Publications by authors named "Carina Heeke"

9 Publications

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Posttraumatic stress in adult civilians exposed to violent conflict, war and associated human rights abuses in the Eastern Mediterranean Region: A systematic review and meta-analysis.

J Affect Disord 2021 Nov 26;294:605-627. Epub 2021 Jun 26.

Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany.

Background: The Eastern Mediterranean Region (EMR) is the stage of the world's most violent conflicts and the origin of the largest refugee population worldwide. These conflicts can result in symptoms of posttraumatic stress (PTS). To date, no comprehensive meta-analysis on proportions of PTS in civilians from the EMR has been conducted. Sample characteristics, methodological, conflict-related and displacement-related factors might affect rates of PTS.

Methods: A systematic literature search for studies investigating PTS in adult civilians from the EMR was conducted until March 2020 and resulted in 118 individual study samples that were suitable for inclusion. A quality assessment was conducted. A random effects meta-analysis on proportions and sensitivity analyses were performed, and a 95% prediction interval was calculated. Subgroup analyses to identify moderators (e.g. diagnostic instruments, displacement) were conducted.

Results: The quality of the included study samples varied. The pooled estimate of proportions from all 118 study samples was 0.31 (95% CI: 0.27 - 0.35). Heterogeneity was considerable (Q = 10151.58, p < .0001; I = 98.64%). The prediction interval was 0.01 to 0.76. The results remained unchanged after excluding nine outlier study samples. Heterogeneity remained high in all subgroups (range of I: 87.91 to 99.62).

Limitations: Due to heterogeneity the pooled estimate cannot be interpreted. Moderators contributing to heterogeneity could not be detected.

Conclusions: The proportion of symptoms of PTS in civilians from the EMR varies considerably. The prediction interval indicates that the true rate falls between 1% and 76%. Future studies need to identify variables that affect heterogeneity.
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http://dx.doi.org/10.1016/j.jad.2021.06.042DOI Listing
November 2021

Association Between Prolonged Grief and Attitudes Toward Reconciliation in Bereaved Survivors of the Khmer Rouge Regime in Cambodia.

Front Psychiatry 2020 10;11:644. Epub 2020 Jul 10.

Department of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany.

Background: During the Khmer Rouge regime in Cambodia, about a quarter of the population died, resulting in many individuals losing close relatives. Still today, many individuals are suffering from the psychological consequences of these losses, which might also affect the process of reconciliation within the Cambodian society. The aim of this paper is therefore to investigate the association between symptoms of prolonged grief and attitudes toward reconciliation.

Methods: A sample of 775 survivors of the Khmer Rouge regime who lost relatives during the conflict were interviewed about their losses and traumatic events, prolonged grief (PG; Complicated Grief Assessment Self-Report, CGA-SR), posttraumatic stress disorder (PTSD Checklist - Civilian Version) and attitudes toward reconciliation (Readiness to Reconcile Inventory, RRI).

Results: A higher symptom severity of PG was significantly associated with readiness to reconcile even when controlling for other relevant variables (β = -0.22; p <.001). Persons who met caseness criteria for PG were significantly less ready to reconcile, t(773) = 5.47, p <.001, than persons who did not meet caseness for PG.

Conclusion: PG seems to be a relevant mental health correlate of attitudes toward reconciliation. The results of the current study underline the importance of also considering PG with regard to the reconciliation process in Cambodia and possibly also in other post-conflict regions.
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http://dx.doi.org/10.3389/fpsyt.2020.00644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366248PMC
July 2020

Same same but different? DSM-5 versus ICD-11 PTSD among traumatized refugees in Germany.

J Psychosom Res 2020 07 5;134:110129. Epub 2020 May 5.

Freie University Berlin, Department of Clinical-Psychological Intervention, Habelschwerdter Allee 45, 14195 Berlin, Germany; Center UEBERLEBEN gGmbH, Turmstr. 21, 10559 Berlin, Germany.

Objective: The recent changes in diagnostic criteria for posttraumatic stress disorder (PTSD) in the 5th edition of the DSM and the 11th edition of the ICD marked a shift towards two perspectives on the same disorder. Previous studies indicate lower prevalence rates for the ICD-11-model as compared to the DSM-5 model. Main purpose of this study is to examine the concordance between ICD-11 and DSM-5 PTSD rates, and to assess the overlap of the two PTSD definitions with anxiety and depression among refugees.

Methods: 167 traumatized refugees were assessed with the PCL-5 for the DSM-5 PTSD model. A subset of the items was used as criteria for the ICD-11 model. Depression and anxiety were measured with the HSCL-25.

Results: The DSM-5-algorithm for PTSD identified significantly more cases (n = 147; 88%) than the ICD-11 algorithm (80%; n = 134). Level of agreement between the diagnostic systems was substantial (Κ = 0.67, p < .001) and 9% (n = 15) met criteria under one diagnostic system only. Overlap with depression and anxiety was high under both diagnostic systems.

Conclusion: PTSD rates indicated a highly distressed sample of survivors of war and trauma. Our data provide further evidence that the DSM-5 diagnoses a larger number of persons than the ICD-11. Although the level of agreement was substantial, the observed discrepancies represent a challenge for research and practice to reliably identify individuals with PTSD. Especially for refugees, this might affect their access to mental health care and appropriate treatment during an asylum procedure.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110129DOI Listing
July 2020

Same same but different? DSM-5 versus ICD-11 PTSD among traumatized refugees in Germany.

J Psychosom Res 2020 07 5;134:110129. Epub 2020 May 5.

Freie University Berlin, Department of Clinical-Psychological Intervention, Habelschwerdter Allee 45, 14195 Berlin, Germany; Center UEBERLEBEN gGmbH, Turmstr. 21, 10559 Berlin, Germany.

Objective: The recent changes in diagnostic criteria for posttraumatic stress disorder (PTSD) in the 5th edition of the DSM and the 11th edition of the ICD marked a shift towards two perspectives on the same disorder. Previous studies indicate lower prevalence rates for the ICD-11-model as compared to the DSM-5 model. Main purpose of this study is to examine the concordance between ICD-11 and DSM-5 PTSD rates, and to assess the overlap of the two PTSD definitions with anxiety and depression among refugees.

Methods: 167 traumatized refugees were assessed with the PCL-5 for the DSM-5 PTSD model. A subset of the items was used as criteria for the ICD-11 model. Depression and anxiety were measured with the HSCL-25.

Results: The DSM-5-algorithm for PTSD identified significantly more cases (n = 147; 88%) than the ICD-11 algorithm (80%; n = 134). Level of agreement between the diagnostic systems was substantial (Κ = 0.67, p < .001) and 9% (n = 15) met criteria under one diagnostic system only. Overlap with depression and anxiety was high under both diagnostic systems.

Conclusion: PTSD rates indicated a highly distressed sample of survivors of war and trauma. Our data provide further evidence that the DSM-5 diagnoses a larger number of persons than the ICD-11. Although the level of agreement was substantial, the observed discrepancies represent a challenge for research and practice to reliably identify individuals with PTSD. Especially for refugees, this might affect their access to mental health care and appropriate treatment during an asylum procedure.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110129DOI Listing
July 2020

Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder.

BMC Psychiatry 2017 03 29;17(1):118. Epub 2017 Mar 29.

Department of Clinical-Psychological Intervention, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Germany.

Background: Exposure to trauma and bereavement is common in conflict-affected regions. Previous research suggests considerable heterogeneity in responses to trauma and loss with varying symptom representations. The purpose of the current study was to (1) identify classes of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptom profiles among individuals who were exposed to both trauma and loss due to the Colombian armed conflict and (2) to examine whether sociodemographic, loss and trauma-related characteristics could predict class membership.

Methods: Three hundred eight victims of internal displacement who had experienced trauma and loss were assessed through measures of PGD (PG-13), PTSD (PCL-C), and social support (DUKE-UNC). Latent class analysis (LCA) was performed to analyze differential profiles by symptoms of PGD and PTSD and multinomial logistic regression was used to analyze predictors of class membership.

Results: LCA revealed a four-class solution: a resilient class (23.6%), a PTSD-class (23.3%), a predominately PGD class (25.3%) and a high distress-class with overall high values of PGD and PTSD (27.8%). Relative to the resilient class, membership to the PGD class was predicted by the loss of a close family member and the exposure to a higher number of assaultive traumatic events, whereas membership to the PTSD class was predicted by the perception of less social support. Compared to the resilient class, participants in the high distress-class were more likely to be female, to have lost a close relative, experienced more accidental and assaultive traumatic events, and perceived less social support.

Discussion: Specific symptom profiles emerged following exposure to trauma and loss within the context of the Colombian armed conflict. Profiles were associated with distinct types of traumatic experiences, the degree of closeness to the person lost, the amount of social support perceived, and gender. The results have implications for identifying distressed subgroups and informing interventions in accordance with the patient's symptom profile.
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http://dx.doi.org/10.1186/s12888-017-1286-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372336PMC
March 2017

[Sequential traumatization, trauma-related disorders and psychotherapeutic approaches in war-traumatized adult refugees and asylum seekers in Germany].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016 May;59(5):621-6

Klinische Psychologie und Psychotherapie, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Deutschland.

The impact of war and violence on the mental and physical health of the civilian population is immense. Traumatization is often experienced sequentially, which leads to a higher risk for developing trauma-related disorders (PTSD, depression, chronic pain).Refugees traumatized by war experience specific stressors related to their status of residence (e. g., application hearing, length of the asylum procedure). Together with limited access to health care, these constitute additional risk factors for developing somatic and psychological illnesses.Adequate treatment for this highly vulnerable group requires a multimodal approach facilitated by translators. According to the S3 guidelines (S3-Richtlinien), trauma-adapted psychotherapeutic treatment has to be complemented by the activities of social workers, by medical treatment, and by legal advice.
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http://dx.doi.org/10.1007/s00103-016-2337-4DOI Listing
May 2016

Applicability of the ICD-11 proposal for PTSD: a comparison of prevalence and comorbidity rates with the DSM-IV PTSD classification in two post-conflict samples.

Eur J Psychotraumatol 2015 18;6:27070. Epub 2015 May 18.

Department of Clinical Psychology and Psychotherapy, Freie Universität Berlin, Berlin, Germany.

Background: The World Health Organization recently proposed significant changes to the posttraumatic stress disorder (PTSD) diagnostic criteria in the 11th edition of the International Classification of Diseases (ICD-11).

Objective: The present study investigated the impact of these changes in two different post-conflict samples.

Method: Prevalence and rates of concurrent depression and anxiety, socio-demographic characteristics, and indicators of clinical severity according to ICD-11 in 1,075 Cambodian and 453 Colombian civilians exposed to civil war and genocide were compared to those according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Results: Results indicated significantly lower prevalence rates under the ICD-11 proposal (8.1% Cambodian sample and 44.4% Colombian sample) compared to the DSM-IV (11.2% Cambodian sample and 55.0% Colombian sample). Participants meeting a PTSD diagnosis only under the ICD-11 proposal had significantly lower rates of concurrent depression and a lower concurrent total score (depression and anxiety) compared to participants meeting only DSM-IV diagnostic criteria. There were no significant differences in socio-demographic characteristics and indicators of clinical severity between these two groups.

Conclusions: The lower prevalence of PTSD according to the ICD-11 proposal in our samples of persons exposed to a high number of traumatic events may counter criticism of previous PTSD classifications to overuse the PTSD diagnosis in populations exposed to extreme stressors. Also another goal, to better distinguish PTSD from comorbid disorders could be supported with our data.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438098PMC
http://dx.doi.org/10.3402/ejpt.v6.27070DOI Listing
May 2015

When hope and grief intersect: rates and risks of prolonged grief disorder among bereaved individuals and relatives of disappeared persons in Colombia.

J Affect Disord 2015 Mar 29;173:59-64. Epub 2014 Oct 29.

Berlin Center for Torture Victims, Germany; Department of Clinical Psychology and Psychotherapy, Free University of Berlin, Germany.

Background: Forced disappearance is a frequent phenomenon in violent conflicts and regimes, yet little is known about unresolved grief processes as a possible outcome of the disappearance of a loved one. This study investigates prolonged grief disorder (PGD) and its risk factors in a sample of persons who lost a significant other to disappearance as compared with a sample of bereaved individuals, both groups having experienced displacement due to the armed conflict in Colombia.

Method: In a cross-sectional study conducted in four Colombian provinces, 73 persons who lost a significant other to disappearance and 222 bereaved individuals completed measures of PGD (PG-13), depression (HSCL-25), and PTSD (PCL-C) via face-to-face interviews. Trauma- and loss-related variables, including the extent to which significant others of disappeared persons hoped that their loved one was still alive, were assessed.

Results: Results indicated that 23% of participants who lost a significant other to disappearance met criteria for PGD as compared to 31.5% in bereaved participants. No differences were found between the two groups in terms of symptom severity of PGD, depression, posttraumatic stress disorder, or traumatic exposure. Regression analysis indicated that, among relatives and friends of disappeared persons, the extent of hope predicted PGD above and beyond depression severity whereas among bereaved persons, PGD was predicted by time since the loss, the number of traumatic events and symptom severity of PTSD and depression.

Limitations: The instruments were not validated for use in Colombia; generalizability of findings is limited.

Conclusion: Forced disappearance is related to prolonged grief reactions, particularly when those left behind maintain hope that the disappeared person is still alive.
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http://dx.doi.org/10.1016/j.jad.2014.10.038DOI Listing
March 2015

Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia.

J Affect Disord 2013 Jan 4;144(1-2):87-93. Epub 2012 Aug 4.

Berlin Center for Torture Victims, Turmstr. 21, 10559 Berlin, Germany.

Background: During the Khmer Rouge (KR) regime from 1975 to 1979 millions of Cambodians were confronted with the death or murder of family members. The long-term psychological consequences of these traumatic losses have not yet been investigated. The purpose of this study was to determine the rate and potential predictors of prolonged grief disorder (PGD) in survivors of the KR regime.

Method: The Inventory of Complicated Grief-Revised (ICG-R) was administered in a sample of N=775 Cambodians in face-to-face interviews who had lost at least one family member during the KR regime. Symptoms of PTSD were assessed with the PTSD Checklist-Civilian Version and symptoms of depression and anxiety with the Hopkins Symptom Checklist-25.

Results: The prevalence of PGD in the sample was 14.3%. PGD was moderately associated with symptoms of depression, anxiety and PTSD. The loss of a spouse, a child, or a parent was associated with higher symptom severity of PGD than was the loss of a sibling or distant relatives. PGD was predicted by the relationship to the deceased and symptoms of depression and PTSD.

Limitations: Limitations of the study include the non-random sampling recruitment. The ICG-R has not been validated for use in Cambodia.

Conclusions: The vast majority of Cambodians lost family members during the KR regime. Even three decades later, PGD was prevalent in a substantial proportion of the present sample and related to other psychiatric disorders. The results underline the importance of examining PGD in studies of war-related psychological impairment.
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http://dx.doi.org/10.1016/j.jad.2012.05.063DOI Listing
January 2013
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