Publications by authors named "Anselm Crombach"

18 Publications

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Practical guidelines for online Narrative Exposure Therapy (e-NET) - a short-term treatment for posttraumatic stress disorder adapted for remote delivery.

Eur J Psychotraumatol 2021 Mar 1;12(1):1881728. Epub 2021 Mar 1.

vivo international, Konstanz, Germany.

: Online therapy has become increasingly desirable and available in recent years, with the current COVID-19 pandemic acting as a catalyst to develop further protocols enabling therapists to conduct online treatment safely and efficaciously. Offering online treatment potentially means that treatments are available to clients who would otherwise have no access, closing the gap in the provision of mental health services worldwide. : This paper focuses on practical guidelines using online Narrative Exposure Therapy (e-NET). It aims to be an addition to the general manual of NET to enable therapists to deliver online treatment. The face-to-face version of NET is a well-known short-term and evidence-based treatment for posttraumatic stress disorder; e-NET is currently being tested in several additional trials. : The differences between NET and e-NET are elaborated and depicted in detail. : Difficulties encountered in e-NET delivery, e.g. confidentiality, dealing with interruptions, comorbid symptoms among others, are similar to those that occur during face to face interventions but the solutions have to be adapted. Dissociation is often regarded as a challenge in face-to-face treatment, and requires particular attention within the online setting. Therefore, tools for addressing dissociation in this particular setting are presented. : These practical guidelines show the advantages as well as the challenges therapists face when conducting e-NET. They aim to empower therapists working with trauma clients to conduct e-NET confidently and safely.
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http://dx.doi.org/10.1080/20008198.2021.1881728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128121PMC
March 2021

Effective Adoption of Tablets for Psychodiagnostic Assessments in Rural Burundi: Evidence for the Usability and Validity of Mobile Technology in the Example of Differentiating Symptom Profiles in AMISOM Soldiers 1 Year After Deployment.

Front Public Health 2021 15;9:490604. Epub 2021 Apr 15.

Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.

Research on the use of mobile technology in health sciences has identified several advantages of so-called mHealth (mobile health) applications. Tablet-supported clinical assessments are becoming more and more prominent in clinical applications, even in low-income countries. The present study used tablet computers for assessments of clinical symptom profiles in a sample of Burundian AMISOM soldiers (i.e., African Union Mission to Somalia; a mission approved by the UN). The study aimed to demonstrate the feasibility of mHealth-supported assessments in field research in Burundi. The study was conducted in a resource-poor setting, in which tablet computers are predestined to gather data in an efficient and reliable manner. The overall goal was to prove the validity of the obtained data as well as the feasibility of the chosen study setting. Four hundred sixty-three soldiers of the AMISOM forces were investigated after return from a 1-year military mission in Somalia. Symptoms of posttraumatic stress disorder (PTSD) and depression were assessed. The used data-driven approach based on a latent profile analysis revealed the following four distinct groups, which are based on the soldiers' PTSD and depression symptom profiles: Class 1: moderate PTSD, Class 2: moderate depression, Class 3: low overall symptoms, and Class 4: high overall symptoms. Overall, the four identified classes of soldiers differed significantly in their PTSD and depression scores. The study clearly demonstrates that tablet-supported assessments can provide a useful application of mobile technology in large-scale studies, especially in resource-poor settings. Based on the data collected for the study at hand, it was possible to differentiate different sub-groups of soldiers with distinct symptom profiles, proving the statistical validity of the gathered data. Finally, advantages and challenges for the application of mobile technology in a resource-poor setting are outlined and discussed.
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http://dx.doi.org/10.3389/fpubh.2021.490604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083058PMC
May 2021

Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators.

Psychother Res 2021 Jul 18;31(6):695-710. Epub 2020 Nov 18.

Non-Governmental Organization vivo international e.V., Konstanz, Germany.

Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET). Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression. In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term. NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.
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http://dx.doi.org/10.1080/10503307.2020.1847345DOI Listing
July 2021

The cycle of violence as a function of PTSD and appetitive aggression: A longitudinal study with Burundian soldiers.

Aggress Behav 2020 09 3;46(5):391-399. Epub 2020 May 3.

Dr. Amelung Private Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Königstein im Taunus, Germany.

During deployment, soldiers face situations in which they are not only exposed to violence but also have to perpetrate it themselves. This study investigates the role of soldiers' levels of posttraumatic stress disorder (PTSD) symptoms and appetitive aggression, that is, a lust for violence, for their engaging in violence during deployment. Furthermore, factors during deployment influencing the level of PTSD symptoms and appetitive aggression after deployment were examined for a better comprehension of the maintenance of violence. Semi-structured interviews were conducted with 468 Burundian soldiers before and after a 1-year deployment to Somalia. To predict violent acts during deployment (perideployment) as well as appetitive aggression and PTSD symptom severity after deployment (postdeployment), structural equation modeling was utilized. Results showed that the number of violent acts perideployment was predicted by the level of appetitive aggression and by the severity of PTSD hyperarousal symptoms predeployment. In addition to its association with the predeployment level, appetitive aggression postdeployment was predicted by violent acts and trauma exposure perideployment as well as positively associated with unit support. PTSD symptom severity postdeployment was predicted by the severity of PTSD avoidance symptoms predeployment and trauma exposure perideployment, and negatively associated with unit support. This prospective study reveals the importance of appetitive aggression and PTSD hyperarousal symptoms for the engagement in violent acts during deployment, while simultaneously demonstrating how these phenomena may develop in mutually reinforcing cycles in a war setting.
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http://dx.doi.org/10.1002/ab.21895DOI Listing
September 2020

Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi.

BMC Psychiatry 2018 07 18;18(1):233. Epub 2018 Jul 18.

Non-Governmental Organization vivo international e.V., Konstanz, Germany.

Background: In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.

Methods: Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants' economic well-being.

Results: Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges' g = 3.44) and depression (Hedges' g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges' g = 2.55; Hedges' g = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month's worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.

Conclusions: Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants' privacy.

Trial Registration: UKCR2014 , the 19.06.2014, retrospectively registered.
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http://dx.doi.org/10.1186/s12888-018-1799-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052646PMC
July 2018

The individual contribution of DSM 5 symptom clusters of PTSD, life events, and childhood adversity to frontal oscillatory brain asymmetry in a large sample of active combatants.

Biol Psychol 2017 10 25;129:305-313. Epub 2017 Sep 25.

Department of Psychology, University of Konstanz, Konstanz, Baden-Württemberg, Germany; MSH Medical School Hamburg, University of Applied Sciences and Medical University, Germany.

Post-Traumatic Stress Disorder (PTSD) has been linked to deviations in lateralized frontal functional oscillatory activity. This is possibly because left and right DLPFC have differential roles in regulating both memory and stress response, which are both dysfunctional in PTSD. However, previous results are heterogeneous, and could be attributable to individual symptom clusters, traumatic or aggressive life events, early life stress, or the interaction of these factors. In a large sample of active combatants (N=401), we regressed these factors on frontal electroencephalography (EEG) asymmetry across 5 frequency bands (delta: 2-4Hz; theta: 4-8Hz; alpha: 8-12Hz; beta: 12-24Hz; gamma: 24-48Hz). Negative cognition and mood was associated with stronger relative left delta and theta band power. Traumatic life events showed stronger right alpha and beta band power. Traumatic life events in interaction with hyperarousal predicted stronger relative right left-right imbalance (theta, alpha, and beta bands), whereas childhood adversity, in interaction with negative cognition and mood, predicted stronger relative left left-right imbalance (delta, theta, alpha and beta bands). The contribution of lateralized DLPFC dysfunction to PTSD is thus dependent on the individual complexities of subsymptom clusters and life history, and future studies need to take these factors into account.
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http://dx.doi.org/10.1016/j.biopsycho.2017.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678498PMC
October 2017

Succumbing to the Call of Violence - Sex-Linked Development of Appetitive Aggression in Relation to Familial and Organized Violence.

Front Psychol 2017 9;8:751. Epub 2017 May 9.

Department of Psychology, University of KonstanzKonstanz, Germany.

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, = 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, = 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.
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http://dx.doi.org/10.3389/fpsyg.2017.00751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422546PMC
May 2017

Predicting domestic and community violence by soldiers living in a conflict region.

Psychol Trauma 2017 Nov 9;9(6):663-671. Epub 2017 Mar 9.

Department of Psychology, University of Konstanz.

Objective: Past research revealed war trauma and posttraumatic stress disorder (PTSD) symptoms as potential predictors for domestic and community violence in crisis regions and among soldiers in different armed conflicts. The impact of family violence and other adversities experienced in childhood as well as of a combat-enhanced appeal for aggressive behavior (appetitive aggression) remains to be specified.

Method: In the present study, the authors separately predicted violence against children, intimate partner violence and community violence in 381 Burundian soldiers returning from foreign deployment and living in a post- conflict region. Using path analysis, they aimed to disentangle the independent contributions and pathways of the following variables: Exposure to war trauma and childhood familial violence, PTSD and depression symptom severity, and appetitive aggression.

Results: Childhood familial violence had an independent effect on all contexts of violence and was the only significant predictor for violence against the soldiers' own children. Intimate partner violence was additionally predicted by depression symptom severity, while community violence was additionally predicted by PTSD symptom severity and appetitive aggression.

Conclusions: Besides war-related mental ill-health and appetitive aggression, violent experiences during childhood development must not be overlooked as a factor fueling the cycle of violence in conflict regions. (PsycINFO Database Record
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http://dx.doi.org/10.1037/tra0000262DOI Listing
November 2017

Feasibility and effectiveness of narrative exposure therapy and cognitive behavioral therapy in a context of ongoing violence in South Africa.

Psychol Trauma 2017 05 6;9(3):282-291. Epub 2016 Oct 6.

Department of Psychology, University of Konstanz.

Objective: In an observer-blinded intervention trial, we tested the reduction of posttraumatic stress symptoms, aggressive attitude, and behavior in young males living in a context of ongoing community and gang violence by means of (a) forensic offender rehabilitation narrative exposure therapy (FORNET), and (b) the cognitive-behavioral intervention "Thinking for a Change" (TFAC). A waiting list served as the control condition.

Method: A total of 39 young men were included in the data analysis: 15 completed FORNET, 11 underwent cognitive-behavioral therapy (CBT), and 13 were on a waiting list for later treatment. The primary efficacy endpoints were the PTSD Symptom Scale-Interview (PSS-I) severity score, the Appetitive Aggression Scale (AAS) score, and the number of perpetrated violent event types 8 months (on average) after treatment.

Results: Only in the sample receiving FORNET were posttraumatic stress disorder (PTSD) scores significantly reduced at the first follow-up (Cohen's d = -0.97) and significantly different from those of the control group (Cohen's d = -1.03). The changes in scores for appetitive aggression and perpetrated events were not significant for any of the treatment conditions.

Conclusions: The study shows that trauma-focused treatment can reduce the psychological symptoms of posttraumatic stress even for individuals living under unsafe conditions in low-income urban communities. However, achieving changes in violent behavior within a context of ongoing violence may require more than the treatment of trauma-related suffering, confrontation with one's offenses, or cognitive-behavioral interventions. (PsycINFO Database Record
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http://dx.doi.org/10.1037/tra0000197DOI Listing
May 2017

Appetitive Aggression in Women: Comparing Male and Female War Combatants.

Front Psychol 2015 5;6:1972. Epub 2016 Jan 5.

Department of Psychology, University of KonstanzKonstanz, Germany; Department of Clinical Psychology, Université LumièreBujumbura, Burundi.

Appetitive aggression refers to positive feelings being associated with the perpetration of violent behavior and has been shown to provide resilience against the development of PTSD in combatants returning from the battlefield. Until this point, appetitive aggression has been primarily researched in males. This study investigates appetitive aggression in females. Female and male combatants and civilians from Burundi were assessed for levels of appetitive aggression. In contrast to non-combatants, no sex difference in appetitive aggression could be detected for combatants. Furthermore, each of the female and male combatant groups displayed substantially higher levels of appetitive aggression than each of the male and female civilian control groups. This study demonstrates that in violent contexts, such as armed conflict, in which individuals perpetrate numerous aggressive acts against others, the likelihood for an experience of appetitive aggression increases- regardless of whether the individuals are male or female.
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http://dx.doi.org/10.3389/fpsyg.2015.01972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4700207PMC
January 2016

Violent Offending Promotes Appetitive Aggression Rather than Posttraumatic Stress-A Replication Study with Burundian Ex-Combatants.

Front Psychol 2015 8;6:1755. Epub 2015 Dec 8.

Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International Konstanz, Germany ; Department of Clinical Psychology, Université Lumière de Bujumbura Bujumbura, Burundi.

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.
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http://dx.doi.org/10.3389/fpsyg.2015.01755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672083PMC
December 2015

Intergenerational violence in Burundi: Experienced childhood maltreatment increases the risk of abusive child rearing and intimate partner violence.

Eur J Psychotraumatol 2015 15;6:26995. Epub 2015 Dec 15.

Department of Clinical Psychology, University Lumière of Bujumbura, Bujumbura, Burundi.

Background: Experiencing abuse during childhood affects the psychological well-being of individuals throughout their lives and may even influence their offspring by enhancing the likelihood of an intergenerational transmission of violence. Understanding the effects of childhood maltreatment on child-rearing practices and intimate partner violence might be of particular importance to overcome the consequences of violent conflicts in African societies.

Objective: Using Burundi as an example, we aimed to explore the associations between childhood maltreatment, intimate partner violence, perceived partner intimidation, gender and the probability of violently acting out against one's own children or romantic partner.

Methods: Amongst a sample of 141 men and 141 women in the capital of Burundi, we identified those who had biological children and those who lived or had lived in relationships. Using culturally appropriate instruments, we enquired about their exposure to childhood maltreatment and partner violence as well as their inclinations to act out violently.

Results: We found that childhood maltreatment and perceived partner intimidation were strong predictors for the perpetration of violence against children. Moreover, we found that women were more likely to use violence against children if they experienced partner violence and less likely to resort to violence if they felt intimidated. Men were more likely to perpetrate violence against their partner. Childhood maltreatment was again a strong predictor. The more women experienced partner violence, the more they fought back.

Conclusions: Childhood maltreatment is a strong predictor for domestic violence and has to be addressed to interrupt the cycle of violence in post-conflict countries.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696461PMC
http://dx.doi.org/10.3402/ejpt.v6.26995DOI Listing
December 2015

Appetitive Aggression and Adverse Childhood Experiences Shape Violent Behavior in Females Formerly Associated with Combat.

Front Psychol 2015 17;6:1756. Epub 2015 Nov 17.

Department of Psychology, University of Konstanz Konstanz, Germany ; Department of Psychology, University Lumière Bujumbura, Burundi.

This study investigated the impact of violent experiences during childhood, posttraumatic stress disorder (PTSD) and appetitive aggression on everyday violent behavior in Burundian females with varying participation in war. Moreover, group differences in trauma-related and aggression variables were expected. Appetitive aggression describes the perception of violence perpetration as fascinating and appealing and is a common phenomenon in former combatants. Semi-structured interviews were conducted with 158 females, either former combatants, supporters of armed forces or civilians during the civil war in Burundi. The PTSD Symptom Scale Interview was used to assess PTSD symptom severity, the Appetitive Aggression Scale to measure appetitive aggression and the Domestic and Community Violence Checklist to assess both childhood maltreatment and recent aggressive behavior. Former combatants had experienced more traumatic events, perpetrated more violence and reported higher levels of appetitive aggression than supporters and civilians. They also suffered more severely from PTSD symptoms than civilians but not than supporters. The groups did not differ regarding childhood maltreatment. Both appetitive aggression and childhood violence predicted ongoing aggressive behavior, whereas the latter outperformed PTSD symptom severity. These findings support current research showing that adverse childhood experiences and a positive attitude toward aggression serve as the basis for aggressive behavior and promote an ongoing cycle of violence in post-conflict regions. Female members of armed groups are in need of demobilization procedures including trauma-related care and interventions addressing appetitive aggression.
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http://dx.doi.org/10.3389/fpsyg.2015.01756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646969PMC
December 2015

Treating Traumatized Offenders and Veterans by Means of Narrative Exposure Therapy.

Front Psychiatry 2015 22;6:80. Epub 2015 Jun 22.

Vivo International ( www.vivo.org ) ; Department of Psychology, Division of Clinical Neuropsychology, University of Konstanz , Konstanz , Germany.

Violent offenders and soldiers are at high risk of developing appetitive aggression and trauma-related disorders, which reduce successful integration into societies. Narrative exposure therapy (NET) for forensic offender rehabilitation (FORNET) aims at reducing symptoms of traumatic stress (e.g., posttraumatic stress disorder) and controlling readiness for aggressive behavior. It follows the logic of the evidence-based trauma-focused NET with special emphasis on violent acts in past and future behavior. In NET, the therapist guides the client by means of exposure through his traumatic experiences in chronological order linking the negative emotions, such as fear, shame, and disgust, to the past context and integrating the traumatic experiences into the autobiographical memory. During FORNET, we also encourage verbalization of any positive emotions and experiences linked to past violent and aggressive behaviors. This recall of positive emotions (linked to the there and then) is contrasted with feelings that emerge during the narration process (here and now). In this way, the therapist helps the client to anchor the whole range of sensory and bodily experiences, cognitions, and emotions to the contextual cues. Over the process of the therapy, we support the client to begin the role change from a violent offender to a citizen, who is capable of living a non-violent and socially adjusted life. Finally, the client develops visions and wishes for the future to support a successful integration into society. Several studies with veterans and violent youths have proven the feasibility of FORNET, found evidence of a positive outcome (recovered mental health, fewer offenses committed, less drug intake, and improved integration into civil society), and highlighted the importance of addressing the whole range of experiences while treating violent offenders or veterans.
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http://dx.doi.org/10.3389/fpsyt.2015.00080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475792PMC
July 2015

Predictors of posttraumatic stress and appetitive aggression in active soldiers and former combatants.

Eur J Psychotraumatol 2015 21;6:26553. Epub 2015 Apr 21.

Department of Psychology, University of Konstanz, Konstanz, Germany.

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408319PMC
http://dx.doi.org/10.3402/ejpt.v6.26553DOI Listing
April 2015

A study on reintegration of street children in Burundi: experienced violence and maltreatment are associated with mental health impairments and impeded educational progress.

Front Psychol 2014 16;5:1441. Epub 2014 Dec 16.

Department of Psychology, Clinical Psychology and Clinical Neuropsychology, University of Konstanz Konstanz, Germany ; Department of Clinical Psychology, University Lumière of Bujumbura Bujumbura, Burundi ; Non Governmental Organization Vivo International Konstanz, Germany.

Street children are exposed to violence, and subsist in poor and generally precarious conditions. In conflict regions, institutional care facilities are often the only well established way to care for vulnerable children. Providing access to school education is considered to be key to allow successful integration into society. However, adverse effects of psychological disorders may pose another serious obstacle. In semi-structured interviews in a sample of 112 Burundian male youths (mean age = 15.9 years), we assessed exposure to traumatic stressors, regularly and recently occurring violence as well as prevalence of posttraumatic stress disorder (PTSD), depression, substance dependence, suicidal risk, and progress in school. Former street children (n = 32) and other vulnerable children (n = 50) in a residential center were compared to children living in the streets (n = 15) or with families (n = 15). While the children living in the center were less regularly exposed to violence and reported less substance dependence than street children, PTSD symptoms were common among the former street children. Furthermore, we provided empirical evidence that for the children living in the center, recently experienced violence - mostly minor physical conflicts, psychological violence and neglect - was associated with increased PTSD symptomatology and impeded progress in school. In a population of children who experienced many traumatic incidences and a lot of violence, even minor violent events may trigger and reinforce PTSD symptoms. Hence controlling exposure to violence and addressing mental ill-health in vulnerable children is mandatory for reintegration.
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http://dx.doi.org/10.3389/fpsyg.2014.01441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267266PMC
January 2015

The benefits of aggressive traits: a study with current and former street children in Burundi.

Child Abuse Negl 2014 Jun 7;38(6):1041-50. Epub 2014 Jan 7.

Department of Psychology, University of Konstanz, Box D23, 78457 Konstanz, Germany; Department of Psychology, University Lumière of Bujumbura, Burundi; Vivo International e.V., Germany(1).

Aggressive behavior in children and youths is commonly associated with exposure to violence and maltreatment. Consequently, aggressive behavior has often been explained as a form of reactive behavior in response to violence-inflicted mental suffering. However, perpetrating violence can become appealing, fascinating and exciting, i.e., may acquire appetitive, self-rewarding aspects. We postulated that this appetitive form of aggression reduces the vulnerability for developing Posttraumatic Stress Disorder (PTSD) in insecure and violent environments. Furthermore we investigated the extent to which reactive aggression and appetitive aggression account for recent violent behavior in children and youths. We conducted semi-structured interviews in a sample of 112 children and youths (Mage=15.9 years) recruited from the streets, families and a residential center for vulnerable children in Burundi. We investigated the cumulative exposure to traumatic events and to domestic and community violence, assessed the recently committed offenses, the severity of PTSD symptoms, and the potential for reactive and appetitive aggression. Reactive aggression was positively related to PTSD, whilst appetitive aggression was negatively related to PTSD. Children higher in appetitive aggression were also more likely to display violent behavior. These results suggest that an appetitive perception of violence may be an useful adaption to insecure and violent living conditions reducing the vulnerability of children for trauma-related mental disorders. However, positive feelings experienced through violent or cruel behavior are also an important risk factor for ongoing aggressive behavior and therefore need to be considered in prevention strategies.
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http://dx.doi.org/10.1016/j.chiabu.2013.12.003DOI Listing
June 2014

When combat prevents PTSD symptoms--results from a survey with former child soldiers in Northern Uganda.

BMC Psychiatry 2012 May 14;12:41. Epub 2012 May 14.

Department of Clinical Psychology, University of Konstanz, Konstanz, Germany.

Background: Human beings from time immemorial have eradicated neighbouring tribes, languages, religions, and cultures. In war and crisis, the cumulative exposure to traumatic stress constitutes a predictor of the development of post traumatic stress disorder (PTSD). However, homicide has evolved as a profitable strategy in man, leading to greater reproductive success. Thus, an evolutionary advantage of perpetrating violence would be eliminated if the exposure to aggressive acts would traumatize the perpetrator. We argue that perpetrating violence could actually 'immunize' a person against adverse effects of traumatic stressors, significantly reducing the risk of developing PTSD.

Methods: We surveyed 42 former child soldiers in Northern Uganda that have all been abducted by the Lord Resistance Army (LRA) as well as 41 non-abducted controls.

Results: Linear regression analyses revealed a dose-response effect between the exposure to traumatic events and the Posttraumatic Diagnostic Scale (PDS) sum score. However, the vulnerability to develop trauma related symptoms was reduced in those with higher scores on the Appetitive Aggression Scale (AAS). This effect was more pronounced in the formerly abducted group.

Conclusions: We conclude that attraction to aggression when being exposed to the victim's struggling can lead to a substantial risk-reduction for developing PTSD.
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http://dx.doi.org/10.1186/1471-244X-12-41DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413590PMC
May 2012