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Abstract Soldiers may be exposed to traumatic stress during combat deployment and thus are at risk for developing posttraumatic stress disorder (PTSD). Genetic and epigenetic evidence suggests that PTSD is linked to forming stress-related memories. In the current study, we investigated post-deployment associations of PTSD symptoms with differential DNA methylation in a sample of Burundian soldiers returning from the African Union Mission in Somalia’s war zone. We used a matched longitudinal study design to explore epigenetic changes associated with PTSD symptoms in N = 191 participants. PTSD symptoms and saliva samples were collected at 1–3 (t1) and 9–14 months (t2) after the return of the soldiers to their home base. Individuals with either worsening or improving PTSD symptoms were matched for age, stressful, traumatic and self-perpetrated events prior to the post-assessment, traumatic and violent experiences between the post- and the follow-up assessment, and violence experienced during childhood. A mixed model analysis was conducted to identify top nominally significantly differentially methylated genes, which were then used to perform a gene enrichment analysis. The linoleic acid metabolism pathway was significantly associated with post-deployment PTSD symptoms, after accounting for multiple comparisons. Linoleic acid has been linked to memory and immune related processes in previous research. Our findings suggest that differential methylation of linoleic acid pathway genes is associated with PTSD and thus may merit closer inspection as a possible mediator of resilience.

Abstract Background The results of critical illness and life-saving invasive measures during intensive care unit treatment can sometimes lead to lasting physical and psychological impairments. A multicentre randomized controlled trial from Germany (PICTURE) aims to test a brief psychological intervention, based on narrative exposure therapy, for post-traumatic stress disorder symptoms following intensive care unit treatment in the primary care setting. A qualitative analysis was conducted to understand feasibility and acceptance of the intervention beyond quantitative analysis of the main outcomes in the primary study. Methods Qualitative explorative sub-study of the main PICTURE trial, with eight patients from the intervention group recruited for semi-structured telephone interviews. Transcriptions were analysed according to Mayring's qualitative content analysis. Contents were coded and classified into emerging categories. Results The study population was 50% female and male, with a mean age of 60.9 years and transplantation surgery being the most frequent admission diagnosis. Four main factors were identified as conducive towards implementation of a short psychological intervention in a primary care setting: 1) long-term trustful relationship between patient and GP team; 2) intervention applied by a medical doctor; 3) professional emotional distance of the GP team; 4) brevity of the intervention. Conclusion The primary setting has certain qualities such as a long-term doctor-patient relationship and low-threshold consultations that offer good opportunities for implementation of a brief psychological intervention for post-intensive care unit impairments. Structured follow-up guidelines for primary care following intensive care unit treatment are needed. Brief general practice-based interventions could be part of a stepped-care approach. Trial registration The main trial was registered at the DRKS (German Register of Clinical Trials: DRKS00012589) on 17/10/2017.

Abstract Exposure to traumatic experiences across lifespan shapes the functioning of the hypothalamic pituitary adrenal (HPA) axis and sets individuals at risk to develop symptoms of depression and anxiety. Particularly, HPA axis regulation and the psychological health of the expectant mother have been of interest, as the health of the unborn child may be affected through changes in gestational biology. The present study investigated the potential associations between lifetime trauma, current symptoms (depression and anxiety) and hair cortisol concentrations (HCC) in pregnant women. A total of 149 pregnant women were interviewed in public outpatient clinics with varying gestational age in Greece, Spain and Perú. Lifetime trauma exposure and current symptoms of depression and anxiety were assessed. HCC was measured in scalp-near hair segments (2 cm length) reflecting cumulative cortisol secretion of the past two months. Results showed that trauma load is negatively associated with HCC and higher symptoms of depression and anxiety. There was a negative association between HCC and symptoms. The present findings support the notion that cumulative trauma exposure exerts long-lasting effects on the expectant mother’s HPA axis activity functioning and mental health and may thereby potentially create risk trajectories for the unborn child via changes in gestational biology.

Abstract Epigenetic processes allow plasticity in gene regulation in response to significant environmental events. Accumulating evidence suggests that effective psychotherapy is accompanied by epigenetic changes, rendering DNA methylation a potential biomarker of therapy success. Due to the central role of glucocorticoid dynamics in stress regulation and the alteration of aversive memories, glucocorticoid receptors are likely involved in the molecular processes that are required to successfully treat Posttraumatic Stress Disorder (PTSD). This study aimed to investigate the relationship between methylation at the glucocorticoid receptor gene (NR3C1) and PTSD treatment success of evidence-based psychotherapy. A sample of N = 153 conflict survivors from Northern Uganda (98 females and 55 males) with PTSD were treated with Narrative Exposure Therapy (NET). Diagnostic interviews and saliva sampling took place at pretreatment and 4 and 10 months after treatment completion. We investigated potential associations between PTSD symptom development and methylation changes at 38 CpG sites spanning NR3C1 over the three times of measurement using the repeated measures correlation. After accounting for multiple comparisons, DNA methylation at CpG site cg25535999 remained negatively associated with PTSD symptoms. These results were followed up by mixed models as well as structural equation modelling. These analyses revealed that treatment responders had a significant cg25535999 methylation increase after treatment with NET. Furthermore, lower methylation at cg25535999 pretreatment predicted a higher symptom improvement. Our results suggest different epigenetic profile dynamics at NR3C1 cg25535999 in therapy responders compared to non-responders and underscore the central role of glucocorticoid signaling in trauma-focused therapy.

Abstract The aftermath of traumatization lives on in the neural and epigenetic traces creating a momentum of affliction in the psychological and social realm. Can psychotherapy reorganise these memories through changes in DNA methylation signatures? Using a randomised controlled parallel group design, we examined methylome-wide changes in saliva samples of 84 female former child soldiers from Eastern DR Congo before and six months after Narrative Exposure Therapy. Treatment predicted differentially methylated positions (DMPs) related to ALCAM, RIPOR2, AFAP1 and MOCOS. In addition, treatment associations overlapped at gene level with baseline clinical and social outcomes. Treatment related DMPs are involved in memory formation—the key agent in trauma focused treatments—and enriched for molecular pathways commonly affected by trauma related disorders. Results were partially replicated in an independent sample of 53 female former child soldiers from Northern Uganda. Our results suggest a molecular impact of psychological treatment in women with war-related childhood trauma. Trial registration: Addressing Heightened Levels of Aggression in Traumatized Offenders With Psychotherapeutic Means (ClinicalTrials.gov Identifier: NCT02992561, 14/12/2016).

Abstract Background Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of “retraumatisation” and general skepticism in clinicians concerning the use of exposure therapy. Methods To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points. Results On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms. Conclusions Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren’t found to prevent the overall effectiveness of NET. Trial registration NCT02852616 .

Abstract Background The wars in the Democratic Republic of Congo have left indelible marks on the mental health and functioning of the Congolese civilians that sought refuge in Uganda. Even though it is clear that civilians who are exposed to potentially traumatizing events in war and conflict areas develop trauma-related mental health problems, scholarly information on gender differences on exposure to different war-related traumatic events, their conditional risks to developing PTSD and whether the cumulative exposure to traumatic events affects men and women differently is still scanty. Methods In total, 325 (n = 143 males, n = 182 females) Congolese refugees who lived in Nakivale, a refugee settlement in the Southwestern part of Uganda were interviewed within a year after their arrival. Assessment included exposure to war-related traumatic events, and DSM-IV PTSD symptom severity. Results Our main findings were that refugees were highly exposed to war-related traumatic events with experiencing dangerous flight as the most common event for both men (97%) and women (97%). The overall high prevalence of PTSD differed among women (94%) and men (84%). The highest conditional prevalence of PTSD in women was associated with experiencing rape. The dose-response effect differed significantly between men and women with women showing higher PTSD symptom severity when experiencing low and moderate levels of potentially traumatizing event types. Conclusion In conflict areas, civilians are highly exposed to different types of war-related traumatic events that expose them to high levels of PTSD symptoms, particularly women. Interventions focused at reducing mental health problems resulting from war should take the context of gender into consideration.

BackgroundInterpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat.MethodThe NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment.ResultsImplementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms.ConclusionNETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.

Abstract Background Studies on populations affected by organized violence have shown elevated levels of family violence against children. This form of violence has been found to contribute to children’s psychopathology independently of traumatic experiences related to war, persecution or flight. Little is known, so far, about the exposure to family violence and its relation to mental health in North Korean refugee youth affected by political violence. The aim of this study was to examine the amount of organized and family violence and associated psychopathology in a sample of North Korean refugee youth living in South Korea compared to their South Korean peers. Methods Sixty-five North Korean refugee youth and 65 South Korean youth were recruited. Trained researchers conducted the survey in group meetings of five to ten participants. Using questionnaires researchers assessed traumatic experiences, family and organized violence, PTSD symptoms, depressive symptoms and other mental health problems. Results Higher rates of violence and trauma, and higher levels of mental health problems were found in the North Korean sample compared to the South Korean sample. Linear regression analyses including the various types of trauma as potential predictors showed that the severity of PTSD and depressive symptoms in the North Korean sample were associated with the amount of traumatic events and family violence but not with higher levels of organized violence. Conclusions The findings suggest that in a context of organized violence, abusive experiences by family members constitute an important problem that is strongly linked to the psychopathology of adolescents. Our data suggest that psychological treatment and prevention approaches for North Korean refugees should be carefully tailored to fit the specific requirements of this population and address the mental health of the individual as well as potential problems at the family level.

Background: Survivors of sexual violence are frequently condemned and socially excluded. Myths about rape may translate into stigmatization, diminish disclosure, prevent help-seeking from support structures and worsen mental health. Areas of conflict or organized violence remain the evident hotspots of sexual victimization. However, little is known about prevalence and predictors of rape myths in these settings or their association with survivors’ disclosure, stigmatization and psychopathology. Method: Between September 2018 and May 2019, we assessed in a representative sample of 1066 individuals from six communities in Eastern DRC traumatic exposure, sexual perpetration, threats to social integrity, perceived stigmatization (perceived lack of social acknowledgement, shame), stigmatizing attitudes towards survivors (negative attitudes and willingness to provide support, rape myths acceptance), and mental illness (PTSD, depression). Results: Survivors of sexual violence (33%, n = 184 of women, 16%, n = 84 of men) reported more traumatic exposure, threats to social integrity, shame, perceived lack of social acknowledgement, PTSD symptoms and depression. Their social environment affirmed various stigmatizing attitudes (5-89% affirmations). Beliefs in rape myths were predicted by its average acceptance in the community, education, and witness of others’ sexual victimization. The rates of cases whose history of sexual victimization was socially disclosed were higher in communities and among survivors with low rape myths acceptance and disclosure showed associations with perceived stigmatization. Rape myths acceptance among individuals without a history of sexual victimization was associated with survivors’ recently experienced threats to social integrity which predicted their stigma perceptions and mental illness. Conclusion: Rape myths acceptance in the community is associated with stigma and trauma-related mental illness of sexual violence survivors. This adds up to the psychic burden of trauma.

Background: Posttraumatic Stress Disorder (PTSD) is associated with high levels of functional impairments such as difficulties in academic or occupational performance and in social relationships. With an increasing number of traumatic event types experienced (trauma load), PTSD risk increases in a dose-dependent manner. Accordingly, high rates of PTSD can impair the reconstruction process in post-conflict societies. In order to meet these high needs for mental health services in societies with little access to professional care, task shifting approaches and community-based interventions have been suggested. Narrative Exposure Therapy (NET) has been developed as a short and pragmatic exposure-based PTSD treatment that can be easily trained to lay personnel. Yet, it remains unclear whether NET can be effectively provided by trained lay counsellors even at high levels of trauma load. Objective: To investigate whether trauma load influences the treatment effectiveness of NET provided by trained and supervised local lay counsellors. Method: Linear mixed models were calculated to investigate the influence of trauma load on treatment effectiveness in a sample of N = 323 rebel war survivors from Northern Uganda with PTSD. Results: We found a strong reduction of PTSD symptoms following NET, which was not influenced by trauma load. However, individuals with higher levels of trauma load reported higher PTSD symptoms before therapy as well as 4 and 10 months following treatment completion compared to individuals with lower trauma load. Conclusions: Treatment with NET by lay counsellors is effective independent of trauma load. However, individuals with higher trauma load have a higher probability to show residual symptoms, which might require additional time, sessions or treatment modules.

ObjectiveFormer combatants are exposed to multiple traumatic stressors during conflict situations and usually participate in perpetration of violence. Ongoing perpetration of violence in post conflict areas, linked to mental health problems and appetitive aggression, destabilises peace keeping efforts. The aim of this study is to investigate lifetime exposure to violence and the relationship between this exposure and mental health and current violent behaviour in a sample of female former child soldiers with a history of perpetration of violence in Eastern DR Congo.Methods98 female former child soldiers who had been abducted and forcibly recruited during the M23 insurgency (2012–2014) were assessed for lifetime exposure to trauma including perpetration of violence, clinical outcomes (PTSD and appetitive aggression), and current violent behaviour.ResultsFemale former child soldiers had been exposed to extremely high levels of trauma including perpetration of violence and presented with high levels of mental health problems. Linear regression models showed that current violent behaviour was predicted by both PTSD and appetitive aggression.ConclusionsTrauma exposure predicts ongoing perpetration of violence post conflict via the resulting mental health problems. The findings imply that if PTSD and appetitive aggression symptoms are successfully treated, ongoing violent behaviour in the community post conflict will also decrease.

PURPOSE:Adverse childhood experiences in sensitive periods of the developing brain render the individual at a life-long risk for a broad spectrum of aberrant health outcomes. However, there is a lack of scales for the comprehensive assessment of adverse childhood experiences providing information of various types and the age of occurrence. Based on the complete, experimental version of the Maltreatment and abuse chronology of exposure (MACE-X) scale, the present study aimed to develop and psychometrically test a Norwegian version of MACE. METHODS:The 75-item MACE-X was translated from German to Norwegian and administered as a self-report measure to 90 outpatients and 145 employees at a Division of specialized mental health care in South-Eastern Norway. The outpatients also completed the Childhood trauma questionnaire (CTQ) and the Symptom checklist 90 (SCL-90) to investigate convergent and predictive validity. To investigate test-retest reliability, outpatients completed MACE once more two weeks later. RESULTS:Rasch analysis and Anderson likelihood ratio tests on the combined outpatient and employee data resulted in a 55 item version of the Norwegian MACE. In the outpatient group, test-retest reliability of the MACE-55 was excellent for total scores (ICC ≥ 0.94) and good to excellent for 10 subscale scores (ICC ≥ 0.82). Convergent validity with the CTQ was moderate to high for both total scores (0.63 ≥ r ≥ 0.86) and subscale scores (0.56 ≥ r ≥ 0.82). As compared to CTQ total scores, a MACE total score that combined severity and duration of exposure was numerically more strongly associated with overall psychiatric symptoms and each of nine symptom domains on the SCL-90. CONCLUSIONS:The newly developed Norwegian MACE comprehensively assesses past exposure to adverse childhood experiences with high psychometric properties. This scale is a useful tool for research questions addressing sensitive periods for childhood adversities and associated health phenotypes.

Abstract Background Traumatic events like critical illness and intensive care are threats to life and bodily integrity and pose a risk factor for posttraumatic stress disorder (PTSD). PTSD affects the quality of life and morbidity and may increase health-care costs. Limited access to specialist care results in PTSD patients being treated in primary care settings. Narrative exposure therapy (NET) is based on the principles of cognitive behavioral therapy and has shown positive effects when delivered by health-care professionals other than psychologists. The primary aims of the PICTURE trial (from “PTSD after ICU survival”) are to investigate the effectiveness and applicability of NET adapted for primary care with case management in adults diagnosed with PTSD after intensive care. Methods/design This is an investigator-initiated, multi-center, primary care-based, randomized controlled two-arm parallel group, observer-blinded superiority trial conducted throughout Germany. In total, 340 adult patients with a total score of at least 20 points on the posttraumatic diagnostic scale (PDS-5) 3 months after receiving intensive care treatment will be equally randomized to two groups: NET combined with case management and improved treatment as usual (iTAU). All primary care physicians (PCPs) involved will be instructed in the diagnosis and treatment of PTSD according to current German guidelines. PCPs in the iTAU group will deliver usual care during three consultations. In the experimental group, PCPs will additionally be trained to deliver an adapted version of NET (three sessions) supported by phone-based case management by a medical assistant. At 6 and 12 months after randomization, structured blinded telephone interviews will assess patient-reported outcomes. The primary composite endpoint is the absolute change from baseline at month 6 in PTSD symptom severity measured by the PDS-5 total score, which also incorporates the death of any study patients. Secondary outcomes cover the domains depression, anxiety, disability, health-related quality-of-life, and cost-effectiveness. The principal analysis is by intention to treat. Discussion If the superiority of the experimental intervention over usual care can be demonstrated, the combination of brief NET and case management could be a treatment option to relieve PTSD-related symptoms and to improve primary care after intensive care. Trial registration ClinicalTrials.gov, NCT03315390. Registered on 10 October 2017. German Clinical Trials Register, DRKS00012589. Registered on 17 October 2017.

Abstract Background Anecdotal evidence suggests the frequently traumatic nature of female genital mutilation (FGM). At present, systematic research on the psychological sequelae of this tradition has remained limited. The study provides preliminary, high-quality psychodiagnostic data on potential psychopathological consequences of FGM, with a focus on posttraumatic stress disorder (PTSD), shutdown dissociation and other stress-related variables. Methods We investigated a convenience sample of N = 167 women, supported by the women’s affairs headquarters in Jijiga (capital of the Ethiopian Somali Region) and a local Ethiopian non-governmental organization. Our main outcome measures were PTSD (PSS-I) and shutdown dissociation (ShuD). We also assessed depression and anxiety (HSCL-25), major depression, substance abuse and dependence, suicidality and psychotic disorders (M.I.N.I.; sub-scales A., B., K., and L.). In addition, we collected hair samples to assess hair cortisol concentrations (HCC) as a neuroendocrinological measure. Results The majority of women endured FGM (FGM I: 36%, FGM II/III: 52%) and, regardless of the level of the physical invasiveness, almost all women reported having felt intense fear and/or helplessness. FGM II/III, the more invasive form, was associated with a greater vulnerability to PTSD symptoms (p

Abstract Appetitive aggression is a sub-category of instrumental aggression, characterised by the primary intrinsic enjoyment of aggressive activity. Aggression is heritable, and serotonergic and monoaminergic neurotransmitter systems have been found to contribute to the underlying molecular mechanisms. The aim of this study was to investigate the role that genetic variants in the serotonin transporter (SLC6A4) and monoamine oxidase A (MAOA) genes play in the aetiology of appetitive aggression in South African Xhosa males (n = 290). SLC6A4 5-HTTLPR, rs25531, and STin2 variants, as well as MAOA-uVNTR were investigated for their association with levels of appetitive aggression using Poisson regression analysis. The STin2 VNTR12 allele was found to be associated with increased levels of appetitive aggression (p = 0.003), but with decreased levels of reactive aggression (p = 7 × 10−5). This study is the first to investigate genetic underpinnings of appetitive aggression in a South African population, with preliminary evidence suggesting that SCL6A4 STin2 variants play a role in its aetiology, and may also be important in differentiating between appetitive and reactive aggression. Although the results require replication, they shed some preliminary light on the molecular dichotomy that may underlie the two forms of aggression.

Stress during pregnancy widely associates with epigenetic changes and psychiatric problems during childhood. Animal studies, however, show that under specific postnatal conditions prenatal stress may have other, less detrimental consequences for the offspring. Here, we studied mental health and epigenome-wide DNA methylation in saliva following intimate partner violence (IPV) during pregnancy in São Gonçalo, a Brazilian city with high levels of violence. Not surprisingly, mothers exposed to pregnancy IPV expressed elevated depression, PTSD and anxiety symptoms. Children had similar psychiatric problems when they experienced maternal IPV after being born. More surprisingly, when maternal IPV occurred both during (prenatal) and after pregnancy these problems were absent. Following prenatal IPV, genomic sites in genes encoding the glucocorticoid receptor (NR3C1) and its repressor FKBP51 (FKBP5) were among the most differentially methylated and indicated an enhanced ability to terminate hormonal stress responses in prenatally stressed children. These children also showed more DNA methylation in heterochromatin-like regions, which previously has been associated with stress/disease resilience. A similar relationship was seen in prenatally stressed middle-eastern refugees of the same age as the São Gonçalo children but exposed to postnatal war-related violence. While our study is limited in location and sample size, it provides novel insights on how prenatal stress may epigenetically shape resilience in humans, possibly through interactions with the postnatal environment. This translates animal findings and emphasizes the importance to account for population differences when studying how early life gene–environment interactions affects mental health.

Refugees are exposed to multiple traumatic and stressful events and thereby are at higher risk for developing a variety of psychological sequelae including posttraumatic stress disorder (PTSD). However, the relation of PTSD to other mental health conditions has not been fully revealed in refugee populations. The present study investigated relationships among trauma exposure, PTSD, depression, and insomnia in North Korean refugee youth. Seventy-four refugee youth were assessed for exposure to traumatic events, PTSD, depression, and insomnia symptoms. The results showed high rates of multiple trauma exposures among the refugee youth and high incidences of co-occurring symptoms of PTSD and insomnia in those who have multiple trauma. Furthermore, the overall symptoms and four cluster symptoms of PTSD were strongly correlated with insomnia in addition to depression. In the path model to predict insomnia, PTSD affected insomnia only through depression, indicating that the greater the levels of PTSD suffered, the greater the likelihood for developing sleep problems via depression. The present study indicates how sleep problems relate to trauma-related symptoms, i.e., PTSD and depression in refugee populations, and highlights the need for further investigation of the specific relation between sleep problems and trauma-related symptoms for effective evaluation and intervention.

Background: There is strong support for familial abuse as a risk factor for later delinquency and violent offending, whereas empirical evidence about the contribution of experienced organized violence to the cycle of violence is less clear. Nevertheless not all abused children do become violent offenders. This raises the question of which factors influence these children's risk of future aggressive behavior. Recent evidence suggests that the trait of appetitive aggression plays an important role in the prediction of aggressive behavior. Objective: The focus of the study is to investigate whether exposures to 1) organized; and 2) family violence equally contribute to aggressive behavior and how this is related to a trait of appetitive aggression. Furthermore it is of interest to uncover how the severity of posttraumatic stress disorder (PTSD) symptoms modulates associations between violent experiences and aggression. Method: To answer these questions, we investigated unaccompanied refugee minors who had been exposed to varying levels of both violence types. Using structured interviews, experiences of organized and familial violence, self-committed aggressive acts, the trait of appetitive aggression, and PTSD symptoms were assessed in 49 volunteers. Results: A sequential regression analysis revealed that the trait of appetitive aggression and experienced family violence were independent and significant predictors of self-committed aggressive acts, altogether accounting for 70% of the variance. Exposure to organized violence, however, was not significantly associated with aggressive acts or appetitive aggression. PTSD symptom severity was not correlated with measures of aggression but with the exposure to familial and organized violence. Conclusions: Results suggest that in addition to the impact of family violence, an elevated trait of appetitive aggression plays a crucial role in aggressive behavior and should be considered in psychotherapeutic treatment.

Background: Life in the low-income urban communities of South Africa is imprinted by a cycle of violence in which young males predominantly are in the roles of both victim and perpetrator. There is some evidence that adolescents who show an attraction to cruelty can display high levels of psychosocial functioning despite the presence of posttraumatic stress symptoms. However, the role of appetitive aggression in the context of ongoing threats and daily hassles is not yet fully understood. Objective: In this study, we examine the role of attraction to violence in areas of continuous traumatic stress exposure and its effect on posttraumatic stress disorder (PTSD) severity and violence perpetration. Method: A sample of 290 young males from two low-income Cape Town communities was surveyed. We assessed appetitive aggression with the Appetitive Aggression Scale (AAS), PTSD symptoms with the PTSD Symptom Scale-Interview, the number of witnessed and self-experienced traumatic event types with an adaptation of the Child Exposure to Community Violence questionnaire, and the number of perpetrated violence event types with an adapted offence checklist from the AAS. Results: Appetitive aggression scores were predicted by witnessed as well as self-experienced traumatic events. Higher appetitive aggression scores resulted in higher levels of PTSD severity and perpetrated violence. Conclusions: Young males living in the low-income areas of South Africa may develop an attraction to cruelty in response to exposure to violence. Their willingness to fight in turn can increase the likelihood of continued violent behaviour. In contrast to previous research from postconflict areas, appetitive aggression and engagement in violence do not prevent the development of PTSD, but are instead associated with higher levels of posttraumatic stress. PTSD symptoms such as avoidance and hyperarousal, as well as an attraction to cruelty and thus the willingness to fight, might support survival in areas of ongoing conflict, but at the same time they could fuel the cycle of violence.

Studies in conflict population have repeatedly documented that the number of traumatic event types experienced (trauma load) increases the risk to develop posttraumatic stress disorder (PTSD) in a dose-dependent manner. Misconceptions about survivors' experiences and actions during the war, as well as mental health symptoms frequently lead to stigmatization by their own families and the community, which might render them even more vulnerable for PTSD development and prevent successful recovery. We therefore investigated whether stigmatization affects trauma-related psychopathology beyond the well-known effect of trauma load. The study sample comprised N = 1131 survivors of the rebel war led by the Lord's Resistance Army (LRA) in Northern Uganda, including a large proportion of formerly abducted individuals and child soldiers. We investigated how the experience of stigmatization affects PTSD risk and the likelihood of spontaneous remission, taking trauma load into account. Further, the association of stigmatization with treatment outcome was determined in a subsample of N = 284 individuals with PTSD who received trauma-focused psychotherapy. More than one third of the total sample, and almost two-thirds of the therapy subsample, reported experiences of stigmatization. The main reasons for stigmatization were related to an association with a rebel group (e.g., being called a rebel), followed by mental health problems/PTSD symptoms and HIV/AIDS. Stigmatization was strongly associated with a higher prevalence of lifetime and current PTSD, a diminished probability of spontaneous remission and higher PTSD symptoms before and after trauma-focused psychotherapy, beyond the effect of trauma load. In sum, our results support the assumption that stigmatization aggravates trauma-related psychopathology and impede symptom improvement. In post-conflict regions, community and family interventions which aim at reducing stigmatization and discrimination might therefore complement individual psychotherapy in order to allow survivors to recover and reintegrate into society.

Background: Cross-sectional studies indicate that a substantial proportion of refugees have psychiatric disorders. However, longitudinal studies on the course of psychiatric symptoms and on influencing factors are scarce. The current study investigates the development of symptoms in an untreated refugee sample in Germany and seeks to identify potential predictors.Methods: Over the course of 1 year, 57 refugees participated in monthly assisted self-reports on the phone assessing emotional distress. At the same time, semi-annual, semi-structured clinical interviews focusing on posttraumatic stress disorder (PTSD) and depression were conducted. The overall dropout rate for the year was 23% for the assisted self-reports and 33% for the clinical interviews.Results: Symptoms did not systematically change over the course of the year. On the individual level, a reliable change in PTSD symptoms was observed in 13% who showed improvement and 24% who showed worsening symptoms. Figures for depression symptoms were 24 and 16% respectively. A higher number of traumatic experiences was related to a greater intensity of PTSD symptoms. In addition, postmigrational stressors were associated with a worsening of PTSD symptoms over the course of the year. Emotional distress was associated with current negative life events, unemployment, and frequent visits to physicians.Conclusions: There is on average no improvement or worsening of symptoms over the period of 1 year. However, individual courses vary, and thus show the importance of risk factors. Accordingly, the identification of risk factors such as trauma load and postmigrational stressors can be useful to determine the need of further monitoring and to provide appropriate interventions when necessary.

Background: While studies with survivors of single traumatic experiences highlight individual response variation following trauma, research from conflict regions shows that almost everyone develops posttraumatic stress disorder (PTSD) if trauma exposure reaches extreme levels. Therefore, evaluating the effects of cumulative trauma exposure is of utmost importance in studies investigating risk factors for PTSD. Yet, little research has been devoted to evaluate how this important environmental risk factor can be best quantified. Methods: We investigated the retest reliability and predictive validity of different trauma measures in a sample of 227 Ugandan rebel war survivors. Trauma exposure was modeled as the number of traumatic event types experienced or as a score considering traumatic event frequencies. In addition, we investigated whether age at trauma exposure can be reliably measured and improves PTSD risk prediction. Results: All trauma measures showed good reliability. While prediction of lifetime PTSD was most accurate from the number of different traumatic event types experienced, inclusion of event frequencies slightly improved the prediction of current PTSD. Conclusions: As assessing the number of traumatic events experienced is the least stressful and time-consuming assessment and leads to the best prediction of lifetime PTSD, we recommend this measure for research on PTSD etiology.

Over the past three decades, research and clinical practice related to the field of traumatic stress have developed tremendously. In parallel with the steady accumulation of basic knowledge, therapeutic approaches have been developed to treat people suffering from posttraumatic stress disorder (PTSD) and other trauma-related psychological problems. Today, a number of evidence-based treatments are available. They differ in various ways; however, they also have a number of commonalities. Given this situation, clinicians may wonder which treatment program to use, or more specifically, which treatment components are critical for a successful therapy. In this article, seven pioneers who have developed empirically supported psychotherapies for trauma-related disorders were asked to compose an essay of three parts: first, to provide a brief summary of the treatment they have developed; second, to identify three key interventions that are common and critical in treating PTSD; and third, to suggest important topics and future directions for research. The paper ends with a summary highlighting the identified commonalities (psychoeducation; emotion regulation and coping skills; imaginal exposure; cognitive processing, restructuring, and/or meaning making; emotions; and memory processes), pointing to future directions such as trying to better understand the underlying mechanisms of action, and developing treatments that are tailored to the needs of different patient groups.

Background: The relationships between traumatic stress and self-conscious emotions, such as shame and guilt, remain to be fully explored, especially in refugees, who frequently are exposed to a multitude of stressors. Objective: The aim of the present study was to investigate shame and guilt in refugee minors and to assess to what extent a greater cumulative exposure to traumatic stressors would result not only in more severe posttraumatic stress disorder (PTSD) symptoms but also in higher levels of shame and guilt. Methods: Thirty-two male refugee minors, who were all below the age of 18 when they sought asylum in Germany, agreed to participate. At the time of the assessment, the age ranged from 11 to 20 years. Eighteen refugees had arrived without relatives in their host country (“unaccompanied minors”). In structured diagnostic interviews, a PTSD diagnosis was established using the UCLA PTSD Index. Posttraumatic guilt was assessed by means of the Trauma-related Guilt Inventory, and the Shame Variability Questionnaire was used to record the intensity, duration, and frequency of shame episodes. Results: Feelings of guilt and shame as well as trauma symptoms were all associated with the number of traumatic event types subjects had experienced. Posttraumatic guilt and shame were both correlated with PTSD symptom severity. Conclusions: The findings indicate that cumulative stress such as exposure to multiple traumatic events poses a risk factor for the mental health including greater suffering and functional impairment due to shame and guilt.

The evolutionary model of the defense cascade by Schauer and Elbert (2010) provides a theoretical frame for a short interview to assess problems underlying and leading to the dissociative subtype of posttraumatic stress disorder. Based on known characteristics of the defense stages “fright,” “flag,” and “faint,” we designed a structured interview to assess the vulnerability for the respective types of dissociation. Most of the scales that assess dissociative phenomena are designed as self-report questionnaires. Their items are usually selected based on more heuristic considerations rather than a theoretical model and thus include anything from minor dissociative experiences to major pathological dissociation. The shutdown dissociation scale (Shut-D) was applied in several studies in patients with a history of multiple traumatic events and different disorders that have been shown previously to be prone to symptoms of dissociation. The goal of the present investigation was to obtain psychometric characteristics of the Shut-D (including factor structure, internal consistency, retest reliability, predictive, convergent and criterion-related concurrent validity).A total population of 225 patients and 68 healthy controls were accessed. Shut-D appears to have sufficient internal reliability, excellent retest reliability, high convergent validity, and satisfactory predictive validity, while the summed score of the scale reliably separates patients with exposure to trauma (in different diagnostic groups) from healthy controls.The Shut-D is a brief structured interview for assessing the vulnerability to dissociate as a consequence of exposure to traumatic stressors. The scale demonstrates high-quality psychometric properties and may be useful for researchers and clinicians in assessing shutdown dissociation as well as in predicting the risk of dissociative responding.

Background: During the period between 1993 and 2005, the people of Burundi were trapped within a violent civil war. In post-conflict regions, symptoms of posttraumatic stress disorder (PTSD) were found to be widespread. At the same time, combatants often reported having perceived committing violence as exciting and appealing, an experience referred to as appetitive aggression. Both of these phenomena hamper the building of a functional and peaceful society. Objective: This study aims to investigate the factors that are associated with the level of PTSD and appetitive aggression in former and still active combatants. Methods: Semi-structured interviews were conducted with 948 male Burundians: 556 active soldiers and 392 ex-combatants. PTSD symptom severity was assessed using the PTSD Symptom Scale Interview, while appetitive aggression was assessed using the Appetitive Aggression Scale. Results: Linear regression analyses revealed that the number of traumatic events, childhood maltreatment, and their interaction predicted PTSD symptom severity, whereas self-committed violence did not. The number of traumatic events and self-committed violence were associated with appetitive aggression. Childhood maltreatment alone was not associated with appetitive aggression; however, its interaction with self-committed violence did predict appetitive aggression. When controlling for predictors, ex-combatants reported a higher degree of PTSD symptomatology, whereas active soldiers reported a higher degree of appetitive aggression. Conclusion: We conclude that childhood maltreatment is an additional, significant risk factor that exacerbates the psychological consequences of violent conflicts. Self-committed violence may not necessarily engender trauma-related disorders, but is highly related to appetitive aggression.

Background: Compared to DSM-IV, the criteria for diagnosing posttraumatic stress disorder (PTSD) have been modified in DSM-5. Objective: The first aim of this study was to examine how these modifications impact rates of PTSD in a sample of Congolese ex-combatants. The second goal of this study was to investigate whether PTSD symptoms were associated with perpetrator-related acts or victim-related traumatic events. Method: Ninety-five male ex-combatants in the eastern Democratic Republic of Congo were interviewed. Both the DSM-IV and the DSM-5 PTSD symptom criteria were assessed. Results: The DSM-5 symptom criteria yielded a PTSD rate of 50% (n=47), whereas the DSM-IV symptom criteria were met by 44% (n=42). If the DSM-5 would be set as the current “gold standard,” then DSM-IV would have produced more false negatives (8%) than false positives (3%). A minority of participants (19%, n=18) indicated an event during which they were involved as a perpetrator as their most stressful event. Results of a regression analysis (R 2=0.40) showed that, after accounting for the number of types of traumatic events, perpetrated violent acts were not associated with the symptom severity of PTSD. Conclusions: The findings demonstrate that more diagnostic cases were produced with the DSM-5 diagnostic rules than were dropped resulting in an increase in PTSD rates compared to the DSM-IV system. The missing association between PTSD symptoms and perpetrated violent acts might be explained by a potential fascinating and excited perception of these acts.

Background: A substantial number of refugees present with mental disorders. This appears particularly acute in the currently increasing refugee populations in Europe. Although EU guidelines demand the identification and support of vulnerable individuals such as survivors of trauma, no adequately validated and comprehensive mental health screening instruments for refugees residing in Europe currently exist. Objective: We studied the feasibility, validity, and reliability of the Refugee Health Screener-15 (RHS-15) – a time-efficient and easy-to-implement screening developed by Hollifield et al. (2013) – as a self-rating and interview instrument. Methods: A sample of refugees from different countries (N = 86), representative of those who had arrived around the turn of the year 2015/2016 in Germany, filled in the RHS-15 on their own. A semi-structured clinical interview was later conducted with a random subsample (n = 56). Results: Fifty-two percent of the refugees examined screened positive in the RHS-15, thus indicating current mental health problems. The RHS-15 showed a good feasibility, reliability, and validity in both the self-rating and the interview version. It detected clinically relevant mental health problems when PTSD, depression, anxiety, or somatization problems were present. A shorter 13-item version proved to be equally valid. Conclusions: Together with previous research on the RHS in refugees living in the US, this suggests that the RHS is a time-efficient and accurate instrument that is able to detect common mental health problems in a wide range of refugees. Prospectively, the RHS could be used as an instrument for identifying vulnerable refugees, for example, by integrating it in the initial medical examination in the host community, thereby initiating support.

Appetitive aggression is the attraction to violent behavior, which can peak in the experience of a combat high. In various war and conflict scenarios, members of armed groups have reported developing a desire to hunt and even kill humans. More recently, we reported that the phenomenon has also been observed in female ex-combatants with varying participation in warfare. Despite recent investigations on risk factors for appetitive aggression, sex-specific pathways in the development of appetitive aggression have not yet been delineated. This study investigated moderation effects of sex on previously identified risk factors for appetitive aggression by means of regression analyses in a sample of individuals with varying degrees of warfare participation (overall sample, n = 602). First examining a sample characterized by backgrounds heterogeneous in both sociodemographic data and war experiences, the analysis was then replicated in a subsample of fighters active during the civil war (combatant sample, n = 109). In both samples, regression analyses revealed significant moderation effects of sex. Childhood maltreatment and traumatic events had positive associations on the development of appetitive aggression for males but a negative (childhood maltreatment) or no (traumatic events) association for females. Perpetrated events were more strongly correlated with appetitive aggression for females than for males. This pattern was pronounced for the combatant sample. These results are in favor of sex-linked pathways. In both sexes, appetitive aggression may have evolved as a biologically prepared response to cruel environments but might develop along different trajectories. The current study highlights the need for addressing appetitive aggression in order to support peace-building processes and emphasizes sex specific starting-points.

Background: In the ongoing conflict in the Democratic Republic of the Congo (DRC), civilians have been heavily exposed to traumatic stressors. Traumatizing experiences cumulatively heighten the risk for trauma-related disorders, and with it affect cognitive and psycho-social functioning. Objectives: We aimed at investigating the association between trauma-related disorders and cognitive and psycho-social functioning and hypothesized that PTSD symptom severity would negatively correlate with executive functioning, working memory and psycho-social functioning in everyday life. Method: In total, 323 Congolese refugees (mean age: 31.3 years) who arrived in the Ugandan Nakivale refugee settlement after January 2012 were assessed regarding their exposure to traumatic events, PTSD symptom severity (posttraumatic symptom scale interview), executive functioning (Tower of London), working memory performance (Corsi block tapping task) and psycho-social dysfunctioning (Luo functioning scale). Results: Hierarchical regression analyses indicated a significant negative association between PTSD symptom severity and working memory (β = –0.32, p 0.05). Conclusion: Trauma survivors not only suffer from the core PTSD symptoms but also from impaired cognitive functioning. PTSD symptom severity seems furthermore to be related to impaired psycho-social functioning. Our findings suggest that trauma-related mental health problems may heighten the risk for poverty and lack of prospect and further aggravate the consequences of war and conflict.

Exposure to traumatic stressors and subsequent trauma-related mental changes may alter a person's risk-taking behavior. It is unclear whether this relationship depends on the specific types of traumatic experiences. Moreover, the association has never been tested in displaced individuals with substantial levels of traumatic experiences. The present study assessed risk-taking behavior in 56 displaced individuals by means of the balloon analogue risk task (BART). Exposure to traumatic events, symptoms of posttraumatic stress disorder and depression were assessed by means of semi-structured interviews. Using a novel statistical approach (stochastic gradient boosting machines), we analyzed predictors of risk-taking behavior. Exposure to organized violence was associated with less risk-taking, as indicated by fewer adjusted pumps in the BART, as was the reported experience of physical abuse and neglect, emotional abuse, and peer violence in childhood. However, civil traumatic stressors, as well as other events during childhood were associated with lower risk taking. This suggests that the association between global risk-taking behavior and exposure to traumatic stress depends on the particular type of the stressors that have been experienced.

Background: The likelihood of developing Posttraumatic Stress Disorder (PTSD) depends on the interaction of individual risk factors and cumulative traumatic experiences. Hence, the identification of individual susceptibility factors warrants precise quantification of trauma exposure. Previous research indicated that some traumatic events may have more severe influences on mental health than others; thus, the assessment of traumatic load may be improved by weighting event list items rather than calculating the simple sum score. Objective: We compared two statistical methods, Random Forests using Conditional Interference (RF-CI) and Least Absolute Shrinkage and Selection Operator (LASSO), based on their ability to rank traumatic experiences according to their importance for predicting lifetime PTSD. Methods: Statistical models were initially fitted in a sample of N1 = 441 survivors of the Northern Ugandan rebel war. The ability to correctly predict lifetime PTSD was then tested in an independent sample of N2 = 211, and subsequently compared with predictions by the simple sum score of different traumatic event types experienced. Results: Results indicate that RF-CI and LASSO allow for a ranking of traumatic events according to their predictive importance for lifetime PTSD. Moreover, RF-CI showed slightly better prediction accuracy than the simple sum score, followed by LASSO when comparing prediction results in the validation sample. Conclusion: Given the expense in time and calculation effort by RF-CI and LASSO, and the relatively low increase in prediction accuracy by RF-CI, we recommend using the simple sum score to measure the environmental factor traumatic load, e.g., in analyses of gene × environment interactions.

Background: In violent communities, social rejection as a person with victim–offender attributes is associated with more intense symptoms of posttraumatic stress disorder (PTSD) and a higher propensity towards violence, i.e. appetitive aggression. Successful community reintegration encompassing adequate social acknowledgment of individuals with both a history of violence exposure and perpetration may be necessary to enhance the treatment effects of interventions addressing PTSD and aggression. Objective: In this study, the effects of treatment and post-treatment traumatic events, violent offenses, and social acknowledgment (with sub-dimensions of general disapproval, family disapproval, and recognition as a person with both a history of violence exposure and commission) on changes in PTSD symptom severity and appetitive aggression from baseline to 8-month follow-up were investigated. Method: Data were collected from 54 males recruited through a Cape Town offender reintegration programme for an intervention study targeting trauma and aggression (n = 28 treatment; n = 26 wait-list). Changes in PTSD symptom severity after treatment were assessed with the PTSD Symptom Scale-Interview, changes in appetitive aggression with the Appetitive Aggression Scale (AAS), post-treatment traumatic events with an adapted version of the Child’s Exposure to Violence Checklist, offenses with an adapted checklist from the AAS, and social acknowledgment with an adapted form of the Social Acknowledgment Questionnaire. Results: Path analyses revealed negative relationships between ongoing societal disapproval and changes in PTSD symptom severity and appetitive aggression at 8-months, controlling for age. All other variables were non-significant, except for treatment, which was associated with PTSD symptom reduction. Conclusions: As a complementary strategy to effective psychotherapeutic treatment, increased social acknowledgment may contribute significantly to the alleviation of PTSD symptoms and appetitive aggression. Psychological interventions should, therefore, not neglect the impact of societal factors on treatment effects.

Background: Current knowledge is limited regarding patient characteristics related to treatment outcome of posttraumatic stress disorders (PTSD) in refugees and asylum seekers. Objective: Gender, torture status, offender status, level of anger, and level of depression were investigated for possible effects on the treatment outcome. Method: Patient characteristics were explored in 54 refugees and asylum seekers who had completed a treatment program for PTSD. Non-responders (10), those who had the same or higher levels of symptom severity after treatment, were compared with responders, those who had lower symptom severity after treatment (44). Symptom severity was measured by Clinician-Administered PTSD Scale. The non-responders and responders constituted the dichotomous, dependent variable. The independent variables were gender, torture status, offender status, level of anger, and level of depression. T-tests and Exact Unconditional Homogeneity/Independence Tests for 2X2 Tables were used to study the relationship to treatment outcome. Results: Being male and reporting to have been a violent offender were significantly more frequent characteristics among the non-responders compared to the responders. The levels of pretreatment anger, depression and torture status did not affect the treatment outcome. Conclusions: The study adds support to findings that females benefit more from treatment of PTSD than males and that violent offenders are difficult to treat within the standard treatment programs.

Background: Child soldiers are often both victims and perpetrators of horrendous acts of violence. Research with former child soldiers has consistently shown that exposure to violence is linked to trauma-related disorders and that living in a violent environment is correlated with enhanced levels of aggression. Objective: To gain more insight into the experiences and the mental health status of former child soldiers, we conducted a survey with N=200 former child soldiers and adult combatants in the DR Congo. Methods: We conducted semi-structured interviews concerning military experiences, experienced and perpetrated violence, and mental health. Results: Former child soldiers reported more experienced and perpetrated violence, a greater severity of trauma-related suffering, as well as higher appetitive aggression than adult ex-combatants. Appetitive aggression was related to more perpetrated violence, higher military ranks, voluntary recruitment and higher rates of reenlistments in former child soldiers. Conclusions: Our results indicate that growing up in an armed group is related to higher levels of trauma-related disorders and aggressive behavior. This may explain the challenge of reintegrating former child soldiers. It is thus important to consider mental health problems, particularly trauma-related disorders and aggressive behavior, of former child soldiers for designing adequate reintegration programs.

Background : The relationship between organized violence and family violence, and their cumulative effect on mental health in post-conflict regions remains poorly understood. Objective : 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. Method : 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. Results : 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. Conclusion : 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.

Background: In the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are exposed to massive forms of violence and other traumatic stressors. Nevertheless, many combatants do not suffer from trauma-related disorders, although they have experienced numerous traumatizing events. Perceiving aggressive behavior as fascinating and arousing might be a defense against trauma-related disorders in the violent environment of war and conflict. Objective: Thus, in this study we investigated the relationship between the exposure to traumatic stressors, appetitive aggression, and posttraumatic stress disorder (PTSD) symptom severity. We hypothesized that cumulative traumatic experiences correlated positively and appetitive aggression negatively with PTSD symptom severity. Method: In total, 105 voluntary male combatants from different armed groups in the eastern DRC took part in this study. In a semistructured interview, respondents were questioned about their exposure to traumatic stressors, the extent of appetitive aggression (Appetitive Aggression Scale) and their PTSD symptom severity (PTSD Symptom Scale - Interview). Results: A multiple sequential regression analysis showed that traumatic events were positively related to PTSD symptom severity. For participants with low to medium PTSD symptom severity, appetitive aggression correlated negatively with PTSD symptom severity. Conclusions: The results of this study provide further support for earlier findings that repeated exposure to traumatic stressors cumulatively heightens the risk of PTSD and revealed that appetitive aggression buffers the risk of developing PTSD symptoms under certain circumstances. Thus, the perception of aggressive behavior as fascinating and arousing seem to help combatants to adapt to violent environments but may also be one reason for recurrent failure of reintegration programs for excombatants.

Background : Several instruments, notably Buss and Perry's Aggression Questionnaire, have been developed for the assessment of aggressive behavior. However, in these instruments, the focus has been on reactive rather than instrumental forms of aggression, even though men in particular may find aggressive behavior attractive. A questionnaire or structured interview for the systematic assessment of the attraction to violence is not yet available. Objective : We, therefore, developed a freely available short form for the assessment of a person's attraction to violent and planned forms of aggression based on reports of former combatants on the attraction to violence and the characteristics of instrumental aggression described in the literature. Method : The Appetitive Aggression Scale (AAS) was administered to nine samples drawn from different populations, with a total of 1,632 former combatants and participants from war-affected regions (1,193 male and 439 female respondents). Results : From the initial set of 31 items, a selection of 15 items was extracted to improve the scale's psychometric properties and assess the construct of appetitive aggression validly with respect to content. Cronbach's Alpha coefficient of 0.85 was appropriate. All items loaded significantly on a single factor accounting for 32% of the total variance. Further analysis revealed that the scale measures a specific construct that can be distinguished from other concepts of human aggression. Conclusions : With the AAS, we present an easily administrable tool for the assessment of the attraction to violence.

The cumulative exposure to life-threatening events increases the risk for posttraumatic stress disorder (PTSD). However, over the course of evolutionary adaptation, intra-species killing may have also evolved as an inborn strategy leading to greater reproductive success. Assuming that homicide has evolved as a profitable strategy in humans, a protective mechanism must prevent the perpetrator from getting traumatised by self-initiated violent acts. We thus postulate an inverse relation between a person's propensity toward violence and PTSD. We surveyed a sample of 269 Rwandan prisoners who were accused or convicted for crimes related to the 1994 genocide. In structured interviews we assessed traumatic event types, types of crimes committed, the person's appetitive violence experience with the Appetitive Aggression Scale (AAS) and PTSD symptom severity with the PSS-I. Using path-analysis, we found a dose-response effect between the exposure to traumatic events and the PTSD symptom severity (PSS-I). Moreover, participants who had reported that they committed more types of crimes demonstrated a higher AAS score. In turn, higher AAS scores predicted lower PTSD symptom severity scores. This study provides first empirical support that the victim's struggling can be an essential rewarding cue for perpetrators. The results also suggest that an appetitive aggression can inhibit PTSD and trauma-related symptoms in perpetrators and prevent perpetrators from getting traumatised by their own atrocities.

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.

The scent of blood is potentially one of the most fundamental and survival-relevant olfactory cues in humans. This experiment tests the first human parameters of perceptual threshold and emotional ratings in men and women of an artificially simulated smell of fresh blood in contact with the skin. We hypothesize that this scent of blood, with its association with injury, danger, death, and nutrition will be a critical cue activating fundamental motivational systems relating to either predatory approach behavior or prey-like withdrawal behavior, or both. The results show that perceptual thresholds are unimodally distributed for both sexes, with women being more sensitive. Furthermore, both women and men's emotional responses to simulated blood scent divide strongly into positive and negative valence ratings, with negative ratings in women having a strong arousal component. For women, this split is related to the phase of their menstrual cycle and oral contraception (OC). Future research will investigate whether this split in both genders is context-dependent or trait-like.

Inconsistent findings exist for the activity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with stress related disorders. Recent studies point towards early life stress as a potential modulator.We investigated the impact of childhood sexual abuse on phasic (saliva cortisol reactivity) and tonic (hair cortisol) regulation. Furthermore, we assessed predictors on cortisol accumulation in hair. Women (N = 43) with stress-related disorders underwent a standardized assessment of idiographic adverse and traumatic experiences and psychopathology, while measuring salivary cortisol and, heart rate and blood pressure.Comparing women with and without childhood sexual abuse revealed lower rates of responders and distinct levels of salivary cortisol to the interview in conjunction with a lower heart rate for the abused group. Childhood adversities, traumatic experiences, and depression contributed to higher hair cortisol levels.Our finding of lower response rate and distinct salivary cortisol pattern in individuals with childhood sexual abuse compared to individuals without early sexual abuse supports the role of environmental programming for the HPA axis. Both, childhood adversities and traumatic stress emerge as crucial factors for long-term cortisol secretion. Lower or suppressed phasic cortisol responses to trauma-related stimuli may therefore be associated with higher tonic values. Thus, early exposure to adversities may result in a biological distinct phenotype in adult patients with stress-related disorders.

Current civil wars are characterized by the increasing involvement of civilian populations and the systematic employment of child soldiers. An example of such wars was the conflict in Northern Uganda, where the war-affected population is still challenged by the reintegration of formerly abducted children and youths. A cross-sectional, population-based survey, using a multistage cluster sampling approach of 1,113 Northern Ugandans aged between 12 and 25 in camps for internally displaced persons and locally validated instruments was conducted to assess symptoms and diagnoses of Posttraumatic Stress Disorder (PTSD) and probable Depression in war-affected, as well as formerly abducted individuals. Further objectives were to determine predictors of psychopathology and to relate indicators of maladjustment (i.e., impairments in daily and community functioning, somatic complaints, suicidality, aggressiveness and discrimination) to abduction, level of exposure to violence and psychopathology. 43% of the sample reported abduction by the rebel army. Exposure to violence among this group was higher than for non-abducted youths (t = 28.05; p

BACKGROUND: Posttraumatic stress disorder (PTSD) is a serious psychiatric condition that was found to be associated with altered functioning of the hypothalamic-pituitary-adrenal (HPA) axis and changes in glucocorticoid (GC) responsiveness. The physiological actions of GCs are primarily mediated through GC receptors (GR) of which isoforms with different biological activities exist. This study aimed to investigate whether trauma-experience and/or PTSD are associated with altered expression of GR splice variants. METHODS: GRα and GRβ mRNA expression levels were determined by real-time quantitative PCR in whole blood samples of individuals with chronic and severe forms of PTSD (n = 42) as well as in ethnically matched reference subjects (non-PTSD, n = 35). RESULTS: Individuals suffering from PTSD exhibited significantly lower expression of the predominant and functionally active GRα isoform compared to non-PTSD subjects. This effect remained significant when accounting for gender, smoking, psychotropic medication or comorbid depression. Moreover, the GRα expression level was significantly negatively correlated with the number of traumatic event types experienced, both in the whole sample and within the PTSD patient group. Expression of the less abundant and non-ligand binding GRβ isoform was comparable between patient and reference groups. CONCLUSIONS: Reduced expression of the functionally active GRα isoform in peripheral blood cells of individuals with PTSD seems to be a cumulative effect of trauma burden rather than a specific feature of PTSD since non-PTSD subjects with high trauma load showed an intermediate phenotype between PTSD patients and individuals with no or few traumatic experiences.

Recent studies have suggested a protective role of physiological β-amyloid autoantibodies (Aβ-autoantibodies) in Alzheimer's disease (AD). However, the determination of both free and dissociated Aβ-autoantibodies in serum hitherto has yielded inconsistent results regarding their function and possible biomarker value. Here we report the application of a new sandwich enzyme-linked immunosorbent assay (ELISA) for the determination of antigen-bound Aβ-autoantibodies (intact Aβ-IgG immune complexes) in serum and cerebrospinal fluid (CSF) of a total number of 112 AD patients and age- and gender-matched control subjects. Both serum and CSF levels of Aβ-IgG immune complexes were found to be significantly higher in AD patients compared to control subjects. Moreover, the levels of Aβ-IgG complexes were negatively correlated with the cognitive status across the groups, increasing with declining cognitive test performance of the subjects. Our results suggest a contribution of IgG-type autoantibodies to Aβ clearance in vivo and an increased immune response in AD, which may be associated with deficient Aβ-IgG removal. These findings may contribute to elucidating the role of Aβ-autoantibodies in AD pathophysiology and their potential application in AD diagnosis.

Many studies have reported that during high fertility points in the menstrual cycle, women demonstrate increased preference for men with masculinized faces and bodies. In this study, we analyzed whether appetitive aggression in men serves as an additional signal for a favored partner choice. Appetitive aggression describes the intrinsic motivation to act violently even when not being threatened. This study evaluated the responses of 1212 women to one of four descriptions regarding a soldier's experience after returning from war. The four vignettes included trauma related symptoms with high or low appetitive aggression, or no trauma related symptoms with high or low appetitive aggression. Participants rated their desirability for the soldier in regards to potential long-term and short-term relationships. Results indicate that women preferred a soldier high in appetitive aggression as a short-term mate but not as a long-term relationship. This preference for the “warrior” was higher for women in their fertile window of the menstrual cycle. We conclude that women in their fertile window prefer men exhibiting higher appetitive aggression as a short-term partner, revealing appetitive aggression in men may serve as a signal for a higher genetic fitness.

In a previous report we showed that cognitive training fostering auditory-verbal discrimination and working memory normalized magnetoencephalographic (MEG) M50 gating ratio in schizophrenia patients. The present analysis addressed whether training effects on M50 ratio and task performance are mediated by changes in brain oscillatory activity. Such evidence should improve understanding of the role of oscillatory activity in phenomena such as M50 ratio, the role of dysfunctional oscillatory activity in processing abnormalities in schizophrenia, and mechanisms of action of cognitive training.Time-locked and non-time-locked oscillatory activity was measured together with M50 ratio in a paired-click design before and after a 4-week training of 36 patients randomly assigned to specific cognitive exercises (CE) or standard (comparison) cognitive training (CP). Patient data were compared to those of 15 healthy controls who participated in two MEG measurements 4 weeks apart without training. Training led to more time-locked gamma-band response and more non-time-locked alpha-band desynchronization, moreso after CE than after CP. Only after CE, increased alpha desynchronization was associated with normalized M50 ratio and with improved verbal memory performance. Thus, both types of cognitive training normalized gamma activity, associated with improved stimulus encoding. More targeted training of auditory-verbal discrimination and memory additionally normalized alpha desynchronization, associated with improved elaborative processing. The latter presumably contributes to improved auditory gating and cognitive function.Results suggest that dysfunctional interplay of ocillatory activity that may contribute to auditory processing disruption in schizophrenia can be modified by targeted training.