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Resumo A prevalência de exposição à violência é alta no Brasil, contribuindo para o aumento do número de transtornos relacionados a traumas, especialmente o transtorno de estresse pós-traumático (TEPT). Este estudo tem por objetivo apresentar uma série de casos de pacientes com TEPT que passaram pela terapia de exposição narrativa (NET) em dois centros de saúde do Rio de Janeiro. Os profissionais de saúde receberam duas semanas de treinamento NET. A exposição à violência e a outros eventos potencialmente traumáticos, bem como o TEPT, foram avaliados por entrevistadores antes do tratamento e seis meses depois em entrevistas de acompanhamento conduzidas por avaliadores sob condição cega. O tratamento foi integrado à rotina dos serviços. Oito pacientes completaram a NET e apresentaram redução substancial na severidade do TEPT. Todos reportaram exposição a eventos traumáticos múltiplos, incluindo diferentes tipos de abuso infantil, sexual, violência por parceiro íntimo e comunitária. Cinco pacientes foram expostos à violência comunitária e um à violência doméstica durante ou após o tratamento. Esta série de casos mostra que a NET é um tratamento eficaz para pacientes com TEPT expostos a violências contínuas e pode ser integrado nos serviços públicos de saúde.

In zone di conflitto come la Re-pubblica Democratica del Congo, un’ampia proporzione di popolazione e vittima di violen-za. Le esperienze traumatiche e gli atti di violenza, causando esiti avversi per la salute men-tale e problemi comportamentali, che vanno oltre l’individuo interessando la famiglia, la comunita e il sistema sociale, tramandano il trauma lungo le generazioni. Le dinamiche di evitamento e la comunicazione disfunzionale sulle esperienze traumatiche delle vittime com-portano la costruzione di pregiudizi e marginalizzazione dei sopravvissuti, non rendendo possibile una comprensione collettiva di tali vissuti. I cicli della violenza trovano spazio nel-le comunita che si "organizzano" sulle conseguenze ereditate di traumi conflitto-correlati. Questo articolo espone il modello di sistema sanitario NETfacts, che fornisce un approccio integrato per rispondere alle conseguenze della violenza a livello sia individuale sia di co-munita.

War and crises affect mental health, social attitudes, and cultural norms, which can exacerbate the state of long-term insecurity. With decades of armed conflict, the Democratic Republic of Congo is one example, and violence has become normalized in civilian settings. In this study, we tested the effectiveness of the NETfacts health system, an integrated model of evidence-based individual trauma treatment (Narrative Exposure Therapy [NET]) and a trauma-informed community-based intervention (NETfacts). Alongside changes in mental health outcomes (posttraumatic stress disorder, depression, social disapproval, and shame) we also investigated change in attitudes, including rape myth acceptance, stigmatization of survivors of sexual violence, and skepticism about the reintegration of former combatants. To test whether the additional community intervention is superior to individual NET alone, we implemented a randomized controlled design with six villages and interviewed a sample of 1,066 community members. Our results demonstrate that the NETfacts health system in comparison with NET alone more effectively reduced rape myth acceptance and with it ongoing victimization and perpetration. Community members of the NETfacts group also presented with less stigmatizing attitudes against survivors of sexual violence. Skepticism about the reintegration of former combatants declined in both groups. NETfacts appears to have increased motivation to engage in individual treatment. Synergizing the healing effects of individual and collective trauma exposure, the NETfacts health system appears to be an effective and scalable approach to correct degrading or ignominious norms and restore functioning and mental health in postconflict communities.

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).

Reintegration of ex‐combatants involves multiple challenges. In addition to the trauma‐related psychological sequelae, social obstacles in the community can aggravate psychopathological aggressive tendencies and lead to the continuation of violence in civilian life. However, the association between others’ negative attitudes and ex‐combatants’ ongoing perpetration of violence remains largely unexplored. Between September 2018 and May 2019, we assessed a representative community sample of adults in Eastern DR Congo (N = 1,058) and measured trauma exposure, perpetration, mental health problems (PTSD, depression, and appetitive aggression), perceived stigma (shame, perceived lack of social acknowledgement), experienced stigma, and skepticism toward reintegration with ex‐combatants. Male ex‐combatants (12%, n = 129) had more past trauma and violence perpetration than other community members and a greater number of recent conflicts (including both victimization and perpetration) within the community and with strangers/organized violence. They reported more experienced stigma, more severe PTSD symptoms but were less skeptical about reintegration. Ex‐combatants’ ongoing violence was predicted by an interplay of the community's skepticism toward reintegration and ex‐combatants’ perceived and recently experienced stigma (often attributed to the armed group history) and mental health problems, in addition to lifetime traumatization. These findings promote the need for combined interventions that address individual mental health problems including aggression and collective discriminatory attitudes and behaviors., This article showed that stigmatization presents as additional burden for ex‐combatants in Eastern DRC beyond posttraumatic experiences. Rejective attitudes toward ex‐combatants form the basis of stigmatization and by predicting both mental health problems and aggression present as social drivers of the cycles of violence. Our study demonstrates the importance for intervention programming that combines individual treatment with interventions including ex‐combatants' social environment.

Objective Individuals who return from armed groups present with a history of traumatic events including perpetration. Subsequent severe mental stress and heightened levels of reactive and appetitive aggression may persist and if left untreated, frequently impede peacebuilding and societal stability. In this study, we tested a revised adaptation of Narrative Exposure Therapy (NET; Schauer et al., 2011) for Forensic Offender Rehabilitation (FORNET) implemented in a sample of male former combatants in war-torn regions of the DR Congo. Method We applied a longitudinal parallel-group randomized controlled design with treatment as usual (TAU) as control condition and 3-5 and 6-9 months follow-up assessments. The effect of treatment over time on clinical and social outcomes was tested with GLMMs; appetitive aggression and current violent behavior (CVB) were specified as primary and posttraumatic stress as secondary outcomes. Results FORNET decreased appetitive aggression (within group Cohen's dz = 2.00), CVB (dz = .90) and posttraumatic stress (dz = 1.48) significantly more than treatment as usual. Clinical significance was obtained for all outcomes. Remarkably, NET clients also reduced their substance abuse (dz = .68) even though this was not targeted within the intervention. Depression, perceived social acknowledgement and subjective solidarity with (para)military life decreased. Conclusion FORNET is a compact and scalable psychotherapeutic intervention that effectively reduces current aggressive behavior including physical abuse against children, intimate partner violence (IPV), and community violence. FORNET further decreases appetitive aggression, posttraumatic stress symptoms, and other clinical and social problems that commonly hinder demobilization, reintegration, and post-conflict peacebuilding. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Additional file 1: Model of informed consent.

Objective: Former 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.Methods: 98 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.Results: Female 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.Conclusions: Trauma 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. published

BackgroundAnecdotal 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.MethodsWe 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.ResultsThe 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 ConclusionMore extensive forms of FGM are associated with more severe psychopathological symptoms – particularly with an increased vulnerability to PTSD. Higher hair cortisol levels in women who experienced FGM before their first year of age or had more severe forms of FGM indicate long-term neuroendocrinological consequences of FGM and trauma in general on the stress system. published

Research has identified appetitive aggression, i.e., the perception of committed, violent acts as appealing, exciting and fascinating, as a common phenomenon within populations living in precarious and violent circumstances. Investigating demobilized soldiers in the Democratic Republic of Congo (DRC) demonstrated that violent offending is associated with appetitive aggression and not necessarily with symptoms of posttraumatic stress. In the present study, we sought to replicate these results in an independent and larger sample of demobilized soldiers from Burundi. As with the Congolese ex-combatants, random forest regression revealed that the number of lifetime perpetrated violent acts is the most important predictor of appetitive aggression and the number of lifetime experienced traumatic events is the main predictor for posttraumatic stress. Perpetrated violent acts with salient cues of hunting (pursuing the victim, the sight of blood, etc.) were most predictive for perceiving violent cues appealingly after demobilization. Moreover, the association of violent acts and appetitive aggression as well as traumatic events and posttraumatic stress remains strong even years after demobilization. Patterns of traumatic events and perpetrated acts as predictors for posttraumatic stress and appetitive aggression seem to be robust among different samples of ex-combatants who fought in civil wars. Psychotherapeutic interventions that address these complementary facets of combat-related disorders-namely, posttraumatic stress and appetitive aggression-are indispensable for a successful reintegration of those who fought in armed conflicts and to achieve a successful transition to peace. published

Violent behavior can be intrinsically rewarding; especially combatants fighting in current civil wars present with elevated traits of appetitive aggression. The majority of these fighters were recruited as children or adolescents. In the present study, we test whether there is a developmental period where combatants are sensitive for developing a robust trait of appetitive aggression. We investigated 95 combatants in their demobilization process that were recruited at different ages in the Kivu regions of the eastern Democratic Republic of Congo. Using random forest with conditional inference trees, we identified recruitment at the ages from 16 and 17 years as being predictive of the level of appetitive aggression; the number of lifetime, perpetrated acts was the most important predictor. We conclude that high levels of appetitive aggression develop in ex-combatants, especially in those recruited during their middle to late teenage, which is a developmental period marked by a natural inclination to exercise physical force. Consequently, ex-combatants may remain vulnerable for aggressive behavior patterns and re-recruitment unless they are provided alternative strategies for dealing with their aggression. published

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. Keywords: PTSD; DSM-5; DSM-IV; Congo; ex-combatants; violence Responsible Editor: Stuart Turner, Trauma Clinic, London, United Kingdom. For the abstract or full text in other languages, please see Supplementary files in the column to the right (under ‘Article Tools’). (Published: 25 February 2015) Citation: European Journal of Psychotraumatology 2015, 6 : 24981 - http://dx.doi.org/10.3402/ejpt.v6.24981

In der vorliegenden Arbeit werden die Zusammenhänge verschiedener Formen weiblicher Geni- talverstümmelung, psychischer Gesundheit und endokriner Veränderungen anhand einer Studie mit Frauen in Jijiga (Somali Region, Äthiopien) untersucht.Bisherige Forschungsarbeiten aus dem Bereich weibliche Genitalverstümmelung (engl.: Female Genital Mutilation, FGM) betrachten vor allem die physischen und gynäkologischen Folgen des Eingriffs. Der Zusammenhang von psychischer Gesundheit und weiblicher Genitalverstüm- melung hingegen wird nur in wenigen Studien aus den Ländern Senegal (Behrendt & Moritz, 2005), Ägypten (Chibber et al., 2011) und Irak (Kizilhan, 2011) untersucht. Insgesamt ist dieses Forschungsgebiet bisher wenig erschlossen, weshalb das Hauptanliegen dieser Arbeit die Untersuchung des Zusammenhangs der psychischen Gesundheit und verschiedenen Formen von FGM darstellt. Der Schwerpunkt liegt hierbei auf posttraumatischer Belastungsstörung, Dissoziation, Ängstlichkeit und Depression sowie endokrinen Veränderungen in Zusammenhang mit FGM.Darüber hinaus wird in dieser Arbeit durch die Untersuchung weiterer endokriner Zusammen- hänge ergänzt. Unsichere Lebensumstände, traumatisches Erleben und Stress steigern die Anforderungen des menschlichen Organismus an seine Umwelt, was langfristig unter ande- rem zu Veränderungen des Glukokortikoidspiegels, wie beispielsweise dem des Kortisols, führt (Charmandari et al., 2005). Das Haarkortisol ist ein biologischer Marker für Stress, der sich in den letzten Jahren als retrospektiver Kalender für die Segregation von Kortisol herausgestellt hat (Kirschbaum et al., 2009; Russell et al., 2012). Über die Veränderung des Kortisolgehalts beschnittener Frauen hinaus, ist es ein weiteres Anliegen dieser Arbeit Zusammenhänge der Anzahl traumatischer Lebensereignistypen und der posttraumatischen Belastungsstörung mit den Haarkortisolwerten zu untersuchen.An der Studie nahmen 167 Frauen (FGM I: n = 60, FGM II/III: n = 87) im Alter von 13 bis 80 Jahren teil. Zur Erfassung von Einzelheiten während des Eingriffs der Beschneidung wurde ein ausführlicher Fragenkatalog entworfen. Darüber hinaus wurde familiäre Gewalt über die Checklist of Domestic Violence (Catani et al., 2008) und die Anzahl traumatischer Lebensereig- nistypen anhand der Ereignisliste der Posttraumatic Diagnostic Scale (Foa et al., 1993) erfasst. Die psychische Gesundheit wurde über Symptome der posttraumatischen Belastungsstörung (Posttraumatic Stress Disease Symptom Scale - Interview, Foa et al., 1993), der Dissoziation (Shutdown Dissociation Scale, Schauer & Elbert, 2011), der Depression, der Ängstlichkeit (Hopkins Symptom Checklist 25, Derogatis et al., 1974), der Major Depression, des Sub- stanzmissbrauchs und der -abhängigkeit sowie psychotischen Störungen (Mini International Neuropsychiatric Interview, Sheehan et al., 1998) untersucht.Die Befunde zeigen, dass Frauen, die am schwersten beschnitten (FGM II und FGM III) sind, wie erwartet auch die stärkste Beeinträchtigung der psychischen Gesundheit (PTBS, Ängstlichkeit, Major Depression und Depressivität) aufweisen im Vergleich zu nicht beschnittenen und nach Typ I beschnittenen Frauen. Hinsichtlich dieser Störungen ergeben sich keine Unterschiede zwischen den beiden letztgenannten Gruppen. Dieser Befund spiegelt sich auch unter Einbezug des Effekts der Anzahl traumatischer Lebensereignistypen wider, wobei hier eine Sonderstellung nicht beschnittener Frauen deutlich hervortritt. Bezüglich der Dissoziationssymptomatik unterscheiden sich hingegen beschnittene (FGM I jedoch nur tendenziell) von nicht beschnittenen Frauen, die Beschneidungstypen jedoch nicht untereinander. Die erwarteten Zusammenhänge mit dem Haarkortisol können lediglich für die Anzahl traumatischer Lebensereignistypen bestätigt werden. So zeigt sich kein Zusammenhang verschiedener Formen weiblicher Genitalverstümmelung (No FGM, FGM I und FGM II/III) oder der posttraumatischen Belastungsstörung mit den Haarkortisolwerten. Es wird allerdings ein negativer Zusammenhang von Dissoziation und Haarkortisol unter Kontrolle des Effekts der Anzahl traumatischer Lebensereignistypen entdeckt. Abschließend wird in dieser Arbeit ein pathologisch bedingter Zusammenbruch der adaptiven Steigerung der HHNA-Aktivität in Abhängigkeit traumatischer Erfahrungen diskutiert.Die vorliegende Arbeit kann als Pilotstudie betrachtet werden, die als Grundlage für größere epidemiologische Untersuchungen oder Interventionsplanungen im Bereich FGM herangezogen werden kann. Zum Nachweis kausaler Beziehungen und einer besseren Generalisierbarkeit bedarf es jedoch weiterer Forschung. Darüber hinaus beleuchtet diese Arbeit neue Aspekte der endokrinologischen Forschung anhand einer Stichprobe, die größtenteils frühem Lebensstress ausgesetzt war.