Publications by authors named "Ulrich Schnyder"

177 Publications

Longitudinal association between cognitive depressive symptoms and D-dimer levels in patients following acute myocardial infarction.

Clin Cardiol 2021 Jul 7. Epub 2021 Jul 7.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Background: A prothrombotic tendency could partially explain the poor prognosis of patients with coronary heart disease and depression. We hypothesized that cognitive depressive symptoms are positively associated with the coagulation activation marker D-dimer throughout the first year after myocardial infarction (MI).

Methods: Patients with acute MI (mean age 60 years, 85% men) were investigated at hospital admission (n = 190), 3 months (n = 154) and 12 months (n = 106). Random linear mixed regression models were used to evaluate the relation between cognitive depressive symptoms, assessed with the Beck depression inventory (BDI), and changes in plasma D-dimer levels. Demographics, cardiac disease severity, medical comorbidity, depression history, medication, health behaviors, and stress hormones were considered for analyses.

Results: The prevalence of clinical depressive symptoms (13-item BDI score ≥ 6) was 13.2% at admission and stable across time. Both continuous (p < .05) and categorical (p < .010) cognitive depressive symptoms were related to higher D-dimer levels over time, independent of covariates. Indicating clinical relevance, D-dimer was 73 ng/ml higher in patients with a BDI score ≥ 6 versus those with a score < 6. There was a cognitive depressive symptom-by-cortisol interaction (p < .05) with a positive association between cognitive depressive symptoms and D-dimer when cortisol levels were high (p < .010), but not when cortisol levels were low (p > .05). Fluctuations (up and down) of cognitive depressive symptoms and D-dimer from one investigation to the next showed also significant associations (p < .05).

Conclusions: Cognitive depressive symptoms were independently associated with hypercoagulability in patients up to 1 year after MI. Hypothalamic-pituitary-adrenal axis could potentially modify this effect.
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http://dx.doi.org/10.1002/clc.23689DOI Listing
July 2021

Serum cortisol as a predictor for posttraumatic stress disorder symptoms in post-myocardial infarction patients.

J Affect Disord 2021 Sep 5;292:687-694. Epub 2021 Jun 5.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, and University of Zurich, Zurich, Switzerland.

Background: After an acute myocardial infarction (MI), patients may develop posttraumatic stress disorder (PTSD). There is evidence for alterations in the hypothalamic-pituitary-adrenal axis in PTSD. An association between patients` cortisol level after experiencing an MI and subsequent PTSD symptoms has not been investigated yet. Therefore, the aim of this study was to examine whether serum cortisol measured in patients admitted to hospital for acute coronary care after MI is predictive of PTSD symptoms at three and 12 months post-MI, respectively.

Methods: Patients (N=106) with a verified MI and high risk for the development of MI-induced PTSD symptoms were included in the study within 48 hours of hospital admission for acute coronary intervention. Serum cortisol was measured from fasting venous blood samples the next morning. Hierarchical regression analysis was used to test for an independent contribution of cortisol levels from admission to the Clinician-Administered PTSD Scale sum score three and 12 months after discharge from the coronary care unit.

Results: Hierarchical regression analysis showed that lower serum cortisol levels were significantly associated with more severe PTSD symptoms three months (B=-0.002, p=0.042) and 12 months (B=-0.002, p=0.043) post-MI.

Limitations: The generalizability of the findings is limited to patients with high acute peri-traumatic distress and without an acute severe depressive episode. The study does not provide any information about the diurnal cortisol pattern.

Conclusion: Lower serum cortisol measured during MI hospitalization may predict more severe MI-induced PTSD symptoms three and 12 months after hospital discharge.
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http://dx.doi.org/10.1016/j.jad.2021.05.065DOI Listing
September 2021

An exploratory study of embitterment in traumatized refugees.

BMC Psychol 2021 Jun 10;9(1):96. Epub 2021 Jun 10.

Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), University of Zurich (UZH), Culmannstrasse 8, 8091, Zurich, Switzerland.

Background: Refugees and asylum seekers are frequently exposed to violence, human rights violations and unstable living conditions before, during, and after their displacement. Elevated prevalence rates of psychiatric disorders in forcibly displaced persons are well documented. However, less is known about other problems related to common refugee experiences, such as embitterment, moral injury, and diminished self-efficacy, and how they are related to trauma exposure and post-migration living difficulties.

Methods: A cross-sectional sample of 71 refugees and asylum seekers in treatment were examined regarding exposure to potentially traumatic events, post-migration living difficulties, moral injury appraisals, self-efficacy, and embitterment.

Results: Elevated levels of embitterment were reported by 68% of participants. The regression analysis revealed that greater moral injury appraisals and low levels of self-efficacy were significantly associated with higher levels of embitterment.

Conclusion: The results provide first insights into embitterment and associated factors in refugee populations. Furthermore, they highlight the significance of moral transgressions and low levels of self-efficacy emerging from displacement and traumatic experiences for the development of mental health problems in a clinical sample of refugees. The findings have implications for future research, policy development and clinical practice.
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http://dx.doi.org/10.1186/s40359-021-00599-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193876PMC
June 2021

Course, Moderators, and Predictors of Acute Coronary Syndrome-Induced Post-traumatic Stress: A Secondary Analysis From the Myocardial Infarction-Stress Prevention Intervention Randomized Controlled Trial.

Front Psychiatry 2021 14;12:621284. Epub 2021 May 14.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Acute coronary syndromes (ACS) induce post-traumatic stress symptoms (PTSS) in one out of eight patients. Effects of preventive interventions, the course and potential moderators of ACS-induced PTSS are vastly understudied. This study explored whether a preventive behavioral intervention leads to a decrease in myocardial infarction (MI)-induced PTSS between two follow-up assessments. Sociodemographic, clinical and psychological factors were additionally tested as both moderators of change over time in PTSS and predictors of PTSS across two follow-ups. Within 48 h after reaching stable circulatory conditions, 104 patients with MI were randomized to a 45-min one-session intervention of either trauma-focused counseling or stress counseling (active control). Sociodemographic, clinical, and psychological data were collected at baseline, and PTSS were assessed with the Clinician-Administered Post-traumatic Stress Disorder Scale 3 and 12 months post-MI. PTSS severity showed no change over time from 3 to 12 months post-MI, either in all patients or through the intervention [mean group difference for total PTSS = 1.6 (95% CI -1.8, 4.9), re-experiencing symptoms = 0.8 (95% CI -0.7, 2.2), avoidance/numbing symptoms = 0.1 (95% CI -1.6, 1.7) and hyperarousal symptoms = 0.6 (95% CI -0.9, 2.1)]. Patients receiving one preventive session of trauma-focused counseling showed a decrease from 3 to 12 months post-MI in avoidance symptoms with higher age ( = 0.011) and direct associations of clinical burden indices with total PTSS across both follow-ups ('s ≤ 0.043; interaction effects). Regardless of the intervention, decreases in re-experiencing, avoidance and hyperarousal symptoms from 3 to 12 months post-MI occurred, respectively, in men ( = 0.006), participants with low education ( = 0.014) and with more acute stress symptoms ( = 0.021). Peritraumatic distress ( = 0.004) and lifetime depression ( = 0.038) predicted total PTSS across both follow-ups. We conclude that PTSS were persistent in the first year after MI and not prevented by an early one-session intervention. A preventive one-session intervention of trauma-focused counseling may be inappropriate for certain subgroups of patients, although this observation needs confirmation. As predictors of the development and persistence of PTSS, sociodemographic and psychological factors could help to identify high-risk patients yet at hospital admission.
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http://dx.doi.org/10.3389/fpsyt.2021.621284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183467PMC
May 2021

Self-worth and bonding emotions are related to well-being in health-care providers: a cross-sectional study.

BMC Med Educ 2021 May 21;21(1):290. Epub 2021 May 21.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Haldenbachstrasse 18, CH-8091, Zurich, Switzerland.

Background: Interacting with patients can elicit a myriad of emotions in health-care providers. This may result in satisfaction or put providers at risk for stress-related conditions such as burnout. The present study attempted to identify emotions that promote provider well-being. Following eudaimonic models of well-being, we tested whether certain types of emotions that reflect fulfilment of basic needs (self-worth, bonding with patients) rather than positive emotions in general (as suggested by hedonic models) are linked to well-being. Specifically, we hypothesized that well-being is associated with positive emotions directed at the self, which reflect self-worth, and positive as well as negative emotions (e.g., worry) directed at the patient, which reflect bonding. However, we expected positive emotions directed at an object/situation (e.g., curiosity for a treatment) to be unrelated to well-being, because they do not reflect fulfilment of basic needs.

Methods: Fifty eight physicians, nurses, and psychotherapists participated in the study. First, in qualitative interviews, they reported their emotions directed at the self, the patient, or an object/situation during distressing interactions with patients. These emotions were categorised into positive emotions directed towards the self, the patient, and an object/situation, and negative emotions directed towards the patient that reflect bonding. Second, providers completed questionnaires to assess their hedonic and eudaimonic well-being. The well-being scores of providers who did and did not experience these emotions were compared.

Results: Providers who experienced positive emotions directed towards the self or the patient had higher well-being than those who did not. Moreover, for the first time, we found evidence for higher well-being in providers reporting negative patient-directed emotions during distressing interactions. There was no difference between providers who did and did not experience positive object/situation-directed emotions.

Conclusions: These findings may point towards the importance of "eudaimonic" emotions rather than just positive emotions in interactions with patients. Emotions such as contentment with oneself, joy for the patient's improvement, and, notably, grief or worry for the patient may build a sense of self-worth and strengthen bonding with the patient. This may explain their association with provider well-being.
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http://dx.doi.org/10.1186/s12909-021-02731-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139026PMC
May 2021

Problems after flight: understanding and comparing Syrians' perspectives in the Middle East and Europe.

BMC Public Health 2021 04 13;21(1):717. Epub 2021 Apr 13.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich (USZ), University of Zurich (UZH), Culmannstrasse 8, 8091, Zurich, Switzerland.

Background: Syrian refugees and asylum seekers (SRAs) face multiple stressors after flight, which may vary due to different geographic, economic, cultural and socio-political contexts in the host countries. Past research has recognised the importance of participants' own perspectives. The aims of this multi-country study were to identify and compare self-reported problems of SRAs between various settings.

Methods: A semi-structured client-generated outcome measurement was used to collect data among adult SRAs in Jordan (N = 61), Turkey (N = 46) and Switzerland (N = 57) between September 2018 and November 2019. Answers were analysed following thematic analysis.

Results: Over half of the participants reported practical problems with an emphasis on camp-related problems (Jordan), finances (Turkey), employment (Jordan and Switzerland) and government regulations (Switzerland), followed by psychological, and social issues.

Conclusion: This study highlights the impact of local contextual factors on wellbeing. The findings emphasise that planning preventative procedures and mental health care services for SRAs need to consider local challenges affecting the population in specific countries.
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http://dx.doi.org/10.1186/s12889-021-10498-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045311PMC
April 2021

Insomnia Symptoms and Acute Coronary Syndrome-Induced Posttraumatic Stress Symptoms: A Comprehensive Analysis of Cross-sectional and Prospective Associations.

Ann Behav Med 2021 Feb 13. Epub 2021 Feb 13.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse, Zurich, Switzerland.

Background: Acute coronary syndrome (ACS) induces clinically significant posttraumatic stress symptoms (PTSS) in 12% of patients. Subjective sleep problems are a risk factor for the development of PTSS, but this is underexplored in patients with ACS.

Purpose: To examine the association of insomnia symptoms with ACS-induced PTSS.

Methods: In this longitudinal study with 154 patients (all white, 84.4% male, mean age 58.7 years) with a verified ACS, insomnia symptoms were interviewer assessed at hospital admission and at 3 months, using the Jenkins Sleep Scale (JSS)-4. ACS-induced PTSS were assessed with the Clinician-Administered Posttraumatic Stress Disorder Scale 3 months after hospital admission. In multivariable linear models, insomnia symptoms were regressed on PTSS, adjusting for demographics, clinical variables, health behaviors, and psychological data, including cognitive depressive symptoms.

Results: Greater insomnia symptoms at admission (β = .165, p = .034), greater increase in insomnia symptoms from admission to 3 months (β = .233, p = .008), and greater insomnia symptoms at 3 months (β = .239, p = .002) were independently associated with more severe total PTSS at 3 months. Concerning the individual PTSS clusters, both insomnia symptoms at admission (β = .214, p = .007) and at 3 months (β = .213, p = .012) were independently associated with reeexperiencing symptoms. Removing sleep items from PTSS scores and excluding patients on antidepressants in two sensitivity analyses did not substantially change the results.

Conclusions: Insomnia symptoms could play an important role in the development and severity of ACS-induced PTSS. This relationship seems not simply explained by the fact that sleeping difficulties are inherent to the phenotype of posttraumatic stress disorder.

Clinical Trial Information: NCT01781247.
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http://dx.doi.org/10.1093/abm/kaaa128DOI Listing
February 2021

Myocardial infarction-induced acute stress and post-traumatic stress symptoms: the moderating role of an alexithymia trait - difficulties identifying feelings.

Eur J Psychotraumatol 2020 Sep 4;11(1):1804119. Epub 2020 Sep 4.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, and University of Zurich, Zurich, Switzerland.

Background: It has been acknowledged that medical life-threatening experiences such as an acute myocardial infarction (MI) often lead to acute stress disorder symptoms (ASS), which in turn can result in the development of post-traumatic stress symptoms (PTSS). Previous studies have suggested an association between various traumatic experiences and alexithymia. The association of alexithymia with ASS and PTSS in patients with MI is elusive.

Objectives: The aim of this study was to examine the association of alexithymia with MI-induced ASS and PTSS in patients at high risk of developing PTSD.

Method: Patients ( = 154) were examined twice, once within 48 hours, and then again three months after acute MI. All patients completed the self-rating Acute Stress Disorder Scale (ASDS) within 48 hours after the cardiac event. Three months after hospital discharge, all patients completed the Toronto Alexithymia Scale (TAS-20) and underwent the Clinician-Administered PTSD Scale (CAPS), a structured interview to assess the severity of PTSS. Descriptive statistics, correlations, multivariate linear regressions, and moderation analysis were conducted.

Results: The linear regression model explained 23% of the variance in MI-induced PTSS-symptoms ((6.109) = 5.58, < 0.001,  = 0.23. ASS was significantly related to PTSS severity ( (152) =  < 0.001). The scores of the TAS-20 subscale difficulties identifying feelings (DIF) were found to significantly moderate this relationship (  = 0.03, = 0.04). The scores of TAS-20 subscales DDF and EOT as well as the TAS-20 total score had no influence on the relationship between ASS and PTSS (p > 0.05).

Conclusion: In MI patients with high levels of DIF, ASS predicted the development of PTSS. If replicated, the finding may inform emotion-oriented interventions to investigate whether increasing the capacity to identify feelings following acute MI could be beneficial in preventing the development of PTSS.
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http://dx.doi.org/10.1080/20008198.2020.1804119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803082PMC
September 2020

Pharmacotherapy in the Management of Anxiety and Pain During Acute Coronary Syndromes and the Risk of Developing Symptoms of Posttraumatic Stress Disorder.

J Am Heart Assoc 2021 01 12;10(2):e018762. Epub 2021 Jan 12.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine University Hospital ZurichUniversity of Zurich Switzerland.

Background Benzodiazepines and morphine are given during acute coronary syndromes (ACSs) to alleviate anxiety and pain, and β-blockers may also reduce pain. ACS may induce posttraumatic stress disorder (PTSD) symptoms (PTSS). When taken during trauma other than ACS, benzodiazepines increase the risk of PTSS, but it is unknown if benzodiazepines increase the risk of PTSS in ACS. We examined the effects of drug exposure during ACS on the development of PTSS. Methods and Results Study participants were 154 patients with a verified ACS. Baseline demographics, clinical variables, and psychological measures were obtained through a medical history, through a psychometric assessment, and from patient records, and used as covariates in linear regression analysis. Three months after ACS, the severity of PTSS was assessed with the Clinician-Administered PTSD Scale. During ACS, 37.7% of patients were exposed to benzodiazepines, whereas 72.1% were exposed to morphine and 88.3% were exposed to β-blockers, but only 7.1% were exposed to antidepressants. Eighteen (11.7%) patients developed clinical PTSD. Adjusting for all covariates, benzodiazepine use was significantly associated with the Clinician-Administered PTSD Scale total severity score (unstandardized coefficient B [SE], 0.589 [0.274]; partial =0.18; =0.032) and the reexperiencing subscore (B [SE], 0.433 [0.217]; partial =0.17; =0.047). Patients exposed to benzodiazepines had an almost 4-fold increased relative risk of developing clinical PTSD, adjusting for acute stress disorder symptoms (odds ratio, 3.75; 95% CI, 1.31-10.77). Morphine, β-blockers, and antidepressants showed no predictive value. Conclusions Notwithstanding short-term antianxiety effects during ACS, benzodiazepine use might increase the risk of ACS-induced PTSS with clinical significance, thereby compromising patients' quality of life and prognosis. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01781247.
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http://dx.doi.org/10.1161/JAHA.120.018762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955310PMC
January 2021

Problems faced by Syrian refugees and asylum seekers in Switzerland.

Swiss Med Wkly 2020 Oct 26;150:w20381. Epub 2020 Oct 26.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland / University of Zurich, Zurich, Switzerland.

Background: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

Aim Of He Study: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

Methods: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

Results: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

Conclusions: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

Background: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

Aim Of He Study: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

Methods: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

Results: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

Conclusions: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

Background: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

Aim Of He Study: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

Methods: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

Results: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

Conclusions: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.
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http://dx.doi.org/10.4414/smw.2020.20381DOI Listing
October 2020

Barriers to access to outpatient mental health care for refugees and asylum seekers in Switzerland: the therapist's view.

BMC Psychiatry 2020 07 17;20(1):378. Epub 2020 Jul 17.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland.

Background: More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care.

Methods: An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data.

Results: Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers.

Conclusions: Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.
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http://dx.doi.org/10.1186/s12888-020-02783-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366894PMC
July 2020

Correction to: Evaluating a screener to quantify PTSD risk using emergency care information: a proof of concept study.

BMC Emerg Med 2020 06 29;20(1):53. Epub 2020 Jun 29.

Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY, 10016, USA.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12873-020-00346-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322923PMC
June 2020

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation.

Front Psychiatry 2020 5;11:526. Epub 2020 Jun 5.

Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital, Zurich, University of Zurich, Zurich, Switzerland.

Background: While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration.

Methods: In a sample of refugees receiving psychological treatment in Switzerland ( = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties.

Results: In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors.

Conclusion: These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.
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http://dx.doi.org/10.3389/fpsyt.2020.00526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291948PMC
June 2020

Screening for consequences of trauma - an update on the global collaboration on traumatic stress.

Eur J Psychotraumatol 2020 27;11(1):1752504. Epub 2020 Apr 27.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

This letter provides an update on the activities of "The Global Collaboration on Traumatic Stress" (GC-TS) as first described by Schnyder et al. in 2017. It presents in further detail the projects of the first theme, in particular the development of and initial data on the Global Psychotrauma Screen (GPS), a brief instrument designed to screen for the wide range of potential outcomes of trauma. English language data and ongoing studies in several languages provide a first indication that the GPS is a feasible, reliable and valid tool, a tool that may be very useful in the current pandemic of the coronavirus disease 2019 (COVID-19). Further multi-language and cross-cultural validation is needed. Since the start of the GC-TS, new themes have been introduced to focus on in the coming years: a) Forcibly displaced persons, b) Global prevalence of stress and trauma related disorders, c) Socio-emotional development across cultures, and d) Collaborating to make traumatic stress research data "FAIR". The most recent theme added is that of Global crises, currently focusing on COVID-19-related projects.
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http://dx.doi.org/10.1080/20008198.2020.1752504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241533PMC
April 2020

Age influences structural brain restoration during weight gain therapy in anorexia nervosa.

Transl Psychiatry 2020 05 4;10(1):126. Epub 2020 May 4.

Department of Consultation-Liaison Psychiatry and Psychosomatics, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Neuroimaging studies on anorexia nervosa (AN) have consistently reported globally reduced gray matter in patients with acute AN. While first studies on adolescent AN patients provide evidence for the reversibility of these impairments after weight gain, longitudinal studies with detailed regional analysis for adult AN patients are lacking and factors associated with brain restitution are poorly understood. We investigated structural changes in anorexia nervosa using T1-weighted magnetic resonance images with surface-based morphometry. The sample consisted of 26 adult women with severe AN and 30 healthy controls. The longitudinal design comprised three time points, capturing the course of weight-restoration therapy in AN patients at distinct stages of weight gain (BMI ≤ 15.5 kg/m; 15.5 < BMI < 17.5 kg/m; BMI ≥ 17.5 kg/m). Compared to controls, AN patients showed globally decreased cortical thickness and subcortical volumes at baseline. Linear mixed effect models revealed the reversibility of these alterations, with brain restoration being most pronounced during the first half of treatment. The restoration of cortical thickness of AN patients negatively correlated with age, but not duration of illness. After weight restoration, residual group differences of cortical thickness remained in the superior frontal cortex. These findings indicate that structural brain alterations of adult patients with severe AN recuperate independently of the duration of illness during weight-restoration therapy. The temporal pattern of brain restoration suggests a decrease in restoration rate over the course of treatment, with patients' age as a strong predictor of brain restitution, possibly reflecting decreases of brain plasticity as patients grow older.
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http://dx.doi.org/10.1038/s41398-020-0809-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7198513PMC
May 2020

Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland.

Eur J Psychotraumatol 2020 4;11(1):1717825. Epub 2020 Feb 4.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland.

: Due to their experiences of major stressful life events, including post-displacement stressors, refugees and asylum seekers are vulnerable to developing mental health problems. Yet, despite the availability of specialized mental health services in Western European host countries, refugees and asylum seekers display low mental healthcare utilization. : The aim of this study was to explore structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. : In this qualitative study, key-informant (KI) interviews with Syrian refugees and asylum seekers, Swiss healthcare providers and other stakeholders (e.g. refugee coordinators or leaders) were conducted in the German-speaking part of Switzerland. Participants were recruited using snowball sampling. Interviews were audiotaped and transcribed, and then analysed using thematic analysis, combining deductive and inductive coding. : Findings show that Syrian refugees and asylum seekers face multiple structural and socio-cultural barriers, with socio-cultural barriers being perceived as more pronounced. Syrian key informants, healthcare providers, and other stakeholders identified language, gatekeeper-associated problems, lack of resources, lack of awareness, fear of stigma and a mismatch between the local health system and perceived needs of Syrian refugees and asylum seekers as key barriers to accessing care. : The results show that for Syrian refugees and asylum seekers in Switzerland several barriers exist. This is in line with previous findings. A possible solution for the current situation might be to increase the agility of the service system in general and to improve the willingness to embrace innovative paths, rather than adapting mental healthcare services regarding single barriers and needs of a new target population.
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http://dx.doi.org/10.1080/20008198.2020.1717825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034440PMC
February 2020

Evaluating a screener to quantify PTSD risk using emergency care information: a proof of concept study.

BMC Emerg Med 2020 03 2;20(1):16. Epub 2020 Mar 2.

Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY, 10016, USA.

Background: Previous work has indicated that post-traumatic stress disorder (PTSD) symptoms, measured by the Clinician-Administered PTSD Scale (CAPS) within 60 days of trauma exposure, can reliably produce likelihood estimates of chronic PTSD among trauma survivors admitted to acute care centers. Administering the CAPS is burdensome, requires skilled professionals, and relies on symptoms that are not fully expressed upon acute care admission. Predicting chronic PTSD from peritraumatic responses, which are obtainable upon acute care admission, has yielded conflicting results, hence the rationale for a stepwise screening-and-prediction practice. This work explores the ability of peritraumatic responses to produce risk likelihood estimates of early CAPS-based PTSD symptoms indicative of chronic PTSD risk. It specifically evaluates the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) as a risk-likelihood estimator.

Methods: We used individual participant data (IPD) from five acute care studies that used both the PDEQ and the CAPS (n = 647). Logistic regression calculated the probability of having CAPS scores ≥ 40 between 30 and 60 days after trauma exposure across the range of initial PDEQ scores, and evaluated the added contribution of age, sex, trauma type, and prior trauma exposure. Brier scores, area under the receiver-operating characteristic curve (AUC), and the mean slope of the calibration line evaluated the accuracy and precision of the predicted probabilities.

Results: Twenty percent of the sample had CAPS ≥ 40. PDEQ severity significantly predicted having CAPS ≥ 40 symptoms (p < 0.001). Incremental PDEQ scores produced a reliable estimator of CAPS ≥ 40 likelihood. An individual risk estimation tool incorporating PDEQ and other significant risk indicators is provided.

Conclusion: Peritraumatic reactions, measured here by the PDEQ, can reliably quantify the likelihood of acute PTSD symptoms predictive of chronic PTSD and requiring clinical attention. Using them as a screener in a stepwise chronic PTSD prediction strategy may reduce the burden of later CAPS-based assessments. Other peritraumatic metrics may perform similarly and their use requires similar validation.

Trial Registration: Jerusalem Trauma Outreach and Prevention Study (J-TOPS): NCT00146900.
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http://dx.doi.org/10.1186/s12873-020-00308-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7053081PMC
March 2020

Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: pooled results from the International Consortium to predict PTSD.

Psychol Med 2021 May 3;51(7):1129-1139. Epub 2020 Feb 3.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Background: Research exploring the longitudinal course of posttraumatic stress disorder (PTSD) symptoms has documented four modal trajectories (low, remitting, high, and delayed), with proportions varying across studies. Heterogeneity could be due to differences in trauma types and patient demographic characteristics.

Methods: This analysis pooled data from six longitudinal studies of adult survivors of civilian-related injuries admitted to general hospital emergency departments (EDs) in six countries (pooled N = 3083). Each study included at least three assessments of the clinician-administered PTSD scale in the first post-trauma year. Latent class growth analysis determined the proportion of participants exhibiting various PTSD symptom trajectories within and across the datasets. Multinomial logistic regression analyses examined demographic characteristics, type of event leading to the injury, and trauma history as predictors of trajectories differentiated by their initial severity and course.

Results: Five trajectories were found across the datasets: Low (64.5%), Remitting (16.9%), Moderate (6.7%), High (6.5%), and Delayed (5.5%). Female gender, non-white race, prior interpersonal trauma, and assaultive injuries were associated with increased risk for initial PTSD reactions. Female gender and assaultive injuries were associated with risk for membership in the Delayed (v. Low) trajectory, and lower education, prior interpersonal trauma, and assaultive injuries with risk for membership in the High (v. Remitting) trajectory.

Conclusions: The results suggest that over 30% of civilian-related injury survivors admitted to EDs experience moderate-to-high levels of PTSD symptoms within the first post-trauma year, with those reporting assaultive violence at increased risk of both immediate and longer-term symptoms.
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http://dx.doi.org/10.1017/S0033291719004008DOI Listing
May 2021

5'UTR polymorphism in the serotonergic receptor HTR3A gene is differently associated with striatal Dopamine D2/D3 receptor availability in the right putamen in Fibromyalgia patients and healthy controls-Preliminary evidence.

Synapse 2020 05 7;74(5):e22147. Epub 2020 Jan 7.

Department of Psychology, Unit of Clinical and Health Psychology, University Fribourg, Fribourg, Switzerland.

Background: Extensive literature has investigated the role of serotonin (5-HT) in the control of the central dopamine (DA) systems, and their dysfunction in the pathological conditions. 5-HT stimulates the local DA release in striatal regions via activation of various receptors including serotonin receptor-3 (5-HT3). Several studies have related polymorphisms (SNPs) in the serotonin receptor-3 (HTR3) genes to be associated with the pain modulation and endogenous pain suppression. A few studies suggested a functional role of 5'UTR SNP in the serotonergic receptor HTR3A gene (rs1062613) in the development of the chronic pain and Fibromyalgia syndrome (FMS) in particular. Here, we investigated the effect of a 5'UTR SNP in the serotonergic receptor HTR3A gene (rs1062613) on striatal dopamine D2/D3 receptor (DRD2) availability and reward-associated DA release in response to unpredictable monetary rewards in 23 women with FMS and 17 age-matched healthy female controls. Furthermore, we aimed to examine if SNP rs1062613 is associated with thermal pain and pain tolerance thresholds.

Methods: We used PET and [ C]raclopride to assess the DRD2 availability. In the same participants we used the [ C]raclopride PET bolus-plus-infusion method to measure the [ C]raclopride receptor binding potential (ΔBP) between an unpredictable reward condition and a sensorimotor control condition. DRD2 availability and ΔBP were assessed in MRI-based striatal regions of interest. Thermal pain and pain tolerance thresholds were assessed outside the scanner.

Results: The frequency of SNP rs1062613 genotype differed significantly between groups, indicating that CC homozygotes were more frequent in FMS patients (82.6%) than in healthy controls (41.3%). Our results showed a significant main effect of SNP rs1062613 on [ C]raclopride binding potential in the right caudate nucleus indicating a higher DRD2 receptor availability for CC-genotype of this SNP. Furthermore, we found a significant group × SNP interaction on [ C]raclopride binding potential in the right putamen, indicating a higher DRD2 availability in T-carriers compared to CC genotype of SNP rs1062613 in FMS patients, whereas this effect was not present in healthy controls. However, we did not find an influence of SNP rs1062613 on reward-related DA release. In addition, there was no association between SNP rs1062613 and pain threshold or pain tolerance threshold in our data.

Conclusion: These preliminary results indicate that SNP rs1062613 in the serotonergic receptor HTR3A gene possibly modulates the DRD2 receptor availability.
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http://dx.doi.org/10.1002/syn.22147DOI Listing
May 2020

Are you angry at me? Negative interpretations of neutral facial expressions are linked to child maltreatment but not to posttraumatic stress disorder.

Eur J Psychotraumatol 2019 11;10(1):1682929. Epub 2019 Nov 11.

Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

: Individuals with a high prevalence of child maltreatment, e.g. those with borderline personality disorder, tend to see neutral facial expressions as negative. : Our aim was to assess whether this bias is present in individuals with posttraumatic stress disorder (PTSD) and whether it is linked to child maltreatment. : Thirty-nine PTSD participants, 44 traumatized and 35 non-traumatized healthy controls watched 300 one-second movies showing 30 neutral and 270 emotional facial expressions, and indicated whether they interpreted each as a neutral or as one of nine emotional expressions. : PTSD individuals did not perform differently than the two control groups in the recognition and interpretation of neutral facial expressions ('s < .300). Higher levels of childhood sexual and emotional abuse, and physical neglect were linked to more interpretations of neutral facial expressions as contempt ( < .043), and (for sexual abuse and physical neglect) to more interpretations of neutral facial expressions as anger (p's < .014). Comparisons of statistical model fits suggested that childhood sexual abuse was the most relevant predictor of recognition accuracy in our sample. Alexithymia, state dissociation, interpersonal trauma, and number of experienced trauma types were not associated with deficits in the interpretation of neutral expressions. : Child maltreatment, especially sexual abuse, may shape the interpretation of neutral facial expressions. Future research should explore whether the observed biases extend to real-life situations. If so, therapists might improve the therapeutic relationship with patients with a history of child maltreatment by paying more attention to their own non-verbal communication and their patients' responses to it. Furthermore, similarly to individuals with high depressive and high social anxiety symptoms, facial expression recognition training might counteract negativity bias in individuals with a history of childhood (sexual and emotional) abuse, and (physical) neglect.
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http://dx.doi.org/10.1080/20008198.2019.1682929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853207PMC
November 2019

Editorial: Resilience and Vulnerability Factors in Response to Stress.

Front Psychiatry 2019 17;10:732. Epub 2019 Oct 17.

University of Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.3389/fpsyt.2019.00732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843065PMC
October 2019

Editorial: Resilience and Vulnerability Factors in Response to Stress.

Front Psychiatry 2019 17;10:732. Epub 2019 Oct 17.

University of Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.3389/fpsyt.2019.00732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843065PMC
October 2019

Home treatment for acute mental healthcare: randomised controlled trial.

Br J Psychiatry 2020 06;216(6):323-330

Medical Director, Integrated Psychiatric Services Winterthur - Zurcher Unterland, Switzerland.

Background: Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment.

Aims: To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use.

Method: A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2-F6, F8-F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437).

Results: The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242).

Conclusions: Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.
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http://dx.doi.org/10.1192/bjp.2019.31DOI Listing
June 2020

Editorial: Refugee Mental Health.

Front Psychiatry 2019 26;10:72. Epub 2019 Feb 26.

University Hospital Zurich, University of Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.3389/fpsyt.2019.00072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399381PMC
February 2019

Emotional Reactivity, Emotion Regulation Capacity, and Posttraumatic Stress Disorder in Traumatized Refugees: An Experimental Investigation.

J Trauma Stress 2019 02 6;32(1):32-41. Epub 2019 Feb 6.

School of Psychology, University of New South Wales, Sydney, Australia.

Refugees who suffer from posttraumatic stress disorder (PTSD) often react with strong emotions when confronted with trauma reminders. In this study, we aimed to investigate the associations between low emotion regulation capacity (as indexed by low heart rate variability [HRV]), probable PTSD diagnosis, and fear and anger reaction and recovery to trauma-related stimuli. Participants were 81 trauma-exposed refugees (probable PTSD, n = 23; trauma-exposed controls, n = 58). The experiment comprised three 5-min phases: a resting phase (baseline); an exposition phase, during which participants were exposed to trauma-related images (stimulus); and another resting phase (recovery). We assessed HRV at baseline, and fear and anger were rated at the end of each phase. Linear mixed model analyses were used to investigate the associations between baseline HRV and probable DSM-5 PTSD diagnosis in influencing anger and fear responses both immediately after viewing trauma-related stimuli and at the end of the recovery phase. Compared to controls, participants with probable PTSD showed a greater increase in fear from baseline to stimulus presentation, d = 0.606. Compared to participants with low emotion regulation capacity, participants with high emotion regulation capacity showed a smaller reduction in anger from stimulus presentation to recovery, d = 0.548. Our findings indicated that following exposure to trauma-related stimuli, probable PTSD diagnosis predicted increased fear reactivity, and low emotion regulation capacity predicted decreased anger recovery. Impaired anger recovery following trauma reminders in the context of low emotion regulation capacity might contribute to the increased levels of anger found in postconflict samples.
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http://dx.doi.org/10.1002/jts.22371DOI Listing
February 2019

Differentiating PTSD from anxiety and depression: Lessons from the ICD-11 PTSD diagnostic criteria.

Depress Anxiety 2019 06 25;36(6):490-498. Epub 2019 Jan 25.

Department of Psychiatry, New York University School of Medicine, New York, New York.

Objective: Posttraumatic stress disorder (PTSD) is frequently associated with depression and anxiety, but the nature of the relationship is unclear. By removing mood and anxiety diagnostic criteria, the 11th edition of the International Classification of Diseases (ICD-11) aims to delineate a distinct PTSD phenotype. We examined the effect of implementing ICD-11 criteria on rates of codiagnosed depression and anxiety in survivors with recent PTSD.

Method: Participants were 1,061 survivors of traumatic injury admitted to acute care centers in Israel. ICD-10 and ICD-11 diagnostic rules were applied to the Clinician-Administered PTSD Scale for DSM-IV. Co-occurring disorders were identified using the Structured Clinical Interview for DSM-IV (SCID). Depression severity was measured by the Beck Depression Inventory-II (BDI-II). Assessments were performed 0-60 ("wave 1") and 90-240 ("wave 2") days after trauma exposure.

Results: Participants identified by ICD-11 PTSD criteria were equally or more likely than those identified by the ICD-10 alone to meet depression or anxiety disorder diagnostic criteria (for wave 1: depressive disorders, OR [odds ratio] = 1.98, 95% CI [confidence interval] = [1.36, 2.87]; anxiety disorders, OR = 1.04, 95% CI = [0.67, 1.64]; for wave 2: depressive disorders, OR = 1.70, 95% CI = [1.00, 2.91]; anxiety disorders, OR = 1.04, 95% CI = [0.54, 2.01]). ICD-11 PTSD was associated with higher BDI scores (M = 23.15 vs. 17.93, P < 0.001 for wave 1; M = 23.93 vs. 17.94, P < 0.001 for wave 2). PTSD symptom severity accounted for the higher levels of depression in ICD-11 PTSD.

Conclusions: Despite excluding depression and anxiety symptom criteria, the ICD-11 identified equal or higher proportion of depression and anxiety disorders, suggesting that those are inherently associated with PTSD.
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http://dx.doi.org/10.1002/da.22881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548615PMC
June 2019

A Longitudinal Investigation of Moral Injury Appraisals Amongst Treatment-Seeking Refugees.

Front Psychiatry 2018 18;9:667. Epub 2018 Dec 18.

Department of Consultation-Liason Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

There is currently an unprecedented number of forcibly displaced people worldwide. Understanding psychological mechanisms that contribute to the mental health of refugees and asylum-seekers is important for informing the development of effective interventions for these populations. Moral injury appraisals represent an important potential cognitive mechanism that may contribute to psychological symptoms following exposure to persecution, war, and displacement. In the current study, we investigated the longitudinal association between moral injury appraisals related to one's own perceived transgressions (moral injury-self), others' perceived transgressions (moral injury-other), and PTSD and depression symptoms. Participants in this study were 134 refugees receiving treatment at two outpatient clinics in Switzerland who completed survey measures investigating these concepts. Of these, 71 were followed up 2 to 4 years later. Path analyses revealed that greater depression symptoms were associated with subsequent increases in moral injury-self appraisals (β = 0.25, SE = 0.08, 95% CI [0.11, 0.43], = 0.002). In contrast, greater moral injury-self appraisals were associated with subsequent decreases in PTSD symptoms (β = -0.23, SE = 0.11, 95% CI = [-0.44, -0.31], = 0.035). Findings suggest that different types of moral injury appraisals may be associated with differential psychological outcomes. These results have important potential implications for policy and treatment of refugees and asylum-seekers, highlighting the importance of targeting cognitive factors in the maintenance and treatment of psychological distress, and considering the post-migration context when working with refugees.
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http://dx.doi.org/10.3389/fpsyt.2018.00667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305427PMC
December 2018

Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP).

World Psychiatry 2019 Feb;18(1):77-87

Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals' PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants' item-level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants' education, prior lifetime trauma exposure, marital status and socio-economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow-up PTSD given early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents' female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals' PTSD risk will be a first step towards systematic prevention of the disorder.
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http://dx.doi.org/10.1002/wps.20608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6313248PMC
February 2019

Association of sleep problems with neuroendocrine hormones and coagulation factors in patients with acute myocardial infarction.

BMC Cardiovasc Disord 2018 11 21;18(1):213. Epub 2018 Nov 21.

Department of Psychiatry, Clienia Schlössli AG, Oetwil am See, Switzerland.

Background: Obstructive sleep apnea (OSA) and insomnia are frequent sleep problems that are associated with poor prognosis in patients with coronary heart disease. The mechanisms linking poor sleep with an increased cardiovascular risk are incompletely understood. We examined whether a high risk of OSA as well as insomnia symptoms are associated with neuroendocrine hormones and coagulation factors in patients admitted with acute myocardial infarction.

Methods: We assessed 190 patients (mean age 60 years, 83% men) in terms of OSA risk (STOP screening tool for the assessment of high vs. low OSA risk) and severity of insomnia symptoms (Jenkins Sleep Scale for the assessment of subjective sleep difficulties) within 48 h of an acute coronary intervention. Circulating concentrations of epinephrine, norepinephrine, cortisol, fibrinogen, D-dimer, and von Willebrand factor were measured the next morning. The association of OSA risk and insomnia symptoms with neuroendocrine hormones and coagulation factors was computed using multivariate models adjusting for demographic factors, health behaviors, somatic and psychiatric comorbidities, cardiac disease-related variables, and OSA risk in the model for insomnia symptoms, respectively, for insomnia symptoms in the model for OSA risk.

Results: High OSA risk was identified in 41% of patients and clinically relevant insomnia symptoms were reported by 27% of patients. Compared to those with low OSA risk, patients with high OSA risk had lower levels of epinephrine (p = 0.015), norepinephrine (p = 0.049) and cortisol (p = 0.001). More severe insomnia symptoms were associated with higher levels of fibrinogen (p = 0.037), driven by difficulties initiating sleep, and with lower levels of norepinephrine (p = 0.024), driven by difficulties maintaining sleep.

Conclusions: In patients with acute myocardial infarction, sleep problems are associated with neuroendocrine hormones and coagulation activity. The pattern of these relationships is not uniform for patients with a high risk of OSA and those with insomnia symptoms, and whether they contribute to adverse cardiovascular outcomes needs to be established.

Trial Registration: ClinicalTrials.gov NCT01781247 .
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http://dx.doi.org/10.1186/s12872-018-0947-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6249741PMC
November 2018

Changes in Post-migration Living Difficulties Predict Treatment Outcome in Traumatized Refugees.

Front Psychiatry 2018 9;9:476. Epub 2018 Oct 9.

School of Psychology, University of New South Wales, Sydney, NSW, Australia.

Refugee mental health is affected by traumatic stressors as well as post-migration living difficulties (PMLD). However, their interaction and causal pathways are unclear, and so far, no distinct treatment recommendations regarding exile-related stressors exist. In a 3-year follow-up study, PMLD and symptoms of post-traumatic stress (PTS), depression and anxiety were examined in a clinical sample of severely traumatized refugees and asylum seekers ( = 71). In regression analysis, reduction in PMLD predicted changes over time in depression/anxiety, but not in PTS. The opposite models with PMLD changes as outcome variable proved not significant for PTS, and significant, though less predictive, for depression/anxiety. In addition to well-established trauma-focused interventions for the treatment of PTS, psychosocial interventions focusing on PMLD might contribute to a favorable treatment response in traumatized refugees, particularly with regard to depression and anxiety.
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http://dx.doi.org/10.3389/fpsyt.2018.00476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6189477PMC
October 2018