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Posttraumatic Stress Reactions in Tortured Refugees : Relationship to pain, cognitive impairments, and negative appraisals

Nordin, Linda LU (2019)
Abstract
Refugees, particularly those exposed to torture and other forms of organized violence, often experience a wide range of difficulties, including posttraumatic stress disorder (PTSD), depression, and somatic disturbances, particularly pain. Multimodal treatments have been developed to target this comorbidity in refugees, with evidence suggesting they are moderately effective.
The overall aim of this thesis was to identify ways in which we might improve the efficacy of the multimodal treatment provided to tortured refugees seeking treatment for PTSD, depression, anxiety and somatic complaints. This was done by exploring the relationship between pain and PTSD in this population, at a specialist outpatient clinic in Copenhagen; DIGNITY –... (More)
Refugees, particularly those exposed to torture and other forms of organized violence, often experience a wide range of difficulties, including posttraumatic stress disorder (PTSD), depression, and somatic disturbances, particularly pain. Multimodal treatments have been developed to target this comorbidity in refugees, with evidence suggesting they are moderately effective.
The overall aim of this thesis was to identify ways in which we might improve the efficacy of the multimodal treatment provided to tortured refugees seeking treatment for PTSD, depression, anxiety and somatic complaints. This was done by exploring the relationship between pain and PTSD in this population, at a specialist outpatient clinic in Copenhagen; DIGNITY – Danish Institute Against Torture, both at a symptom level, and at the level of two cognitive processes that had previously been shown to be important to the severity, duration, and impact of PTSD (negative trauma-related beliefs) and pain (pain catastrophizing). Another way of identify ways to improve treatment, was to find out to what extent the clients suffered from cognitive impairments based on a brief screening measured developed for this purposes (SDMT), and whether such impairments were related to traumatic brain injury (TBI), severity of PTSD, depression, anxiety, pain and overall functioning. With these aims, we hoped to help fill important informational gaps in the literature regarding the extent of pain, cognitive impairments and TBI in traumatized refugees.
Study I: The primary aim of the paper was to explore whether pain and disability levels in tortured refugees seeking treatment at DIGNITY were higher than previously estimated in a Danish validation study, and comparable to or exceeding the levels of pain and disability in mixed pain patients presenting for treatment at specialist pain services in Sweden.
Study II: The aim was to explore whether the relationship between pain and PTSD was mediated by pain catastrophizing and negative trauma-related beliefs pre- treatment, and consistent with recommendations from the literature, after controlling for the possible effects of depression on both pain and PTSD.
Study III involved an exploration of the impact of pain symptoms on PTSD, depression, and anxiety outcomes in refugees undergoing the multi-disciplinary treatment at the clinic. The primary aim was to test whether pre-treatment levels of pain predicted outcomes.
Study IV involved an exploration of the severity of cognitive impairments in refugees treated at the clinic, and their relationship to traumatic brain injury (TBI) and the severity of symptoms of PTSD, depression, anxiety, and pain at pre- treatment.
The findings add to a large body of literature suggesting a strong relationship between pain, PTSD, depression, and high levels of disability in traumatized refugees. It shows that interference from pain can lessen the effectiveness of standard multi-modal treatments for refugees. Difficulties in cognitive functioning is also shown to be a significant contributor to overall distress in tortured refugees, suggesting the need for routine screening of head trauma and cognitive impairments. (Less)
Abstract (Swedish)
Flyktingar, speciellt de som varit utsatta för tortyr och annan form av organiserat våld, upplever ofta en rad olika svårigheter, inklusive posttraumatiskt stressyndrom (PTSD), depression och somatiska symtom, särskilt smärta. Multidisciplinär behandling har utvecklats för att handskas med denna komorbiditet hos flyktingar, som har påvisat medelhöga effekter.
Det huvudsakliga syftet med denna avhandling var att undersöka och identifiera sätt att förbättra effektiviteten av multidisciplinär behandling för flyktingar som överlevt tortyr och söker behandling för PTSD, depression, ångest och somatiska symtom (t.ex. smärta). Detta utfördes genom att undersöka relationen mellan smärta och PTSD hos patienter vid en högspecialiserad... (More)
Flyktingar, speciellt de som varit utsatta för tortyr och annan form av organiserat våld, upplever ofta en rad olika svårigheter, inklusive posttraumatiskt stressyndrom (PTSD), depression och somatiska symtom, särskilt smärta. Multidisciplinär behandling har utvecklats för att handskas med denna komorbiditet hos flyktingar, som har påvisat medelhöga effekter.
Det huvudsakliga syftet med denna avhandling var att undersöka och identifiera sätt att förbättra effektiviteten av multidisciplinär behandling för flyktingar som överlevt tortyr och söker behandling för PTSD, depression, ångest och somatiska symtom (t.ex. smärta). Detta utfördes genom att undersöka relationen mellan smärta och PTSD hos patienter vid en högspecialiserad öppenvårdsklinik i Köpenhamn: DIGNITY – Dansk Institut Mod Tortur. Relationen mellan smärta och PTSD studerades både på symtomnivå och genom att undersöka två typer av kognitiva processer som tidigare visats vara viktiga för svårighetsgraden, varaktigheten och inverkan av PTSD (negativa traumarelaterade kognitioner) och smärta (smärtkatastrofiering).
Ytterligare sätt att förbättra behandlingen, var att identifiera i vilken utsträckning klienterna led av kognitiv nedsättning baserat på en kort screening (SDMT) och om sådan nedsättning var relaterad till traumatisk hjärnskada (TBI), svårighetsgrad av PTSD, depression, ångest, smärta och generell funktionsnivå. Med dessa syften hoppades vi fylla viktiga kunskapsluckor i litteraturen avseende smärta, kognitiv nedsättning och TBI för traumatiserade flyktingar.
Studie I: Det primära syftet i denna studie var att undersöka om smärtnivåer och funktionsnedsättning för torterade flyktingar som söker vård på DIGNITY var större än tidigare redovisade nivåer i en liknande dansk population. Vi undersökte även huruvida smärtnivå och funktionsnedsättning var jämförbara med patienter som söker vård på specialistkliniker för smärta i Sverige.
Studie II: Syftet var att undersöka om relationen mellan smärta och PTSD medierades av negativa kognitioner (smärtkatastrofiering och negativa traumarelaterade kognitioner). I överensstämmelse med litteraturen kontrollerades även effekten av depression på både smärta och PTSD.
Studie III utforskade hur smärtsymtom påverkar effekten av PTSD, depression och ångestsymtom på flyktingar som genomgått en multidisciplinär behandling på samma klinik. Det primära syftet var att testa om pre-nivåer av smärta predicerade behandlingsresultaten för dessa symtom.
Studie IV utforskade svårighetsgraden av kognitiva nedsättningar hos flyktingar som behandlas på kliniken och relationen mellan dessa svårigheter och traumatisk hjärnskada (TBI), graden av PTSD, depression och ångestsymtom och smärta innan behandling.
Resultaten kan adderas till en omfattande litteratur som påvisar ett starkt samband mellan smärta, PTSD, depression och höga nivåer av funktionsnedsättning hos traumatiserade flyktingar. Resultaten visar att grad av smärtpåverkan (pain interference) kan minska behandlingseffekterna i en standardiserad multidisciplinär behandling för flyktingar. Kognitiva nedsättningar visade också vara signifikant bidragande till de allmänna besvären som denna population av flyktingar med PTSD upplever, vilket antyder att det finns ett stort behov att rutinmässigt undersökta TBI och kognitiva svårigheter i populationen. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Docent Carlsson, Jessica, University of Copenhagen
organization
alternative title
Posttraumatiska stressreaktioner hos torterade flyktingar : Relationen till smärta, kognitiva funktionsnedsättningar och negativa tankemönster
publishing date
type
Thesis
publication status
published
subject
keywords
Refugees, torture, PTSD, pain, cognitive impairment, TBI
pages
145 pages
publisher
Lund University
defense location
Palaestra, Paradisgatan 4, Lund
defense date
2020-01-31 09:30:00
ISBN
978-91-7895-363-9
978-91-7895-362-2
language
English
LU publication?
yes
id
98871365-c64a-4fd4-8fed-cbc3df1be8c3
date added to LUP
2019-12-19 12:44:09
date last changed
2019-12-20 11:46:12
@phdthesis{98871365-c64a-4fd4-8fed-cbc3df1be8c3,
  abstract     = {Refugees, particularly those exposed to torture and other forms of organized violence, often experience a wide range of difficulties, including posttraumatic stress disorder (PTSD), depression, and somatic disturbances, particularly pain. Multimodal treatments have been developed to target this comorbidity in refugees, with evidence suggesting they are moderately effective.<br/>The overall aim of this thesis was to identify ways in which we might improve the efficacy of the multimodal treatment provided to tortured refugees seeking treatment for PTSD, depression, anxiety and somatic complaints. This was done by exploring the relationship between pain and PTSD in this population, at a specialist outpatient clinic in Copenhagen; DIGNITY – Danish Institute Against Torture, both at a symptom level, and at the level of two cognitive processes that had previously been shown to be important to the severity, duration, and impact of PTSD (negative trauma-related beliefs) and pain (pain catastrophizing). Another way of identify ways to improve treatment, was to find out to what extent the clients suffered from cognitive impairments based on a brief screening measured developed for this purposes (SDMT), and whether such impairments were related to traumatic brain injury (TBI), severity of PTSD, depression, anxiety, pain and overall functioning. With these aims, we hoped to help fill important informational gaps in the literature regarding the extent of pain, cognitive impairments and TBI in traumatized refugees.<br/>Study I: The primary aim of the paper was to explore whether pain and disability levels in tortured refugees seeking treatment at DIGNITY were higher than previously estimated in a Danish validation study, and comparable to or exceeding the levels of pain and disability in mixed pain patients presenting for treatment at specialist pain services in Sweden.<br/>Study II: The aim was to explore whether the relationship between pain and PTSD was mediated by pain catastrophizing and negative trauma-related beliefs pre- treatment, and consistent with recommendations from the literature, after controlling for the possible effects of depression on both pain and PTSD.<br/>Study III involved an exploration of the impact of pain symptoms on PTSD, depression, and anxiety outcomes in refugees undergoing the multi-disciplinary treatment at the clinic. The primary aim was to test whether pre-treatment levels of pain predicted outcomes.<br/>Study IV involved an exploration of the severity of cognitive impairments in refugees treated at the clinic, and their relationship to traumatic brain injury (TBI) and the severity of symptoms of PTSD, depression, anxiety, and pain at pre- treatment.<br/>The findings add to a large body of literature suggesting a strong relationship between pain, PTSD, depression, and high levels of disability in traumatized refugees. It shows that interference from pain can lessen the effectiveness of standard multi-modal treatments for refugees. Difficulties in cognitive functioning is also shown to be a significant contributor to overall distress in tortured refugees, suggesting the need for routine screening of head trauma and cognitive impairments.},
  author       = {Nordin, Linda},
  isbn         = {978-91-7895-363-9},
  language     = {eng},
  month        = {12},
  publisher    = {Lund University},
  school       = {Lund University},
  title        = {Posttraumatic Stress Reactions in Tortured Refugees : Relationship to pain, cognitive impairments, and negative appraisals},
  url          = {https://lup.lub.lu.se/search/ws/files/73337727/Linda_Nordin_webversion_utan_studies.pdf},
  year         = {2019},
}