PTSD among Bosnian refugees: a survey of providers' knowledge, attitudes and service patterns.

The objective of this study was to investigate providers' knowledge, attitudes and service provision patterns for Bosnian refugees with PTSD and to consider the overall implications for trauma-related mental health services. A survey instrument was developed and administered to 30 randomly selected service providers working with Bosnian refugees in Chicago. This sample includes primary medical care providers (n = 7), community social service providers (n = 12), and mental health service providers (n = 11). Results showed that knowledge about PTSD is highest in mental health service providers, as is amount of previous training and education about PTSD. Less than half of all providers systematically assess for PTSD, and standardized instruments for PTSD are rarely used. The top three overall recommendations for services were ranked as: 1. Psychotherapy; 2. No intervention; 3. Psychiatric evaluation. In general, less than half of providers hold attitudes toward refugees as suffering from illnesses or mental disorders, or that "something" is wrong with them. Likewise, only half of the providers reported providing education to refugees and their families about the possible mental health consequences of trauma. In conclusion, assessment, intervention and educational activities of providers are not consistent with literature documenting that PTSD is highly prevalent in refugee populations. New training programs, model development, and research initiatives are needed to address the needs of refugees.

[Psychotherapeutic testimony be refugees from Bosnia-Herzegovina: a pilot study]. / Psihoterapija svjedocenjem sa izbjeglicama iz Bosne i Hercegovine: pilot studija.

GOAL: The authors wished to describe the need of the psychotherapy by the witnessing in the group of the adult refugees who have survived the genocide in B&H. METHODOLOGY: The subjects of the study were 20 refugees from B&H with the residence in Chicago, which gave the written assent for participation in the study of the psychotherapy by witnessing. All the participants were this method, what in the average were 6 sessions, the approximative duration 90 minutes, once a week or once in two weeks. The participants were tested by the application of the standardized instruments for PTSP, depression, traumatic events, the global functioning and the previous therapy, after the last seance and after 2 and 6 months. RESULT: The estimations done after the therapy showed significantly the decrease in the percentage of the diagnoses of PTSP (repeated living, escaping, increase arousing attention). The symptom of the depression have also significantly lower, and the estimation of the global functioning was significantly higher. To the testing after 2 and 6 months showed that the further significant decreasing of the symptoms and the significant increase of the functioning. CONCLUSION: This pilot study offers the preliminary proves that psychotherapy by the witnessing of the symptoms of PTSP and also the depression as well as to the improvement of the functioning in the survived political and war violence.

Profiling the trauma related symptoms of Bosnian refugees who have not sought mental health services.

The objective of this study was to profile trauma related psychiatric symptoms in a group of refugees not seeking mental health services and to consider the services implications. The study involved research assessments of two groups of Bosnian refugees: those who have not presented for mental health services and those who have. A total of 28 of 41 nonpresenters (70%) met symptom criteria for posttraumatic stress disorder (PTSD) diagnosis. All service presenters (N = 29) met symptom criteria for PTSD diagnosis. The group that did not present for services reported substantial but lower trauma exposure, PTSD symptom severity, and depression symptom severity. They had significant differences on all subscales of the MOS SF-36, indicating better health status. We concluded that those who do not seek services have substantial symptom levels, but their self-concept appears to be less oriented toward illness and help seeking. Innovative access, engagement, and preventive interventions are needed to address those who have symptoms but do not readily seek help for trauma mental health services.

Case series: PTSD symptoms in adolescent survivors of "ethnic cleansing." Results from a 1-year follow-up study.

OBJECTIVE: The authors describe the psychiatric sequelae of "ethnic cleansing" in adolescent Bosnian refugees, via a 1-year follow-up study. METHOD: Ten Bosnian adolescent refugees from the war in Bosnia-Herzegovina received a baseline assessment within the first year after their resettlement and a follow-up assessment 1 year later. Evaluations included an assessment scale for posttraumatic stress disorder (PTSD) symptom severity. RESULTS: At baseline, 3 subjects met criteria for PTSD. At follow-up, this diagnosis persisted in none of these subjects, though 1 subject met criteria at follow-up only. For the group, mean PTSD severity scores at baseline and at follow-up were 8.9 and 4.0, respectively. At baseline, reexperiencing symptoms were present 43% of the time, avoidance symptoms were present 33% of the time, and hyperarousal symptoms were present 33% of the time; at follow-up, these proportions were 35%, 16%, and 18%, respectively. CONCLUSIONS: Overall, rates of PTSD symptoms diminished during the 1-year follow-up interval, suggesting that they may be transient and not representative of enduring psychopathology. This finding may reflect the relative resiliency of adolescents, as well as a variety of factors that facilitated adaptation in our particular group of adolescent refugees.

Testimony psychotherapy in Bosnian refugees: a pilot study.

OBJECTIVE: The authors sought to describe the use of the testimony method of psychotherapy in a group of traumatized adult refugees from genocide in Bosnia-Herzegovina. METHOD: The subjects were 20 Bosnian refugees in Chicago who gave written informed consent to participate in a case series study of testimony psychotherapy. All subjects received testimony psychotherapy, averaging six sessions, approximately 90 minutes, weekly or biweekly. Subjects received standardized instruments for posttraumatic stress disorder (PTSD), depression, traumatic events, global functioning, and prior psychiatric history. The instruments were administered before treatment, at the conclusion of the treatment, and at the 2- and 6-month follow-ups. RESULTS: The posttreatment assessments demonstrated significant decreases in the rate of PTSD diagnosis, PTSD symptom severity, and the severity of reexperiencing, avoidance, and hyperarousal symptom clusters. Depressive symptoms demonstrated a significant decrease, and there was a significant increase in scores on the Global Assessment of Functioning Scale. Two-month and 6-month follow-up assessments demonstrated further significant decreases in all symptoms and an increase in scores on the Global Assessment of Functioning Scale. CONCLUSIONS: This pilot study provides preliminary evidence that testimony psychotherapy may lead to improvements in PTSD and depressive symptoms, as well as to improvement of functioning, in survivors of state-sponsored violence.

PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States.

OBJECTIVE: The authors' goal was to describe the characteristics of posttraumatic stress disorder (PTSD) symptoms on resettlement in the United States and at 1-year follow-up among Bosnian refugees as well as possible factors affecting the PTSD symptom profile among these refugees. METHOD: They used standardized instruments to assess 34 Bosnian refugees for PTSD at resettlement in the United States and 1 year later. RESULTS: Fifteen of the refugees were diagnosed with PTSD at 1-year follow-up, compared with 25 at initial assessment. The average PTSD severity score at follow-up was 12.5, compared with 20.6 at initial assessment. At 1-year follow-up, 25 of the refugees experienced a decrease in severity of PTSD symptoms, one remained the same, and eight experienced an increase in severity. Older refugees were significantly more likely to have PTSD than younger refugees, and older refugees had more severe symptoms. CONCLUSIONS: The level of PTSD diagnosis and symptoms in Bosnian refugees remained substantial 1 year after their resettlement in the United States, although there were notable overall decreases. Older refugees appeared to be at greater risk.

Individual change after genocide in Bosnian survivors of "ethnic cleansing": assessing personality dysfunction.

The authors used the SCID-DES (disorders of extreme stress) instrument to assess for personality change in Bosnian survivors of "ethnic cleansing." Twenty four refugees underwent systematic, trauma-focused, research assessments, including the SCID-DES interview. Overall, this group of Bosnian survivors had been severely traumatized as a result of the Serbian nationalists' genocide. However, no subject met diagnostic criteria for DES. The SCID-DES yields far lower rates of trauma-related personality change in Bosnian survivors of genocide than in adult survivors of prolonged early life traumas. Therefore, the DES construct may have better application to prolonged, interpersonal, early life traumas than to the prolonged, communal traumas of genocide.

Childhood trauma histories in adolescent inpatients.

The authors describe the prevalence of childhood traumatic experiences among adolescent inpatients. A Childhood Trauma Chart Review Scale (CTCRS) was developed to assess traumatic experiences during childhood and adolescence. The CTCRS was reliably applied to the medical records of 75 adolescent inpatients who had been given structured clinical interviews for DSM-III-R diagnoses at the time of admission. Most subjects (81%) had experienced at least one traumatic event during childhood, with loss of caregiver being the most frequent type of traumatic experience. Many subjects had multiple types of traumatic experiences, during both early and late childhood. A history of childhood trauma was associated with greater functional impairment and higher likelihood of having a personality disorder, but with no difference in Axis I diagnoses.

Psychiatric consequences of "ethnic cleansing": clinical assessments and trauma testimonies of newly resettled Bosnian refugees.

OBJECTIVE: The authors describe the psychiatric assessments and trauma testimonies of 20 Bosnian refugees of "ethnic cleansing" who have recently resettled in the United States. METHOD: Refugees referred from agencies managing refugee resettlement underwent systematic, trauma-focused, clinical interviews that included standardized assessment scales. RESULTS: The traumatic experiences of ethnic cleansing in these Bosnian refugees were genocidal in nature. The number of types of traumatic experiences correlated positively with age. Posttraumatic stress disorder (PTSD) was diagnosed in 65% of the refugees, and depressive disorders in 35%. PTSD severity scores were correlated with the number of types of traumatic events experienced. CONCLUSIONS: Ethnic cleansing has caused high rates of PTSD and depression, as well as other forms of psychological morbidity, in this group of resettled Bosnian refugees. The longitudinal sequelae of ethnic cleansing as a form of massive psychic trauma remain to be studied.

[The search for historical truth: psychotherapeutic work with Bosnian refugees]. / Die Suche nach der historischen Wahrheit: Psychotherapeutische Arbeit mit bosnischen Flüchtlingen.

The trauma haunting refugees from ex-Yugoslavia is inextricably bound up with complex processes of historical change. In order to be able to understand and treat their severe psychic problems, psychotherapists have to go in search of the historical truth, which is frequently masked by myths and obsolete notions. Only when a psychotherapist who has received the relevant interdisciplinary schooling acknowledges the existence of completely new historical experiences can s/he provide effective support for Bosnian Muslims fleeing "ethnic cleansing" and attempting to achieve self-healing, learning and growth after such an extreme form of collective and individual destruction. In this way the psychotherapist becomes an initiated listener and a unique witness of a form of historical truth that for the traumatized patients themselves is at first entirely or largely beyond recall and comprehension.