Post-traumatic stress disorder and life events among
recently resettled refugees
Post-traumatic stress disorder and life events among recently Department of Public Health Sciences, Division of Psychosocial This work is dedicated to absent friends: Hartmut Apitzsch for his clinical sensitivity and dedication, generous sharing of wisdom, and Sten W. Jakobsson for his compassion, inspiration and sense of justice Dissertation for the degree Doctor of Medical Science presented at Karolinska Institutet 2002.
Søndergaard, Hans Peter (2002): Post-traumatic stress disorder and life events amongrecently resettled refugees. Stockholm, Sweden. Karolinska Institutet, Department of PublicHealth Sciences, Division of Psychosocial Factors and Health. ISBN: 91-7349-318-X Abstract
Søndergaard, Hans Peter (2002): Post-traumatic stress disorder and life events among
recently resettled refugees.
Stockholm, Sweden. Karolinska Institutet, Department of Public
Health Sciences, Division of Psychosocial Factors and Health. ISBN 91-7349-318-X.
BackgroundIn refugee health, one topic is the importance of posttraumatic stress disorder (PTSD) from apublic health point of view.
The present study was initiated in order to study the prevalence of PTSD through structuredassessment in a group of recently resettled refugees, and to study important classes of presentlife events and their interaction with health by means of qualitative and quantitative methodsas well as hormonal markers. Further, associations between traumatisation, PTSD andalexithymia were of interest.
Subjects and methodsParticipants eligible for the study were every fourth 18-48 years old recently resettledrefugees from Iraq with at least five years of schooling. Eighty-six out of 321 eligible subjectsparticipated.
The study was prospective in design and used questionnaires in order to collect informationabout life events and self-reported health at baseline and three follow-up assessments at threemonth intervals. At the same time, blood samples were collected and stored. At the end ofdata collection, samples were analysed for cortisol, thyroxine, prolactin, and dehydroepian-drosterone sulphate (DHEA-s). Participants were screened with a specific health interview,and subjects exceeding a low cut-off score – 75/86 -were examined using a structured clinicalassessment procedure for posttraumatic stress disorder.
Questionnaires were translated into Arabic and South Kurdic and back-translated.
ResultsThe prevalence of PTSD among the participants was 37.2 % and was higher among males,which was consistent with lower self-reported trauma exposure among females.
The significant life events of importance for present health were distress in significant others,concerns related to issues of family reunion, and inordinate demands in the introductionprogramme. Housing problems were associated with deteriorated health in PTSD subjects.
The pattern of cortisol changes was the same in PTSD and non-PTSD subjects, whereas therewas an interaction with PTSD for DHEA-s.
PTSD was associated with higher alexithymia score, but this was related to increaseddysphoric affect.
The health screening interview was without complications. Subjects with concentrationdifficulties were 23 times more likely to have a PTSD diagnosis.
ConclusionsPTSD is prevalent in refugees. During the observation period, factors such as housingproblems and self-perceived inordinate demands were associated with deteriorated healthmarkers. Vulnerable subjects are easy to identify, and self-reported distress predictsdeteriorated health. Distress in significant others abroad is a very prevalent stressor, andconcern for significant others in the home country is thus a factor of importance for mentalhealth in refugee populations. According to the longitudinal analysis, DHEA-s and relatedsteroid molecules could be associated with pathophysiology in PTSD.
Recent life events are important for present health status of refugees and interact withprevious traumatic experiences.
Key words: Refugee, posttraumatic stress disorder, life change event, dehydroepiandrosteronesulphate, prolactin, thyroid hormones, cortisol, questionnaires, emotions List of publications
This thesis is based on the following papers, which will be referred to in the text by theirRoman numerals.
Paper I. Søndergaard HP, Ekblad S, Theorell T: Self-reported life event patterns and theirrelation with health among recently resettled Iraqi and Kurdish refugees into Sweden. J NervMent Disease 2001; 189:838-845 Paper II: Søndergaard, HP, Hansson L-O, Theorell T: Elevated blood levels of DHEA-s varywith symptom load in posttraumatic stress disorder; findings from a longitudinal study ofrefugees in Sweden. Accepted for publication Psychotherapy and Psychosomatics.
Paper III. Søndergaard HP, Theorell T: A longitudinal study of hormonal reactionsaccompanying life events in recently resettled refugees. Accepted for publicationPsychotherapy and Psychosomatics.
Paper IV: Søndergaard HP, Ekblad S, Theorell T: Screening for Post-traumatic StressDisorder among Refugees. Accepted for publication Nordic J Psychiatry Paper V: Søndergaard HP, Theorell T: Alexithymia, Emotions, and PTSD; findings from aprospective study of refugees. Submitted.
The papers were reprinted with permission from the publishers Lippincott Williams and Wilkins, Inc.; S. Karger List of contents
Prologue. 1Refugees in the world and in Sweden . 1The asylum process . 2The recent history and peoples of Iraq . 3The introduction of refugees . 4Assimilation, integration, or marginalisation? . 4Extreme trauma and sequelae; posttraumatic stress disorder and alexithymia . 6Neurobiological science and PTSD. 8Alexithymia . 9Life event research . 9”Stress hormones” . 12Cortisol . 12Thyroxine . 13Prolactin. 13DHEA-s . 13Longitudinal studies in refugee populations . 14Table 1. Longitudinal psychosocial studies of refugees with repeated measurements . 15 Setting. 20Design. 20Subjects . 20Materials and instruments . 21Selection and diagnostic procedure. 22Paper I: . 23Paper II: . 23Paper III:. 24Paper IV:. 24Paper V:. 25Ethical considerations. 26 Demographics. 27Trauma history according to the HTQ, and PTSD diagnosis. 27 Table A: Findings from the Harvard Trauma Questionnaire . 28 Non-participation. 29Drop-out (attrition) . 29Self-rating score and hormone levels . 29Treatment. 30 Five cases . 30Paper I. 32Paper II . 33Paper III. 34Paper IV. 35Paper V . 35 Major findings . 36Important life events. 37Differential reaction patterns between PTSD and non-PTSD. 39Dehydroepiandrosterone and PTSD. 41Screening for PTSD. 42Alexithymia . 43Implications . 44Limitations. 46Methodological problems and possible solutions . 47 Recruiting participants . 47Measurement of life events in special groups . 47 Measurements, validity and reliability issues. 48 Research of the integration process in refugee groups. 50Studies of a putative role of DHEA-s in PTSD. 50 Acknowledgements . 51References . 52Appendix . 66 Table B: Self-rating values of GHQ-28, Hopkins symptom checklist-25 anxiety and depression, and Impact ofEvent Scale-22. 66Table C: Serum levels of cortisol, thyroxine, dehydroepiandosterone, and log-transformed prolactin at eachassessment. . 67Table D: Paired samples t-test for IES-22, GHQ-28, and HSCL-25 anxiety / depression (first minus lastmeasurement). . 68Table E: Coded categories of life-events according to responses to open-ended questions and number ofreports. 68Table F: Checklist items and number of reports . 70 Abbreviations
GABAA-receptor: The A Receptor subtype for GABA HPA axis: the integrated system comprising the hypothalamic, pituitary, and adrenal system HT-3 receptor: Type 3 receptor for Serotonin (Hydroxytryptamine) IPM: The Swedish National Institute for Psychosocial Factors and Health TAS-20: Toronto Alexithymia Scale with twenty items UNHCR: United Nations High Commissioner for Refugees Background
PrologueDuring the original discussions leading to this work it became clear that there was a need to study the health of refugees with regard to the effects of previous trauma as well as present living conditions. It took some time to find ways to do this; but finally we were given the opportunity to co-operate with what is now the City of Stockholm’s Integration Department.
For practical reasons, we chose to focus on the largest group, which, as was to be expected, consisted of Arabic and Sorani speaking refugees from Iraq.
Refugees in the world and in SwedenThe number of refugees world-wide is high. According to the statistics of the United Nations High Commissioner for Refugees (UNCHR) [1], the number of persons of concern to UNCHR worldwide has increased steadily from 15 000 000 (1990) to 22 000 000 in 2000.
About twelve million are refugees in camps or in neighbouring countries, one million are asylum seekers in the Western world, and at least eight millions are internally displaced persons, which means that they lack the protection of international law.
Most refugees live in neighbouring countries and refugee camps. Many refugees are received in third countries and subsequently gain permission to remain permanently. Among the latter group of refugees accepted in third countries, a minority is granted asylum as political refugees, which gives certain rights. More commonly, they are seen as ’de facto’ refugees, or are granted asylum for humanitarian reasons [2].
The number of foreign-born subjects in Sweden Dec. 31st, 2000 was 1 003 798, which is 11.3 per cent of the total population. A total number of 731 028 subjects were granted residency status during 1980-2000. Of these, 275 109 belonged to various legally defined refugee groups, while 354 032 were classified as relatives of these subjects.
On the other hand, during this period only 8 175 subjects obtained residency status as labour immigrants. Further, the number of guest students was 30 084, 17 163 children were adopted and 46 465 immigrants from other European countries with equal rights on the labour market Thus most of the immigration to Sweden during the past two decades is explained by refugee Of the total number (9045) of subjects granted residency during the year 2000 within the refugee regulations, 594 were Africans, the majority from Somalia, 144 were from South America, 4 904 were from Asia, mostly Iraqi refugees, and 3 253 were Europeans with the largest group coming from former Yugoslavia.
The asylum processThe legal process by which a subject may eventually obtain residency in Sweden under the Immigration Act differs depending on the circumstances [3]. As mentioned earlier, the number of labour immigrants is small. Refugees and their first-rank relatives may belong to different groups from a legal point of view.
One such group is quota refugees, whose residency status has been decided beforehand after negotiations between the UNHCR and the national governments.
The normal process, however, is that a refugee applies for asylum, and that such an application is processed by the Migration Board. If an application is rejected, there is a possibility to appeal the decision to the Aliens Appeal Board, at this stage the applicant has the right to legal assistance. The mean time for processing an application during 1999, the most recent year with complete statistics, was 283 days in the cases where permission was granted, and 440 days in cases that were taken under consideration but finally rejected [4].
During 2001, 6 571 out of 12 782 applications (51.4 %) were rejected, and of these an unknown number were appealed. In the annual report of the Aliens’ Appeal Board [5] the frequency of consent – a change of a decision of rejection - is said to be 16-19 % depending on the category. The mean time for processing the appeal case is 211 days. The mean acceptance rate of about 50 % conceals differences; in reality, asylum applicants from most countries have a high rejection rate, whereas a few countries show a high acceptance rate.
During the year 2000 and in preceding years Iraqi citizens had a high acceptance rate; according to the practice of the immigration authorities, Iraq was considered an unsafe The reasons for, or legal categories of granted residency status, are the following (in parentheses; percentage for the year 2001): ’Refugees’ (4 %), ’Quota refugees’ (14 %), ’Humanitarian grounds’ (72 %), and ’Others in need of protection’ (10 %).
Subjects who have obtained residency status have the right to apply for family reunion; i.e.
residency status for their spouse and children under 18 years of age. This process is often as time-consuming as the asylum application itself. Such an application process starts with an interview at a Swedish embassy, often in a third country when it is impossible or unsafe to do so in the home country. The waiting period before the interview is often 3-6 months, and the time for processing the application is about the same. Regarding this process, no statistics exist [4]. In consequence, many resettled refugees have their nuclear family in an unsafe or financially strained situation for an extended period of time.
The recent history and peoples of IraqThe history of Iraq during the past decades has been chaotic, due to the political situation [6].
The country is strategically situated, has vast resources of oil, and has been seen as a key country for political stability in the region. The dictatorship of Saddam Hussein has an extensive record of very severe human rights violations. A war raged between Iraq and Iran 1980-86. After the invasion of Kuwait 1990-1, massive air-strikes were launched against the country with severe consequences for the infrastructure; followed by an ’intifada’, a rebellion against the regime mostly effected by the population in the south. This uprising was crushed Iraq has numerous population groups that are distinguished on the basis of their religion, language or culture. Often, specific groups have been put under severe pressure by the regime, used as scapegoats or deprived of their economic resources.
First and foremost, the Kurds in Northern Iraq have a long history of tensions in the relationship to Baghdad. In 1983, 8000 men and boys of a Kurdish clan were rounded up by the army and almost certainly killed. The most well-known crisis was the attack on Halabja 1988, where 4000 people were killed with chemical weapons. This is only one episode of the operation named al-Anfal (The spoils of war, as the operation was named), where numerous other incidents have been reported the use of chemical weapons. According to many sources, the operation amounted to a genocide [7]. Maybe 200 000 people disappeared.
The flight of hundreds of thousands of Kurds of Northern Iraq into the mountains after the Gulf War took place because a similar retribution was anticipated [6] (pp 256-9). There have also been civil wars or prolonged periods of unrest between the main clan leaders in the The main Kurdish dialect is Sorani (South Kurdic). Another Kurdish group, traditionally inhabiting the border zone next to Iran, are the Feili Kurds, with their own language Feili. A large number of Feili Kurds –Kurds that are Shia Muslims- were deported to Iran in 1980; and in the process, their belongings were confiscated by the Iraqi regime.
Among the Arabic speaking population, a number of ethnic groups – distinguishable by religion - exist. Shia Muslims make up the majority of the population, but during the existence of Iraq, those in power have predominantly been Sunni Muslims. During the regime of Saddam Hussein, a clan or structure of kinship of probably no more than 10 000 individuals have been governing Iraq through systems of patronage. There was a small number of Sefardic Jews, but they were expelled, killed, or managed to flee during the 1967 Yom Kippur War. Several Christian groups exist, comprising about 3 % of the total population. The so- called Mandean Baptists, one of the oldest Christian groups -followers of John the Baptist- The introduction of refugeesRefugees, once they have obtained residency status, are received into the community. This phase is regulated by a specific agreement between the state and the municipalities, which regulates the financial stimuli and the co-ordination of refugee reception [8]. According to this aggreement, an individual introduction plan should be established in each case. Also, co- operation should be sought between different sectors responsible for health care, school The goal of refugee introduction is that the subjects are able to live a normal life in the new society, which includes among others that the individual has the means to support himself and to take an active part in Swedish community life.
According to a recent report from the Swedish National Audit Office, the aims of refugee introduction defined by the Parliament have not been attained, mostly because of a lack of co- operation between different actors [9].
Assimilation, integration, or marginalisation?A hot topic today is the integration of refugees; in Europe this has become a major political issue, and right-wing populist parties have obtained a high number of votes in several countries by campaigning against immigration. Lack of integration is used as an argument.
With regard to the entry of foreign-born immigrants into the mainstream culture and social life of the host country, a number of different terms are used. These are often of sociological origin [10]. They denote different views of what is desirable; thus the term ”integration” means that the subjects have been fully amalgamated into the host country with regard to culture, language and participation in all aspects of the society.
”Assimilation” has a slightly different meaning and can be seen as a more gradual process.
”Creolization” is a term borrowed from linguistics and is sometimes used to denote a mixture ”Marginalisation” is used as a term for lack if integration, or assimilation.
The term used in the medical literature - as a Medical Subjects Heading- is ”acculturation”; which denotes the acquisition of culture, or cultural competence. It has another meaning however, i.e. the directed change of one culture, instead of ’incorporation’, the free interchange of artefacts, customs, and beliefs.
The above-mentioned terms share the perspective of the host country. Another view, the perspective of the immigrants, is rarely voiced. In sociological literature, exclusion [10] has been used to denote the keeping of certain groups outside societal structures, such as health care, working life, etc. by way of structural conditions.
The impact of psychological trauma on the first and second generation is rarely discussed in the context of integration, assimilation, or marginalisation in the sociological or anthropological literature on immigrants and ethnic minorities.
On the other hand, there exists a medical and psychological literature about refugees, immigrants, or cultures and populations outside the Western part of the world. A traditional view is exemplified by transcultural psychiatry, which often focuses upon ways in which culture – such as folk belief systems, religions, or traditions - can influence the expression of psychiatric or psychosomatic illness [11]. In social psychiatry, demographic factors are Since the introduction of post-traumatic stress disorder (PTSD) to the diagnostic systems, and since wars, repression, and political violence have been recognised as decisive factors in refugee health, a large number of publications concern PTSD among refugees. However, the criticism has been made that knowledge regarding PTSD is sometimes wrongly used in situations where subjective meaning, cultural coping strategies, and social, political or existential context are disregarded [12] [13]. In this way, the diagnosis of PTSD can become a stigma instead of a meaningful diagnosis. Also, PTSD has been regarded as a ”political” diagnosis with no true medical meaning [14], while others have stressed that clinical observations of war trauma sequelae have rapidly been forgotten after each war [15].
The possible role of PTSD as an obstacle of integration is virtually absent in the sociological literature on integration as well as in the general political discourse, possibly due to ignorance, or perhaps because of the fear of stigmatisation or ”medicalisation” of specific Extreme trauma and sequelae; posttraumatic stress disorder and alexithymiaIt is undisputed that severe psychological trauma has adverse health effects in a high proportion of those exposed to it. Most refugees have experienced a series of such events, either first-hand or through threats to, or the loss or victimisation of significant others. Such events – or the imminent threat thereof - are often the reason for leaving the home country. It is often the sequelae that cannot be escaped.
A spectrum of health consequences has been described after severe traumatic events. In Norwegian survivors of an oil-rig disaster, the general, psychosomatic, and psychiatric morbidity was higher each year over the eight years follow-up period in comparison to control subjects [16]. After a landslide associated with the outbreak of a volcano, increased levels of anxiety, depression, and post-traumatic stress were found in a ’dose-dependent manner’ [17].
After the Hanshin earthquake, Japanese internists noted an increase in pneumonias and fewer cases of acute asthma during the first months, and later on, an increased prevalence of severe stomach ulcers. Diabetes control also deteriorated in the aftermath of the earthquake [18].
An accident at the nuclear power plant situated on Three Mile Island lead to increased self- perceived distress and increased cortisol and katecholamine excretion in subjects living near the power plant, compared with three control groups [19].
Studies of subjects who experienced the Hurricane Andrew disaster in Florida showed among other things decreased natural killer cell cytotoxicity at follow-up, which was associated with damage caused by the hurricane, and with self-reported PTSD symptoms [20].
In a cohort of Armenians followed-up after an earthquake, mortality from all causes and from heart disease peaked 6 months after the disaster. A nested case-control study from this large cohort showed an association between loss of family members or material possessions, and risk of developing heart disease, hypertension, diabetes mellitus, and arthritis [21]. A number of other studies support increased specific somatic morbidity after severe psychological A number of trauma-specific psychiatric disorders have been described during the history of psychiatry [25]. ‘Hysteria’, which today is termed dissociative disorders, was considered by Pierre Janet to be related to ’traumatic reminiscences’. After the First World War, publications appeared concerning ”shell shock”, then considered to be caused by the pressure waves from detonations. Freud changed his opinion regarding the association of traumatic experiences and ’hysteria’ several times [26]. His pupil Kardiner [25] was the first to describe what is to-day considered as core features of the post-traumatic stress disorder, namely severe sleep disorder with disturbed dreaming, and a number of other signs of increased arousal.
Horowitz’ observations of the cycle of intrusion/denial and numbing in subjects after severe traumatic experiences [27], along with Kardiner’s observations of increased arousal, became incorporated into the diagnostic criteria for posttraumatic stress disorder (PTSD) in DSM-III [28]. Further, a number of overlapping trauma-related diagnoses are presently used by clinicians, such as DES (disorders of extreme stress)[29], or complex PTSD [30, 31]. This specific disorder is considered by some to be caused by excessive long-term on-going traumatisation during different maturation phases [30-35]. Or, expressed more plainly, sometimes PTSD is an acute disorder that is easy to treat or might heal spontaneously under favourable conditions, and sometimes it is chronic. In the latter case it is often associated with negative childhood experiences or cumulative trauma [36]. It is also possible that posttraumatic states might be incorporated in the character structure in such a way that PTSD is no longer the presenting issue [37, 38]. While these concepts make good sense to clinicians working with an array of traumatised populations, depression and PTSD are the most commonly diagnosed conditions in refugee populations [39-41].
Depression that is co-morbid with PTSD has been regarded as a specific clinical form [42, 43]. It has been discussed whether symptom overlap between PTSD and depression – notably anhedonia, disordered sleep, and concentration problems - could explain the apparent high co- morbidity; but this does not seem to be the case [44]. Co-morbid depression in subjects with PTSD has also been regarded as more difficult to treat than uncomplicated depression [45, The longitudinal course of PTSD has been studied in different groups. Various cohort studies suggest that chronic cases seldom enjoy permanent remission [47-50]. Even when PTSD may no longer be diagnosable, survivors may lead restricted lives [51].
The prevalence of PTSD in refugee groups varies between different groups. One of the lowest prevalence rates reported in the literature is 10 % [39], but in most studies it is ”disturbingly high”[52-57] [58-65], in the words of one author. Thulesius and Håkansson found a prevalence of 18-33 % in Bosnian refugees in Sweden, compared with 0.3-1 % in primary care visitors [66]. While it is established that PTSD is more prevalent in refugee populations, this has not necessarily made an impact on clinicians who treat refugee patients. In a diagnostic study of foreign-born patients at an outpatient clinic the prevalence of PTSD was 40%; but in a control sample of foreign-born patients from the same facility, this diagnosis was non-existent using routine diagnostic procedures [67, 68].
The functional impairment of PTSD sufferers is rarely described in the literature [69]. In order to fulfil the criteria for PTSD it is required that the individual should exhibit clinically significant distress or impairment in social, occupational, or other important areas of functioning. Several studies of different populations have shown cognitive problems in PTSD, affecting memory and visuo-spatial functions [70-81].
Neurobiological science and PTSDThe biological research on PTSD has been extensive since the diagnosis was established. It is not the intention to review the research literature on PTSD. Only hypotheses or findings that are relevant for the interpretation of findings in this project will be mentioned briefly.
PTSD has been characterised as a multi-system disorder involving several neuroendocrine systems, which implies that medication is of limited effect in PTSD compared with depression, panic, etc. The systems that are best studied are the HPA-axis, and adrenomedullary system. Excretion of catecholamines is increased, and cortisol excretion is lowered. The combination of these findings has been considered to give PTSD a unique neuroendocrine profile compared with other diagnostic groups [82-84]. The HPA axis has showed changes on all levels. Accordingly, increased levels of corticotrophin releasing factor (CRF) in cerebrospinal fluid [85], decreased cortisol suppression at dexamethasone test [86- 95], and increased levels of cortisol binding globulin [96] have been shown in PTSD. This has created an impression of a “static” picture of low cortisol in PTSD. It has, however, been shown that the cortisol regulation is highly dynamic in PTSD [97].
Other neuroendocrine systems have also been shown to be abnormally regulated in PTSD, such as the opioid [98-109], and immune systems [20, 24, 110-112].
Findings of diminished hippocampal volume in chronic PTSD have been published [113]. The findings have varied, and it is still disputed whether this finding is caused by PTSD or is preexistent and might indeed be a vulnerability factor in the development of PTSD. The matter is complicated since most of this research has been carried out on Vietnam veterans, with possibilities of confounding by post-war factors. Only a few longitudinal studies of hippocampal volume after psychological trauma have been carried out in accident victims and maltreatment-related PTSD in children [114, 115]. These studies, which were small, did not show any difference at baseline, but on the other hand there was neither any difference in hippocampal volume after 6 months in ten accident victims who developed PTSD nor after 2 years in nine children with maltreatment-related PTSD. It is thus concluded from both of these studies that a possible reduction in hippocampal volume may be a feature of long- standing PTSD. The topic of possible changes in hippocampal volume is highly interesting since it has been found in chronic PTSD, and because hippocampal dysfunction could explain many of the cognitive problems and the clinical symptoms of PTSD subjects such as failure of explicit memory function [35, 116-118].
AlexithymiaThe concept of alexithymia has been used to denote specific traits in drug abusers, subjects with certain psychosomatic disorders, and subjects with severe psychological traumata [119].
Alexithymia has been conceptualised in various ways. A related concept is pensée operatoire which has been observed in certain psychosomatic patients by Marty and de M’Uzan [120].
Sifneos defined alexithymia as a psychic dysfunction in which the expression of symbolic thinking and fantasies is reduced, somatisation is common, feelings are poorly communicated, empathy is impaired and intimate interpersonal relations are difficult to maintain [121].
Bagby et al. have developed a self-rating scale for alexithymia which consists of 20 items (TAS-20) [122]. The scale has been found in many studies, even cross-culturally, to consist of 3 factors, inability to identify affect, inability to describe affects, and operational thinking.
Various studies of alexithymia have pointed to neurophysiological differences in alexithymic subjects [123, 124]. It has also been shown that subjects with PTSD show a higher prevalence of alexithymia, similar results being found using various methods [125-130] [131-134].
Life event researchOne of the aims of the present work was to study how frequently occurring life events interact with previous health in affecting health changes in a group of refugees. The study of life events as predictors of disease has a long tradition in psychosomatic medicine and psychiatry.
Adolph Meyer introduced life charts in the clinical assessment of psychiatric and psychosomatic patients [135]. This developed further into methods of describing, quantifying, and understanding the means whereby life events could interact with health. Life events have been studied as predictors of an array of diseases, ranging from illness in general to mental disorders [136-138], cardiovascular disorders [139, 140], immunological function [111, 112, 141-143], and cancer [144-146]. The methodological issues in this field of research are complicated since life events interact with genetic predispositions, social context, and coping style [147]. Confounding is possible in a number of ways; for instance subjects with an illness may attribute more weight to recent life events than control subjects.
Life change events can differ with regard to type; thus bereavement, loss, work stress, or traumatic stressors are not necessarily equal with regard to effects on health. Even the absence of events can be perceived as stressful [148]. Events perceived as positive may also act as stressors in certain persons [149] with low self-esteem. In the literature, a distinction is made between life events, daily “hassles”, and demanding life conditions.
One way of conceptualising the possible effect of life events - in the widest sense - on health is to use the concept of ”allostatic load” [150]. Allostatic load – the ’deforming impact’ has also been used in relation to excessive adaptation. Disturbed allostasis is common to various biological pathways leading from stress to disease.
In research on stressors and life events, many methods have been applied. The most obvious one is to interview subjects about their experiences and reactions. Such a method is time- consuming. The results of a few interviews, especially if they are done retrospectively, may be difficult to interpret; issues such as individual vulnerability, variance in reports, such as a tendency to over-report, or – the opposite - denial of threatening events, and various other factors may bias the interpretation. Brown et al. [151] maintain that such interviews should be strictly operationalised and that independent informers should confirm the occurrence of events. According to the sociological view, the event itself, and the contextual factors Another method of recording life events is to use standardised checklists. Here again interpretation is subject to variability; e.g. an event on the list may have different implications for different subjects. Two views have been advanced. According to the one view [152], subjects tend to rate the impact of specified events similarly on average. Such studies have shown remarkable stability over time concerning impact ratings of specified life events in large groups. On the other hand, Dohrenwend et al [153] have raised the issue of variance The most influential method in life event research has been the Social Readjustment Rating Scale (SRRS) [154] [155]. The instrument is based on the assumption that the adaptation required in order for the individual to be able to cope with an event is the important factor in deciding how stressful the event is, a concept similar to ‘allostatic load’. On the basis of a checklist of events, studies were carried out that seemed to point to the following implications; 1) the total ‘load’ of life events is decisive for the health consequences of life events. This load – of adaptation requirements - is common to both positive and negative events, at least theoretically. 2) The estimated impact of life events on a list, when these events are rated for impact by many subjects, shows a high correlation among subjects. The implication of this is that people share the capacity to appreciate the stress involved in life events, and further that, in large samples, individual differences in susceptibility or sensitivity tend to be less important. Therefore, life change units can be calculated and explored as In the same book, Rahe [156] presents a model of the pathway between stress and illness. In this model, the following factors are discussed; past experience, psychological defences, physiological reactions, coping, and illness behaviour. The physiological reactions are ‘the black box’ wherein reactions that will lead to later disease might or might not happen.
In this classical book, Brown [157] presents his model and his criticism of the above- mentioned models. First of all, he points to validity issues. He lists three such issues. The first is that an illness that has developed after an event can retrospectively bias the subject or the researcher. This problem is eliminated by a prospective design.
The second source of validity problems, named indirect contamination, is when a factor in the subject, such as anxiety, can lead to both overreporting of certain events and subsequent illness, thus causing a spurious association. The third source of validity problems is when both the event and the illness are caused by another factor, i.e. the notion of confounding.
Brown seems to feel that self-report approaches lead to so many sources of error that other methods are preferable, such as a rating of what he terms ‘contextual threat’ as a way of measuring and understanding social factors of importance for health outcome. For example, even if marriage might be a happy event to most people, it can also entail considerable stress and in specific cases could be a threatening event, e.g. if the marriage is arranged or forced.
Another such example would be childbirth where external contextual factors could differ a great deal and be decisive for the subject’s perception of the event.
Without attempting to discuss the above-mentioned views it seems that size – the number of participants - and precise aim of a given study would influence the weight of the arguments In the same volume, Antonovsky [158] discusses ‘resistance resources’. His research lies behind the widely used questionnaire ‘Sense of Coherence’, which will not be dealt with Cross-sectional studies of reported life events are plagued by retrospective recall bias; on the one hand, reports of events of daily life will often be unreliable with regard to time sequence.
On the other hand, severe traumatic events in adults are unlikely to be forgotten [159]; although even for such events, variance in reporting may arise because of the impact on the brain of severe traumatic events. In rare cases, amnesia will result. More often fluctuations of recall arise, especially for events that are regarded as peripheral by the subjects.
Studies of the impact of life events on health should ideally be longitudinal, i.e. the outcome under consideration should be measured before and after the event, and comparisons should be carried out between individuals with and without the event.
Measurements of the effect of life events could be subjective ratings of impact, or differences on self-rating scales such as rating scales for depression or other symptoms under consideration. The interpretation of self-rating scales or subjective ratings of impact could also be subject to discussion since it could be argued that social desirability [160, 161] or personality features could bias the responses. If a longitudinal study involved support or assistance to the participants, a possibility of participants trying to impress the study leaders through their self-ratings could also exist with exaggerated self-rating scores as a result. On the other hand, cultural or characterological bias against showing distress could work in the A special strategy that has been applied in longitudinal life event research is the measurement of hormonal reactions to stressors [162-165]; this will confirm whether specific events make a psychophysiological impression on the subjects studied.
”Stress hormones”The above-mentioned strategy of measuring stress responses through assessment of hormonal changes in blood or otherwise is based on the knowledge of the physiology of the stress response, as described by Cannon and Selye [166]. Changes in blood or saliva concentration, as well as excretion of certain hormones, have been shown to be associated with stressful life events. Above all, catecholamines react to stress. These reactions are short-lived. Other hormones react slowly and are therefore more feasible to study as markers of psychosocial CortisolCortisol is the most widely studied hormone in stress research. The interest in cortisol originated in Selye’s studies of stress in animals; after exposure to an array of harmful events, cortisol could be shown to be involved in the final common pathway of the stress response.
The physiological role of cortisol is energy mobilisation. Cortisol facilitates some of the crucial physiological processes in acute “energy mobilisation” situations. The cortisol response is an integral part of the HPA-axis activity. Cortisol – either in serum or in saliva - has been one of the most commonly used biological markers of stress in biopsychosocial research [167, 168] and has a long tradition.
ThyroxineThyroid hormones are also known to be involved in stress responses. Central mechanisms have been shown in animal models [169]. In the periphery, cortisol or catecholamines have been shown to reduce the conversion of T4 to T3 –the active metabolite [168, 169]. Thus T4 levels are assumed to mirror long-term stress. In some studies, the rates between thyroxine binding protein in plasma, free and total fractions of T3, reverse T3, and T4 have been calculated. In the present study, only free T4 and free T3 were analysed.
It has also been discussed whether in fact thyrotoxicosis can be caused by stressful life events [170]. The number of longitudinal studies of life events or psychosocial stressors in which thyroxine has been measured as a marker of stress is, however, limited [168].
T3 has also been found in increased levels in World War II veterans with PTSD. This has led to a hypothesis that these higher levels might be a factor underlying chronicity of PTSD ProlactinDifferent forms of stress are known to interact with prolactin secretion [172] [166].
Circulatory levels of prolactin are controlled by pituitary dopamine, which acts as the common final pathway of a large number of stimulatory or inhibitory modulators. It has turned out that the prolactin response varies between different types of stressors. It has been suggested that decreased plasma prolactin level is associated with active coping, while increased levels are associated with reactions involving helplessness or possibly apathy [173].
DHEA-sDehydroepiandrosterone is an anabolic steroid that has been examined in a number of recent studies of psychosocial factors [174-177], because serum levels have been assumed to mirror good health. It decreases with age, and is lower in smokers and in patients with a number of A new development in the history of steroid biology was initiated with Majewska’s discovery 1986 [186] that DHEA-s existed not only in increased amounts in the mammalian brain, but that DHEA-s also showed an action on the GABAA-receptor. This is a so-called non-genomic effect; generally steroid hormones have been thought to exert their effect only through the general mechanism of activation of genes. Further research has shown that DHEA-s could be produced in the brain in response to stress, namely in glial tissues, by independent pathways [187-190]. Since then, a new class of steroid molecules has been proposed, the neurosteroids, which have turned out to potentially influence at least three identified receptor systems, apart from the above-mentioned, the glutamate receptor family, and the 5-HT3 receptor. Apart from DHEA-s, pregnenolone and the 3α-reduced metabolites of progesterone and deoxicorticosterone; 3α, 5α-THP, and 3α, 5α-THDOC, are considered as ’neurosteroids’ by certain authors [191]. DHEA-s has been considered as ‘neuroprotective’ in some models of Most studies of neurosteroids have focused on the possibilities of influencing the ageing process or Alzheimer’s disease. In one study of PTSD, blood levels of DHEA-s were increased, compared with control subjects [194]. In another study baseline levels of DHEA-s as well as levels after a metyrapone test were reduced in PTSD compared with control Longitudinal studies in refugee populationsConsidering that there is a high prevalence of previous traumatic events in refugee populations and accordingly also a higher prevalence of PTSD, the question arises as to how this influences adaptation as well as subsequent development of health after resettlement in Numerous studies have analysed the life situation of refugees. Most of these are cross- One such study in Sweden concludes ”furthermore, a low sense of coherence, poor acculturation, poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychosocial distress in this group than exposure to violence before migration” [195]. No assessment of PTSD was made in this study. In a similar vein, Hondius reports that refugees attribute 40 % of their present health complaints to on-going life stressors [196].
Gorst-Unsworth found that social factors in exile, especially affective support, proved important in determining the severity of both posttraumatic stress disorder and depression [197]. While it is obvious that such present factors should influence health, it is a methodological question as to how strong inferences may be made from cross-sectional studies. For instance ”attribution”, the individual perception of causes, is not equal to causation, but might as well be explained by psychological defence factors such as projection.
Such conclusions are theoretically more convincing if they are based upon longitudinal studies and preferably upon studies that include relevant intervening factors. It might be difficult to study refugees longitudinally, but attempts have been made.
Table 1 lists longitudinal studies of psychological health in refugees, retrieved from Medline May 2002. It can be seen that most of the studies explore predictors, either in the form of retrospective data, or prospectively with assessments at baseline. In some studies, measures of intervening factors between baseline assessment and follow-up are registered. These are sometimes recorded retrospectively; i.e. a new interview is performed at follow-up, which was not performed at baseline. Other studies have analysed demographic changes in such factors as household income, marital status, etc. In a few studies there have been assessments both of the presence of symptoms of PTSD at baseline, and intervening variables. In the studies listed in Table 1, twelve can be identified where intervening variables have been Table 1. Longitudinal psychosocial studies of refugees with repeated measurements Number in
Time per-
ing variables
(Life events
or social
From table 1 it can be seen that even in longitudinal studies, life events or PTSD diagnostic status have often been studied retrospectively. In a review [215], summarising studies published before October, 2001, Hollifield et al. discuss adopting methodologies from life events research to better define how and what events are weighted as traumatic and predictive of poor health. The majority of the studies focus on predictors; which is interesting only to extent that they are used for intervention purposes.
Aims of the study
The study was initiated in order to study refugees during the first period after resettlement.
The prevalence of PTSD, screening methods for the lay identification of individuals at risk for a diagnosis of PTSD, and life events that were important for health at this early stage during the integration process were of interest. Further, the connection between psychological trauma, PTSD, and alexithymia was investigated.
SettingThe study was carried out in co-operation with the Centre for Torture- and Trauma Survivors, the Swedish National Institute for Psychosocial Factors and Health, and the City of Stockholm department responsible for refugee reception. This department belonged to the administration dealing with educational matters. During the study it changed its name to the Department of Integration. Participants eligible for the study were invited by the responsible agency to an information meeting by post. At the meeting, participants were informed about the study. It was repeated that participation was voluntary, and that assistance would be offered if health care needs were detected through the screening procedure. After the meeting, participants who volunteered were given time for blood tests, a screening interview, and the questionnaires were distributed subsequently. Follow-up assessments, blood tests, and diagnostic interviews were carried out at the Centre for Torture and Trauma Survivors.
Data collection started in October 1997 and was concluded April 2000.
DesignThe study was planned and implemented as a follow-up study with baseline assessment and three follow-ups, carried out at three-montly intervals. The follow-ups and baseline assessment included registration of self-recorded life events, self-rated health measurements, and collection of blood samples. A research assistant scheduled the follow-ups, contacted the participants, and collected blood samples between 8 and 10 a.m. Questionnaires were SubjectsSubjects were eligible for participation if they - were recently resettled (< 3 months) - belonged to the largest language groups, i.e. Arabic or Sorani.
- were in the age range 18-48 years, with regard to the feasibility of hormone analysis.
- had at least five years of schooling, and were able to complete questionnaires in their own Every fourth subject fulfilling these criteria was invited to an information meeting, in which they were given written information about the study and informed that participation was Materials and instrumentsThe principle guiding the choice of questionnaires was that the instruments, where possible, should have proven validity and reliability in previous transcultural research.
The following instruments were used in the subsequent papers; ’The Health Leaflet’ (HL) [216], a lay screening questionnaire with binary responses performed by a social worker at the refugee reception agency. The maximum HL score is 15 points; subjects with a score above 4 points were clinically assessed.
Emotion Protocol [217], a list of emotions developed at IPM; the presence of 24 emotions were rated in terms of ’clearly’, ’somewhat’, or ’not at all’.
Toronto Alexithymia Scale (TAS-20) [218].
General Health Questionnaire with 28 items (GHQ-28) [219].
Hopkins Symptom Checklist with 25 items (HSCL-25)[220].
”Life event questionnaire for refugees” [221], developed for this study from an 18-item checklist [222] based on the Holmes-Rahe Life event checklist [223]. The life event checklist consisted of an open-ended section (”Please mention the events during the last three months that were important”) with space for a maximum of 10 events as well as 60 checklist items, derived from a pilot study of seven patients in treatment, and interviews with professionals. A module was attached containing questions about how the questions asked were received.
Harvard Trauma Questionnaire (HTQ) [224].
Impact of Event Scale (IES-22) [225].
In self-rating questionnaires generally, a maximum of two missing values, or a maximum of ten per cent, are replaced with mean values of the rest. In Paper I, only cases with complete Questionnaires were translated and back translated by independent translators according to the Blood samples were cooled on ice immediately, centrifuged, and stored at –70 centigrades until analysis. Cortisol and T4 was analysed by AUTODELFIA assay (Wallac Oy), intra- assay variability < 3.6 % and < 2 %, respectively. Prolactin was analysed by Immulite assay (Diagnostic Products Corporation 1993); intra-assay variability 6.4-9.6 %. DHEA-s was analysed by Immulite assay (Diagnostic Products Corporation), intra-assay variability 6.8-9.5 Selection and diagnostic procedureEligibility criteria for participation in the study were established with regard to the following requirements; participants should belong to the largest language group so that only a few interpreters – accustomed to the procedures in the study - would be necessary, and their age span should be narrow enough to allow for the analysis of hormones as a measurements of on- going stress reactions. At an early stage, it became obvious that some participants wanted the questionnaires to be in Sorani (South Kurdic). The questionnaires were thus also translated The ”Health Leaflet” was chosen as a screening questionnaire.
The trauma history was obtained through the HTQ, where items from a list of traumatic events common in the experience of refugees are rated according to the following categories; ”experienced”, ”witnessed”, ”heard about”, ”no”.
Depression was estimated from the HSCL-25 (cut-off 22.5) and the GHQ-28 ’severe depression’ subscale (cut-off 10.5).
Apart from self-rating scales, the intention was to conduct a comprehensive psychiatric interview as well. This was changed due to feasibility problems. Accordingly, the ambition was narrowed to obtaining an exact diagnosis of PTSD. Therefore, from case number 13 onwards, the SCID interview for PTSD was replaced with CAPS, the Clinician-administered PTSD Scale for DSM-IV [227]. The version used in the present study was 9/96. CAPS, compared with SCID, assesses the presence of a given symptom through a combined rating of frequency and intensity of symptoms during the last month (Frequency either as per cent of time or: zero = never, four = daily or almost daily. Intensity: zero = no distress, four = In the scoring of CAPS, the standard so-called rule-of-three was applied, such that at least a frequency of one, and an intensity of two, of a given symptom was required if it was to be Self-reported life event patterns and their relation to health among recently resettled Iraqi and Kurdish refugees in Sweden. (Qualitative analysis of written statements).
An experienced interpreter translated written self-reported life events in the first part of the life event questionnaire into Swedish in the presence of the author. The translation was transcribed, and the life events were coded into categories. The validation of the list of categories derived from the transcriptions was carried out in the following way; two independent raters (one of the research supervisors and one doctoral student in qualitative research) were presented with the list of categories and coded a sample of the transcript The self-rated impact of the life event categories thus derived was analysed. Since it was discovered that subjects did not distinguish clearly between ’positive’ and ’negative’ the numeric value was assigned. The categorised events were then ranked according to an index Reported events were checked in order to exclude the possibility that the same event was reported twice. Consecutive reports of the same event were eliminated by controlling lateral sources of information in two ways; by comparing open-ended and closed questions, and by checking medical records, if available. The general rule was that an event was coded primarily as having occurred unless collateral information showed that it had occurred repeatedly or that it had occurred before the initial period. The cumulative number of categories of events during the study was computed. In subjects with complete data, events were explored by means of stepwise regression in different models in order to discern the important patterns of cumulative events.
The changes in the GHQ from baseline assessment and number of occurrences of five typical events after baseline were analysed using non-parametric methods (Spearman rank Paper II:Elevated blood levels of DHEA-s vary with symptom load in posttraumatic stress disorder; findings from a longitudinal study of refugees in Sweden. During the analysis of the association of life events with changes in hormones, it appeared that similar categories of events changed DHEA-s levels in opposite directions in subjects with fully developed PTSD compared with non-PTSD. Therefore the association between PTSD diagnostic status and serum DHEA-s had to be explored separately. Cross-sectional analysis of PTSD diagnostic status, depression according to HSCL-25, and age was carried out by means of ANCOVA (analysis of variance and co-variance). In PTSD cases, longitudinal analysis of differences in DHEA-s, and differences in self-rated symptoms of PTSD and co-variate depression were carried out by means of Spearman rank correlation and ANOVA. Regression models with change in DHEA-s as dependent variable, and change in depression and PTSD symptoms were also analysed.
Paper III:A longitudinal study of hormonal reactions accompanying life events in recently resettled Life events and stress-responsive hormones were analysed quantitatively according to specific rules. 1) First-time occurrences of self-reported events were included if the event under consideration was not reported at baseline and was reported for the first time at any of three follow-up assessments. 2) Categorised events from responses to open-ended questions, and checklist items were analysed. 3) A requirement for analysis of particular categories of events was that at least ten cases – negative at baseline - of the event under consideration, and ten cases without the event, were present in the database. 4) In order to increase the number eligible for analysis, instances of first-time occurrences of events, and the corresponding values (hormone measurements and self-rating scores) were transferred to the follow-up with the highest incidence, if they occurred at another follow-up. 5) Effects of events on hormone levels were analysed by way of two-way ANOVA (repeated measurements) under the condition that the distributions were appropriate (Levene’s test had to be non-significant before the event). If at least five subjects with and five subjects without PTSD reported an event, three-way ANOVAs were carried out. 6) Effects of cumulative events (occurring more than once), or longer-term effects (more than three months) were analysed under the condition that the number of subjects without the event(s) and the number of subjects with either one, two, or three occurrences of the event(s) were at least ten. Again, a general linear model (repeated measurements ANOVA) was performed. Further, a possible interaction with PTSD status was explored if at least six cases with and without PTSD were found.
Paper IV:Screening for post-traumatic stress disorder among refugees. Interview, diagnostic procedure, and statistical analysis. The screening procedure (HL) used in the present study in order to select subjects for diagnostic assessment, was examined by comparison with structured assessment for PTSD, and self-rating questionnaires for PTSD (HTQ, IES-22) and depression (HSCL-25, GHQ-28 depression subscale). The comparison with PTSD according to structured diagnosis was analysed by means of Chi-2 analysis and odds ratios for single items. The items that seemed to discriminate best were compared with PTSD diagnostic status, and self-rated depression by Chi-2 test. The three instruments (HL, HTQ, and IES-22) were further compared with structured clinical diagnosis of PTSD by means of discriminant analysis.
Paper V:Alexithymia, emotions, and PTSD, findings from a prospective study of refugees. The following instruments and measurements were used in order to explore the relationship between alexithymia, emotions, and PTSD; TAS-20 with three sub-scales, EP (Emotion Protocol), Trauma exposure in the HTQ, PTSD symptoms in the IES-22, and self-rated Since reliability analysis showed different values in sub-scales of TAS-20, and the number of items varied between sub-scales, rules were established for the replacement of missing values.
A maximum number of 2 out of 7 in sub-scale (factor) I, 1 out of 5 in sub-scale II, 2 out 8 in subscale III, and a maximum of three items totally were replaced.
After this procedure, analysis of variance was carried out for the TAS-20 score as dependent variable and PTSD diagnostic status as the independent. The procedure was repeated on a sub-scale level, and with the depression score as covariate. –Also, Spearman rank correlations were computed for TAS-20, as well as subscales, and self-rated PTSD symptoms. Structural equation modelling (SEM) was used in order to understand the relationship between trauma, depression, PTSD, and alexithymia. Exploratory factor analysis (Varimax, principal components analysis) was applied in order to discern patterns of traumatisation in the HTQ trauma subscale, and to relate factor score to alexithymia in order to examine a possible independent pathway from traumata to alexithymia. SEM and exploratory factor analysis were performed in subjects with complete data only (n=66).
Longitudinal associations between alexithymia (TAS) and serum hormones were examined Emotions and PTSD diagnostic status were cross-tabulated and analysed with non-parametric methods. Again, exploratory factor analysis was used in order to discern patterns of emotions and a possible association with PTSD.
The EP and subscales of TAS-20 were examined by means of Spearman rank correlations.
Ethical considerationsIn the design of the study, medical or psychological assistance was a prerequisite for the ethical acceptability of the study. This may have ameliorated the effects of some of the stressors that made an impact on the participants in the study.
Another possible effect – at least from a theoretical point of view - of the study protocol was the reactualisation of traumatic experiences and subsequent health effects.
The study was approved by the regional research ethics committee of Karolinska Institutet Background dataThe background data are reported to a varying degree in papers I-V, but much is unpublished.
The interested reader can therefore find this information in the following sections.
Eighty-six subjects participated in the study, 32 women and 54 men. Twenty-seven were
unmarried, 56 married, two separated, and one widowed. Fifty-seven had children. The median number of school years were fourteen, 48.8 % reported education beyond high school.
The female participants tended to have slightly more school years (females: mean 13.66, s.d.
Among the married individuals, 20 had their nuclear family in Sweden at baseline, while 30 did not. In six cases the information was missing.
Trauma history according to the HTQ, and PTSD diagnosis
Among participants in the study, 30 subjects did not have a PTSD diagnosis, while 24 had a
subclinical PTSD1, and 32 had a fully developed PTSD. The prevalence of fully developed PTSD was 37.2 %; 42.6 % among males and 30 % among females. Subjects with PTSD were 2.8 years older than subjects without PTSD (logistic regression; B= 0.051; n. s.).
Men reported on average 7.31 different self-experienced traumatic events, women 5.31 The exposure to trauma can be seen in Table A.
The types of trauma that were most strongly associated with PTSD diagnosis in the present group were near-death experience (Exp(B)=11), murder of family member or friend (Exp(B)=14), and torture (Exp(B)=6), when these experiences were dichotomised into “experienced myself” and others.
1 Subclinical PTSD is defined as either formerly fully developed PTSD (lifetime PTSD) and /or the fulfilment ofthe A criteria, one B criterion, two C-criteria, and one D-criterion.
Table A: Findings from the Harvard Trauma Questionnaire Non-participation
Three hundred and twenty-one subjects –every fourth of those eligible for participation- were
invited to the information meeting; 86 (26.8 %) were willing to participate. Non-participants were 3 years younger than participants. They did not differ significantly with regard to language group, gender, and education from participants. With regard to the lower age among the non-participants, the association between age and likelihood of PTSD diagnosis was examined. The Beta coefficient for age among the participants (logistic regression) was found to be 0.051. Therefore, the age-adjusted prevalence of PTSD among the non-participants is calculated to about 30 %. Of course, many other factors might have influenced the decision to participate in the study. One factor, in view of the access to health-care, might have been self- perceived poor health. On the other hand, it has been shown that avoidance in PTSD sufferers could decrease participation [228, 229].
The most conservative estimate of PTSD prevalence among the 321 randomly chosen participants in the study is based on the assumption that none of the non-participants had a PTSD diagnosis; in that case the estimated prevalence of fully developed PTSD is around ten Drop-out (attrition)
The attrition is expressed as the absence of blood samples at each follow-up. Of the 86
subjects included in the study, 66 (75 %) participated in the first follow-up, 67 (78 %) in the second, and 63 (73 %) in the third follow-up. Fifty-six subjects (65 %) participated at all four points of time; 64 in three follow-ups (74 %).
Some of the factors that may explain attrition in this study are mentioned in (Paper I).
When attrition is defined as participation in only one or two assessments, the rate was 24.4 %.
Comparison between groups did not show any statistically significant differences with regard to attrition on the one hand, and age, education, gender, as well as PTSD diagnostic status on the other hand. Subjects who remained in the study did not differ from drop-outs with regard to number of traumata and sum of trauma score in the HTQ, GHQ, or HSCL-depression Self-rating score and hormone levels
In Table B and C in the Appendix, the values of self-rating questionnaires and serum hormone
levels at each point of time are presented.
The assistance given during the data collection can be divided into pharmacological
prescriptions, supportive actions such as sick-leave or medical certificates during the process of family reunion etc., and regular psychotherapy.
The total number of visits for any treatment purposes during the study was 376 (mean 5.22, The total number of psychotherapy sessions was 159 (mean 2.24, range 0-23), eight subjects were offered treatment during the data collection phase that could be characterised as psychotherapy, while 12 had one or a few sessions that were of a psychotherapeutic character.
The total number of prescription periods was 54 (mean 0.76, range 0-3).
The total number of recorded actions taken was 92 (mean 1.28, range 0-5).
None of these factors were associated with change on the GHQ-28 during the study. In the IES-22, a weak correlation was found between the sum of actions taken and change in the IES-22 (Nonparametric correlation, Rho= 0.274, p=0.041), but not number of therapy sessions, or prescriptions. This suggests that the practical support may have been most Five casesOn the basis of the largest differences in self-rated health (GHQ-28) between start and last follow-up during the study, five individual cases were chosen to illustrate the general situation of the participants. Three of the subjects chosen had the highest symptom reduction, whereas the other two showed the largest increase.
Case A (worse): Single male, 30 years old. One year before inclusion in the study, his father was killed; he was himself arrested and subjected to torture. He had been arrested several times during his 20-ies because of his father’s political activities. At the same time as his father was killed, three siblings and their families disappeared. Another sister is living in Sweden. A is depressed and has some symptoms of PTSD and has previously fulfilled the criteria for PTSD. He is offered supportive therapy and is prescribed antidepressant After the first assessment the treatment sessions show three main themes; childhood memories of persecution of his minority, his ambivalence towards the father whose political activity may have caused his death and the unknown fate of his siblings, as well as grave concern for his mother who is living in dire circumstances in a third country.
The therapist is very active in helping the patient establish contacts with helping agencies, such as lawyers, regarding his efforts to bring his mother to Sweden. At the end of the data collection, he suffers a major setback with regard to his mother. At a follow-up therapy session 3 months later, his mother has arrived and A expresses great relief.
Case B (improved): 37-year old male who has previously had PTSD after torture and imprisonment. He is married and lives with his wife and children, has completed university studies. Does not express anything at the clinical assessment apart from concern for relatives and friends in Iraq. No treatment offered. During the study, he participates in all follow-ups.
In his responses in the life event questionnaires, the following pattern is revealed: A great deal of concern regarding relatives and the situation in the home country, with an expression of relief before last follow-up. On three follow-up occasions he reports having accomplished something positive (checklist items). The third child is born. There are no reports of impossible demands, and no housing problems are reported.
Case C (improved): 42-year-old female, well-educated, with a long marriage where the permanent problem has been that one of them belonged to an ethnic minority. This meant that both experienced severe threats and some persecution. After fleeing Iraq with the children, she was separated from her husband and does not know his whereabouts. She is bitter because they had opportunities to flee earlier and some of the persecution they both suffered might have been avoided. The flight included serious traumatisation because she was caught together with the children in a transit country and suffered considerable hardship and threat.
After this experience she fulfils criteria for PTSD and depression.
C is offered treatment and after seventeen therapy sessions the aims of the treatment are fulfilled according to patient and therapist.
Case D (improved): Woman, 30 years old, married, with 2 children. Experienced war and witnessed atrocities. Escaped internal conflicts in Kurdistan. Recently her father died in the home country, and her mother is frail. Is clearly depressed without PTSD. Develops low back pain. Is prescribed antidepressants but cannot tolerate the treatment. During the study, some concerns regarding close relatives diminish.
Case E (worse): Male, 39 years old. Single, skilled worker. Did military service during 2 wars. Wounded twice, lost many comrades during the wars. Severe PTSD at psychiatric assessment. E was offered treatment but did not continue after 3 visits, unclear why.
Describes loneliness, difficulties remembering new information, difficulties of orientation to new environment. During the study he reports few events but the pervasive pattern is feeling ill, out of control, confused, and worried about relatives. Immediately before last follow-up, As can be seen from these cases, the first phase after asylum is granted is associated with many post-migration stressors, where concern for relatives is one of the most pervasive.
Another important factor has to do with having to adapt to a new and challenging environment without necessarily possessing the capacity to do so. Case B illustrates an uncomplicated early post-asylum phase; in spite of considerable hardship in the past, in the present he lives with his family and reports experiences of accomplishment. Case E did not accept treatment and feels bewildered, ill, and out of control. Case A and Case C needed support, and both seemed to use it constructively.
Another way of looking at these patterns is in quantitative terms. In an exploratory factor analysis of patterns of events, one could discern two major patterns; the first pattern was strongly associated with decreased number of PTSD symptoms at last follow-up, and reports of progess regarding family reunion. The other pattern was associated with an increased GHQ-28 score connected with reports of school stress and housing problems.
Paper IThis paper reports the categories of events derived from the responses to open-ended questions. The categories can be seen in the Appendix together with the total number of The impact ratings in the questionnaire did not work as expected because the notion of ‘positive’ and ‘negative’ impacts ratings were not usually understood in the Arabic or Kurdish languages. In the spontaneous comments, however, doubts regarding whether an events was perceived as “positive” or “negative” were uncommon. Therefore an index was calculated based on the total number of reports – including baseline - and the numeric impact rating. In this way it became possible to see which events were characteristic for the whole group, and the importance ascribed to them by the participants. Obtaining residency and attaining family reunion were rated as the most positive events, followed by reports of increased autonomy.
The most negative events were distress, illness or similar trouble affecting significant others, and events of perceived hostility towards refugees.
One way of reducing the high number of different experiences was to cluster them into four groups; positive and negative events either outside Sweden, or inside Sweden. It turned out that adversity in Sweden, and positive events affecting significant others outside Sweden, were correlated with changes in self-perceived health (change in the GHQ-28). The opposite, negative events outside Sweden, and positive events inside Sweden, were not correlated with The total (cumulative) numbers of characteristic events were analysed in sub-groups by gender and PTSD status. It turned out that housing problems, which were highly prevalent, seemed to affect subjects with PTSD much more strongly than those without PTSD.
Reports of adaptation problems were associated with a decline in self-perceived health. The major groups of positive events abroad were associated with moderate improvement in health.
One participant is cited because he voices a theme that was recurrent in the responses, namely Paper IIDuring the analysis of hormonal reactions to life events (Paper III), it turned out that one of the hormones used as marker in the study, dehydroepiandrosterone sulphate (DHEA-s), behaved unexpectedly. It showed a different pattern in PTSD compared with non-PTSD subjects. It was therefore necessary to explore this phenomenon. The analysis of the phenomenon was further complicated by the well-known fact that DHEA-s shows a negative DHEA-s is the water-soluble form of dehydroepiandrosterone, which is a precursor of anabolic and gonadal steroids. It has a low serum concentration in a number of diseases, especially in immunological disorders. Serum levels decrease with age. The concentration of DHEA is also known to vary highly among various tissues [188] and is higher in the brain than in other tissues. In the past decade new knowledge has been obtained regarding DHEA-s and a few other steroid molecules such as progesterone and pregnenolone. They are therefore termed “neurosteroids”. DHEA can be produced in the mammalian brain in astroglia in stress paradigms such as hypoxic stress. One implication of this is that circulatory levels of DHEA-s do not necessarily mirror the production in the adrenals only. DHEA-s and other neurosteroids have non-genomic effects by influencing common receptors in the brain, especially GABAA. In some animal models relevant to stroke, DHEA-s has shown neuroprotective properties as well [193, 230, 231]. One study has shown increased levels of In the analysis of serum DHEA-s there was an interaction between self-rated depression and PTSD diagnosis. DHEA-s was higher in PTSD but not significantly in the cross-sectional analysis. In a longitudinal analysis of PTSD cases, increased levels of DHEA-s were observed with increased self-rated symptoms, and conversely lowered values with a decreased symptom level. This finding, in combination with the finding of different patterns of DHEA-s serum levels after different life events in PTSD compared with non-PTSD, should be The conclusion of the study is thus that a possible role of DHEA-s and other neurosteroids in PTSD should be studied further. Another conclusion is that studies of DHEA-s in other psychiatric disorders such as depression or bulimia may be confounded by co-morbid PTSD.
Paper IIIThe effects of self-reported life events on stress-responsive hormones were analysed by means of ANOVA. Many events were ineligible for analysis because they were too few, or conversely, so prevalent that a contrast group did not exist among the participants. The results of the analyses are shown in Table 1 (open-ended responses) and Table 2 (checklist items) in The main results of this study are that the events that showed significant differences between subjects (measurements before and after / with and without reports of particular events) belonged to a few categories. First of all, negative events affecting significant others and perceptions of excessive demands were associated with increased serum cortisol.
In a few of these stressful events, even T4 increased.
Prolactin decreased after several events, the common denominator of which seemed to be frustration in situations of dependency.
After a number of events, serum DHEA-s changes showed an interaction with PTSD diagnostic status. DHEA-s also changed with positive events.
The longer-term effects of events, and possible effects of events cumulatively were analysed.
Few events fulfilled the criteria for analysis, and the reported events that showed significance were few. Again, the pattern was compatible with the findings of the short-term analysis of hormones; strain in relationships and perceptions of excessive demands were associated with changes suggestive of stress. Here, the only finding of increased prolactin in the present study was related to repeated reports of housing difficulties.
After family reunion, an interaction effect of PTSD on DHEA-s levels was very clear-cut (F=17.688, df 3/33, p=0.000), when comparing subjects who had reported a family reunion during the study with the rest of the participants.
A seemingly paradoxical result emerged regarding presumably similar categories; the open- ended coded responses labelled ‘too high demands in school’ and the checklist response ‘too high demands in language school’ showed different responses. In the checklist, responders had decreased cortisol levels, in the open-ended responses subjects showed decreased prolactin. In the longer term, subjects who complained spontaneously more than once, and subjects who checked the item – if they had PTSD diagnosis - showed increased cortisol Paper IVIn this paper, the ‘Health Leaflet’ (HL) as a screening interview for PTSD in refugee reception is examined. It is compared with structured clinical diagnosis of PTSD, and two well-known self-rating instruments, the HTQ, and the IES-22.
One question in the HL regarding concentration difficulties was associated with a highly increased risk of having a diagnosis of PTSD. Having difficulties concentrating is a symptom required for diagnosing PTSD, but this is also the case for several other questions in the interview. Apart from this, in the identification of PTSD cases, the HL with a cut-off level of 10.5 was inferior to self-rating questionnaires for PTSD when analysed with discriminant Paper VThis paper explores alexithymia. TAS-20 scores and findings in the emotion protocol (EP) are compared and related to the clinical diagnosis of PTSD and self-rated symptoms of PTSD, as It is found that a diagnosis of PTSD, as expected, is associated with an elevated alexithymia TAS-20 scores can be separated into three factors (subscales), difficulties identifying feelings, difficulties expressing feelings, and externally-oriented thinking. In the present study, an elevated alexithymia score in PTSD is explained by a high score on one of the three subscales (Factor I), namely ‘difficulties identifying feelings’.
Change in this subscale had a positive correlation with change in self-rated PTSD symptoms It was found that alexithymia, especially Factor I, was associated with a high prevalence of dysphoric affects. Thus alexithymia in PTSD can be understood as a defence against dysphoric affects that are common in PTSD.
Some support was found for an independent pathway from trauma (near-death experience and murder of significant other) to alexithymia.
Major findingsThe major findings in this follow-up study of refugees after resettlement are as follows: Among the participants, more than one third had a PTSD diagnosis. The most conservative estimate of the prevalence in the population from which the participants were chosen, is ten per cent. A more likely estimate is 30 %, based on age adjustment. This is similar to the prevalence of 18-33 % found among Bosnian refugees in Sweden by Håkansson and Thulesius. The difference between these two populations is that the Bosnians had been living under peace-time conditions for most of their life until war and “ethnic cleansing” broke out, while the refugees from Iraq, irrespective of their ethnic origin, had experienced lifelong repression and several wars. The trauma exposure seemed to be higher among men than women, and this could explain the higher prevalence of PTSD in men in this specific The implications of this finding are related to the capacity to adapt to the further challenge of integration. It is therefore important to identify which factors in their present life situation will ameliorate the condition, and which ones will lead to deterioration or chronicity? In other words, during the introduction period, which is eighteen to twenty-four months, there is opportunity to heal or harm. The problem is that many stressors - such as unresolved housing problems, protracted insecurity and the fear involved in waiting for a spouse or children- mean that a large portion of this so-called introduction phase is not genuinely an introduction, since a significant proportion of the subjects suffer from ongoing re-traumatisation. Such a phenomenon of retraumatisation has also has been described by Ekblad et al. among Kosovar refugees temporarily evacuated to Sweden [202]. This means that the window of opportunity offered by the introduction phase is non-existent in many cases. Language acquisition – a prerequisite for integration- is inhibited by PTSD symptom load (Söndergaard, Theorell: Next, if the massive traumatisation behind this figure could cause this high prevalence of PTSD, then what further stress-related morbidity might have been found in this group if they had been examined equally meticulously for disorders like arterial hypertension, diabetes, or hyperlipaemia? Several cases of previously undetected hypertension, diabetes, and hyperlipemias were found during this study.
An examination by the National Board of Health and Welfare found some indication of a health screening procedure during the asylum phase in only eleven per cent of of the asylum applicants in Stockholm [233]. Such an examination should be routinely performed according to the National Board of Health and Welfare.
During the present study of subjects who should have access to health care, it was also observed that it was often hard to find health care when subjects had such needs. One factor, not the only one, seemed to be the lack of permanent housing or the participants’ frequent We have not studied the children of the cohort under consideration, but one implication is that a significant proportion of the children will grow up with traumatised parents during some of their most formative years. As Almqvist and Brandell-Forsberg [59] have pointed out, a number of the children will have their own traumatic experiences as well; often unrecognised by their parents. These children are very important for this country in the future, and it seems to be of the outmost importance to direct attention to their possibility of a healthy Important life eventsThe hypothesis of this study was that many factors in the participants’ present life could influence self-perceived health and stress-responsive hormones. This hypothesis was supported. After having analysed the study, however, the author is surprised that it was at all possible to find any specific patterns of associations in the group, since the clinical impression is that the first period after resettlement is a turmoil of stressors as well as positive events.
Patterns were discernible despite the relatively small number of participants and the attrition.
As can be seen in Table D, among the subjects retained in the study, there was a slight reduction in the IES-22 symptoms of PTSD while the GHQ-28 and HSCL-25 scores were The life events recorded during the study can be seen in the Appendix, table E and F. Both the advantages and the disadvantages of both approaches used can be studied, i.e. open-ended responses as well as the checklist approach. First of all, a comparison shows that events that are grouped in almost identical categories in the checklist and in the open-ended questions, respectively, are more frequently reported in the checklist. On the other hand, the events that were reported in the subjects’ own words were more often associated with a discernible impact, such as the self-report of school-stress analysed in Paper III.
Many circumstances, such as the deteriorated housing situation during the study, were not anticipated by the research group during the planning phase of the study. The effect of unanticipated events could not have been measured in the longitudinal design with the checklist items that were included after the pilot study.
In Paper I, it was found that positive events in Sweden did not have any measurable effects on self-perceived health. The positive events in Sweden were often grouped under ‘miscellaneous positive’ events, or were reports of small leaps forward such as increased autonomy, or accomplishments in school. Such positive events in Sweden were more often reported by subjects with good health at baseline, with the exception of “experiences of support”, which was often reported by subjects in distress.
Against the background of the concern, worry, or fear attached to negative issues generally, it is not in any way remarkable that effects of positive events were not very obvious in the short In Paper I, another finding is that the cumulative number of negative events abroad reported in the open-ended responses did not exert any discernible effects on self-rated health. This may have several explanations. The first possibility is that anxious or depressed participants may have a propensity to report many such events. Another interpretation is that there may be a “ceiling effect”. This is supported by the high number of reports of concern for significant others in the home country in the checklist, an item that was generated in a pilot study and was checked by the majority of the participants. In other words, concern for significant others in the home country is a long-term on-going stressor in a high proportion of refugees.
The main finding, however, is that both positive events abroad – relief after a protracted period of concern for others or issues of family reunion, and cessation of wars or severe threats towards whole peoples or nations - as well as negative events in the new host country do exert a significant influence on self-perceived health. At least some of these can be It has been shown in several other studies, such as those mentioned above in the list of longitudinal studies of refugees that early post-migration adversity has long-term effects on health. It seems that distress experienced and expressed by the subjects is a good predictor of subsequent deterioration in health. The caseworkers in the reception programme can make a difference provided they are given the means to do so, something they do not have at present.
Such resources would include easy access to health care, since the caseworkers themselves are not allowed to decrease the pressure on individuals. An alternative is of course that the caseworkers themselves are allowed to rely on their common sense, judgement, and Differential reaction patterns between PTSD and non-PTSDIn Paper I it was also found that some events seemed to have differential effects in PTSD subjects compared with non-PTSD. One of the most commonly reported negative circumstances during the study was the difficult housing situation. Even if the situation was very difficult, we were not aware of any participants that were actually homeless during the study. It was, however, observed that many subjects feared such a development. Sometimes it was obvious that the participants had been given information they had not understood or remembered. The caseworkers were sometimes unaware of the cognitive deficits of some of In the analysis of the hormones in Paper III, there was no reaction or interaction with diagnostic status concerning first-time reports of housing problems. Thus, a difference between PTSD and non-PTSD subjects seems to arise with long-term difficulties. From a clinical point of view, every therapist treating PTSD knows that the patients need to withdraw, have severe sleeping problems, and are easily startled by unexpected sounds. There was a very clear negative development in self-reported health related to housing problems among the PTSD subjects, which was not seen among the rest of the participants. The same might be said of subjects who reported difficulties of orientation even if the tendency was less The reports of resolved housing problems showed an interaction between PTSD and non- PTSD with regard to thyroxine, prolactin, and DHEA-s. This is the only event during the study to influence three hormones at the same time. It might therefore be interpreted as an important event. The small numbers should caution against further interpretations, but it could be interpreted that PTSD subjects are less likely to experience relief after positive events. This has been observed clinically by the author, e.g. subjects who are granted residency after a long waiting period need considerable time before they are able to fully understand that the Table 3 in Paper I shows data that too high demands – comprising category P and V in table E in the appendix - could not be explored among the PTSD subjects because of missing values, or missing reports. During the study it was common for the identified PTSD subjects to be on half-time sick-leave. It is noteworthy that the health effects of too high demands are obvious The hormonal reactions to life events reported for the first time after baseline assessment are statistically significant in a number of situations. These have similarities with the situations reported in Paper I. Negative events pertaining to significant others influenced cortisol in both the open-ended responses and the checklist, whereas distress in relationships would more often be accompanied by decreased prolactin. Cortisol behaved mostly in the same way in PTSD as in non-PTSD. In the situations where there was an interaction, cortisol increased in PTSD. This contradicts the notion of ‘low cortisol’ in PTSD and supports the notion that cortisol is as dynamic in PTSD as in non-PTSD. On the other hand, PTSD subjects might react more strongly to some stressors.
The category “Stress over language school” and the checklist item “Demands in school too high” show a curious discrepancy. While the first occurrence of the item is associated with a subsequent clear reduction in cortisol, the self-voiced occurrence of the category is accompanied by a reduction in plasma prolactin indicating anxiety. The interpretation offered by the author is two-fold. The item seems to be confounded. There is no doubt that most participants appreciated starting a more normal life, and the reports coincided in time with this. It could thus mirror a relaxation. On the other hand; it could be seen that the category self-voiced distress with regard to language training repeatedly, and the item as well in PTSD cases, were associated with increased cortisol levels longitudinally. The next part of the interpretation is that there seems to exist a difference between formulating a situation in one’s own words, and checking an item. The category and item constitute one of the few comparable events in the open-ended responses and the closed questions. The other one is illness in significant others. In that case, however, the categories and items do not overlap completely, but the hormonal patterns are similar.
In studies of occupational stress, the demand-control model of Theorell and Karasek [234] has demonstrated repeatedly that lack of influence (control) is harmful when demands are high.
Without having used this instrument in the present study, it is tempting to conclude that this also applies to the subjects studied here.
The conclusion of this study of life events is that refugees – as with everyone else - are in fact influenced by their ongoing living conditions. This is true regardless of a PTSD diagnosis. It is also an important finding that even if PTSD symptoms did diminish slightly during the study, self-perceived health in general did not improve during the study. This could be attributed to living conditions and too high demands in vulnerable subjects. These factors would be easy to identify. The most practical way of identifying them would be to listen to Dehydroepiandrosterone and PTSDDuring the data analysis, a strange pattern was noted with regard to DHEA-s. While there was no difference in blood levels of DHEA-s between PTSD and non-PTSD subjects, the hormone behaved differently; there were instances of interaction, and different correlations with changes in GHQ over time. DHEA-s was therefore analysed specifically with regard to PTSD diagnostic status. The conclusion of this analysis was that DHEA-s, after adjustment for age, was higher in subjects with PTSD on all four occasions. This attained statistical significance at first follow-up after baseline assessment only. Division of the subjects into depressed and non-depressed made it possible to reveal an interaction between PTSD and depression at baseline. This might mean that PTSD is a potential confounder in other studies of DHEA-s in The strongest interaction between PTSD at inclusion in relation to long-term change in DHEA-s was the event of family reunion, when subjects granted family reunion were compared with the other subjects. It is interpreted that family reunion is of major importance In PTSD subjects, the longitudinal pattern was clearer. Subjects who improved showed lower serum levels over time, while higher levels coincided with deterioration.
At the time, there were no reports on DHEA-s in PTSD. One publication by Spivak et al.
[194] was subsequently found; this publication was originally incorrectly categorised on Medline. It showed increased levels of DHEA-s in non-depressed Israeli war veterans with PTSD. Another study showed no difference in DHEA-s between PTSD and non-PTSD subjects before and after metyrapone challenge. The latter study reports higher depression scores in PTSD subjects but no attempt was made to extricate the effects of depression on DHEA-s. The difference between those studies and the present one is that the others are cross- sectional case-control studies. The present study, on the other hand, is a follow-up study with a number of subjects with sub-clinical PTSD among the non-PTSD subjects. This is both a weakness and a strength. The weakness resides in the possibility of confounding because of borderline cases and a high number of traumatised individuals even among the non-PTSD subjects. The strength is the longitudinal design, which confirms that change in DHEA-s is indeed related to change in PTSD symptoms and not to co-morbid depression in PTSD It is far too early to draw any conclusions about the possible role of DHEA-s in PTSD.
However, many questions arise from this finding. For instance, is the possible increase of DHEA-s secondary to the findings of changed HPA regulation? This could, for instance, depend on a decreased synthesis of anabolic and gonadal steroids – metabolites of DHEA-s -, caused by inhibition of gonadal steroid hormone releasing factors effectuated by increased levels of CRF centrally as well as by central and peripheral effects of cortisol [235].
Interpreted in this way, increased levels of DHEA-s may possibly be an epiphenomenon of the numerous stress-induced changes in the regulation of steroid hormones generally.
A more exciting interpretation is the one of Spivak et al. They interpret their finding in view of the central effects of DHEA-s as a non-competitive blocker of the GABAA receptor. Also, they suggest that the increased circulatory levels might be of a central origin. The finding that DHEA-s and other steroid molecules can be produced in glial tissues implies that increased circulatory levels might be explained by such a mechanism. Implicit in this hypothesis is the further interpretation that an explanation may have been found for many PTSD symptoms, e.g. increased irritability, and cognitive problems. The irritability could be explained by decreased sensitivity to GABA caused by non-competitive inhibition, and the cognitive problems by a blockade of the glutamate receptors in the GABA receptor complex [73, 236].
One more question arises, that is, if the finding holds in further studies, namely the phylogenetic meaning. Is there a protective effect of DHEA-s, such as neuroprotection in the All these questions can only find answers in further studies. Such studies would have to be longitudinal studies of PTSD subjects, and studies examining whether levels of DHEA or DHEA-s are increased centrally, as well as similar studies of the other putative DHEA-s was indeed associated with positive health effects in this study, but unfortunately a PTSD diagnosis is a confounder. It might, however, turn out to be a useful marker of Screening for PTSDA screening questionnaire that had previously been developed with the aim of assisting social workers and other non-medical professions was used for health screening. The questionnaire was analysed and it seemed to work less well than was expected. However, the cut-off chosen for selecting subjects for structured diagnostic interviews was comfortably lower than the best cut-off for identifying PTSD. It is thus highly unlikely that anyone with a diagnosis of PTSD remained unidentified because of the discriminatory performance of the screening interview.
The interview, or later developments, can play an important role in refugee reception. The main function of the interview, according to our view, is to break the “conspiracy of silence” that can arise from the professionals’ fear of intruding on the privacy of the client, and the avoidance of the trauma in the client. It was observed that some colleagues were apprehensive of the procedure, fearing to elicit “nervous breakdown” that would be difficult to handle. We observed no such reactions. The only case that we suspected to be elicited by the procedure, a paranoid reaction, turned out to have a different explanation. Although the screening interview may not have been optimal, it helped in identifying depression as well, and helped the caseworkers identify cases with specific needs. It is therefore strongly recommended that a health and needs assessment of some kind is included as a routine procedure in refugee reception, in order to avoid unrealistic introduction plans and harmful stress. Unfortunately, it has been the experience at other sites where the interview has been used that it is difficult to



Australasian Journal of Dermatology (2002) 43 , 175–178 Treatment of interdigital tinea pedis with 25% and 50% tea tree oil solution: A randomized, Andrew C Satchell,1 Anne Saurajen,1 Craig Bell2 and Ross StC Barnetson1 1 Department of Dermatology, Royal Prince Alfred Hospital, Camperdown and 2 Australian Tea Tree Oil Research Institute, Southern Cross University, Lismore, and Epiderm

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