstances and a high PTSD prevalence. However, limited data on the frequency of sleep problems in refugees with diagnosed PTSD exist. This study examined the frequency of sleep problems in refugees with PTSD and their associations with symptoms of PTSD. Additionally, we investigated the contribution of sleep problems to social functioning and quality of life. Participants (N = 70) were refugees from different countries of origin currently living in Germany. All participants met the criteria for PTSD and completed measures of PTSD symptom severity, subjective sleep problems, social impairment, and quality of life. There was a very high frequency of sleep problems in the sample (100%), and sleep problems were significantly associated with both clinician-rated, r = .47, and self-rated, r = .30, PTSD symptom severity after controlling for overlapping items. Contrary to expectations, sleep problems did not predict social impairment, d = 0.16, nor quality of life, d = 0.13, beyond the effect of other PTSD symptoms. The findings highlight the widespread frequency of sleep problems among refugees. Future studies should assess the causal nature of the association between sleep problems and measures of psychosocial functioning in more detail and examine its dynamic change over time.

Do changes in dysfunctional posttraumatic cognitions differentially predict PTSD symptom clusters?

OBJECTIVE: In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity-despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters. METHOD: As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models. RESULTS: Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for. CONCLUSION: The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Culturally adapted cognitive behavioural group therapy for mental disorders in refugees plus problem solving training (ReTreat): study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Since a high proportion of refugees in Germany suffer from mental disorders, culturally adapted treatments are needed that target a broad range of symptoms. There is much evidence for the efficacy of culturally adapted cognitive behavioural therapy (CA-CBT). Given the promising results of CA-CBT, the combination with problem solving training (CA-CBT+) represents a novel approach that potentially improves the refugees' ability to cope actively with psychosocial problems. This randomised controlled trial evaluates the efficacy of 12-session outpatient CA-CBT+ compared with to treatment as usual (TAU) in a sample of refugees suffering from at least one DSM-5 disorder. METHODS AND ANALYSIS: The present study will be carried out as two-group randomised trial with 1:1 individual allocation to either (1) culturally adapted cognitive behavioural therapy in a group setting (CA-CBT+) or (2) TAU. The study takes place at four sites in Germany, randomising in total 138 adult refugees with at least one primary DSM-5 diagnosis to the treatment conditions. In CA-CBT+ the patients receive 12 sessions of 120 min duration over the course of 12 weeks providing psychoeducation, meditation and other techniques of emotional regulation, stretching and problem solving training. The primary outcome is treatment response operationalised by a clinically significant change in General Health Questionnaire (GHQ-28) score. Follow-up visits will take place 3 and 9 months after the end of the intervention. Secondary outcomes include changes in psychopathological symptoms, somatic symptoms and quality of life. Intention-to-treat analysis will be performed. Adverse and serious adverse events will be analysed. Further, healthcare usage and economic outcomes will be assessed and analysed. Primary and secondary outcomes will be analysed using appropriate statistical methods. ETHICS AND DISSEMINATION: The study has been approved by the Ethics Commission of the German Psychological Society (ref: StangierUlrich2019-1018VA). Results will be disseminated via presentations, publication in international journals, and national outlets for clinicians. Furthermore, intervention materials will be available, and the existing network will be used to disseminate and implement the interventions into routine healthcare. TRIAL REGISTRATION NUMBER: DRKS00021536.

The Bi-factor model of repetitive negative thinking: Common vs. unique factors as predictors of depression and anxiety.

BACKGROUND AND OBJECTIVES: Different forms of repetitive negative thinking (RNT) have traditionally been conceptualized as being distinctly linked to specific disorders. However, emerging evidence suggests that a common process lies at the core of different RNT manifestations. This common process might also largely explain the link between RNT and psychopathology. To examine the latent factor structure of RNT, we compared three structural-equation models, assuming (a) a common factor across different RNT measures (single-factor model); (b) scale-specific factors for each RNT measures (separate-factor model); and (c) both a common and scale-specific factors (bi-factor model). We additionally tested whether these latent factors predicted depression and anxiety at a follow-up time-point. METHODS: A community sample (N = 523) completed an online assessment comprising measures of rumination, worry and content-independent RNT as well as depressive and anxiety symptoms at baseline (t1) and three months later (t2). RESULTS: The bi-factor model showed the best fit to the data among the three models. Moreover, the common factor of the bi-factor model significantly predicted depression and anxiety three months later. Next to the common factor, some but not all scale-specific factors additionally predicted symptoms. LIMITATIONS: The study was conducted in a non-clinical sample and the assessment of psychopathology was restricted to depressive and anxiety symptoms. CONCLUSIONS: The findings support transdiagnostic conceptualizations of RNT, which highlight common aspects of different forms of RNT as well as the relevance of RNT across different diagnostic categories.

Mechanisms of Change in Trauma-Focused Treatment for PTSD: The Role of Rumination.

OBJECTIVE: Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination. METHOD: As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models. RESULTS: Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor. CONCLUSIONS: The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Dropout from psychological interventions for refugees and asylum seekers: A meta-analysis.

BACKGROUND: Refugees and asylum seekers often suffer from migration stressors and related psychopathology. However, providing this population with psychological treatment has a number of barriers (e.g., culture and language differences), which are widely thought to hinder the success and continuation of treatment. OBJECTIVE: The current systematic review and meta-analysis aims to provide first comprehensive evidence on the prevalence and predictors of dropout in treatment provided for refugees and asylum seekers. METHOD: We synthesized the existing evidence on dropout from psychological and psychosocial interventions provided to adult refugees and asylum seekers resettled in high-income countries. Specifically, we meta-analyzed the prevalence of dropout from treatment and explored the factors that predict dropout. Our database search in Pubmed, PsycINFO, Web of Science, and PTSDpubs identified 28 eligible randomized controlled trials (RCTs; 2,691 participants; 39 active treatment conditions), published up to January 31, 2021. RESULTS: Results showed a weighted average dropout rate of 19.14%, 95% confidence interval [14.66, 24.60] across studies and treatment conditions. Subgroup analyses and meta-regressions revealed no statistically significant predictors for dropout. However, several refugee-specific variables (e.g., longer mean duration in country of resettlement, lower rate of insecure asylum status) may merit closer attention in future research. CONCLUSIONS: These findings suggest that, in contrast to widespread assumption, the estimated average dropout rate is comparable to those reported in nonrefugee populations. However, more research is needed to establish the underlying mechanisms of dropout, which may differ across populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Brief imagery rescripting vs. usual care and treatment advice in refugees with posttraumatic stress disorder: study protocol for a multi-center randomized-controlled trial.

Background: Many refugees have experienced multiple traumatic events in their country of origin and/or during flight. Trauma-related disorders such as posttraumatic stress disorder (PTSD) or complex PTSD (CPTSD) are prevalent in this population, which highlights the need for accessible and effective treatment. Imagery Rescripting (ImRs), an imagery-based treatment that does not use formal exposure and that has received growing interest as an innovative treatment for PTSD, appears to be a promising approach. Objective: This randomized-controlled trial aims to investigate the efficacy of ImRs for refugees compared to Usual Care and Treatment Advice (UC+TA) on (C)PTSD remission and reduction in other related symptoms. Method: Subjects are 90 refugees to Germany with a diagnosis of PTSD according to DSM-5. They will be randomly allocated to receive either UC+TA (n = 45) or 10 sessions of ImRs (n = 45). Assessments will be conducted at baseline, post-intervention, three-month follow-up, and 12-month follow-up. Primary outcome is the (C)PTSD remission rate. Secondary outcomes are severity of PTSD and CPTSD symptoms, psychiatric symptoms, dissociative symptoms, quality of sleep, and treatment satisfaction. Economic analyses will investigate health-related quality of life and costs. Additional measures will assess migration and stress-related factors, predictors of dropout, therapeutic alliance and session-by-session changes in trauma-related symptoms. Results and Conclusions: Emerging evidence suggests the suitability of ImRs in the treatment of refugees with PTSD. After positive evaluation, this short and culturally adaptable treatment can contribute to close the treatment gap for refugees in high-income countries such as Germany. Trial registration: German Clinical Trials Register under trial number DRKS00019876, registered prospectively on 28 April 2020.

Antecedentes: Muchos refugiados han experimentado múltiples eventos traumáticos en su país de origen y/o durante la huida. Los trastornos relacionados con el trauma, como el trastorno de estrés postraumático (TEPT) o el trastorno de estrés postraumático complejo (TEPTC), son frecuentes en esta población, lo que pone de relieve la necesidad de un tratamiento accesible y eficaz. La reescritura de imágenes (ImRs, en sus siglas en inglés), un tratamiento basado en imágenes que no utiliza la exposición formal y que ha recibido un creciente interés como tratamiento innovador para el TEPT, parece ser un enfoque prometedor.Objetivo: Este ensayo controlado aleatorizado tiene como objetivo investigar la eficacia de la ImRs para los refugiados en comparación con cuidado habitual y consejería de tratamiento (UC+TA) en la remisión del TEPT(C) y la reducción de otros síntomas relacionados.Método: Los sujetos son 90 refugiados en Alemania con un diagnóstico de TEPT según el DSM-5. Serán asignados aleatoriamente para recibir UC+TA (n = 45) o diez sesiones de ImRs (n = 45). Las evaluaciones se llevarán a cabo al inicio, post-intervención, con un seguimiento de tres meses y un seguimiento de 12 meses. El resultado primario es la tasa de remisión del TEPT(C). Los resultados secundarios son la gravedad de los síntomas del TEPT y del TEPTC, los síntomas psiquiátricos, los síntomas disociativos, la calidad del sueño y la satisfacción del tratamiento. Los análisis económicos investigarán la calidad de vida y los costos relacionados con la salud. Medidas adicionales evaluarán los factores relacionados con la migración y el estrés, los predictores de la deserción, la alianza terapéutica y los cambios sesión por sesión en los síntomas relacionados con el trauma.Resultados y conclusiones: Las evidencias emergentes sugieren la idoneidad de la ImRs en el tratamiento de los refugiados con TEPT. Después de una evaluación positiva, este tratamiento corto y culturalmente adaptable puede contribuir a reducir la brecha de tratamiento para los refugiados en países de altos ingresos como Alemania.