Background: Extreme violence and psychological abuse have been extensively documented and are pervasive in prostitution. Survivors of prostitution report high levels of posttraumatic stress disorder, dissociation, depression, and self-loathing. These are the same sequelae reported by torture survivors.Objective: Severe forms of violence have been categorized as torture by experts. The authors note that torture is commonly suffered during prostitution and should be appropriately named.Method: Using standardized measures and including a new measure of torture, we interviewed 45 women in the United States about their torture experiences in prostitution and their symptoms of PTSD, dissociation, childhood trauma, health status and somatic symptoms. The interviewees had exited prostitution and were in supportive programmes.Results: Formerly prostituted interviewees reported acts of physical, sexual, and psychological torture, including strangulation, rape, beatings, restriction of movement, denial of privacy, sleep, or food, and being forced to witness the torture of others. The 45 women had high levels of PTSD and dissociation. They endorsed needs for individual counselling, substance abuse treatment, and other medical care.Conclusions: A recognition of the physical, sexual, and psychological torture experienced in prostitution would strengthen psychological and medical interventions for survivors. Naming specific acts of prostitution as torture will reduce the survivor's shame and self-blame. Holistic treatment includes medical and psychological interventions and peer support, as seen in torture rehabilitation programmes for survivors of state-sponsored torture. This research supports the perspective that private or non-state-sponsored torture against women and marginalized populations should be clinically and legally understood in the same way as state-sponsored torture.

The impact of caregiving on caregivers' mental health is typically considered within the caregiver stress and burden literature; however, more recently, research has investigated the experience of post-traumatic stress symptoms (PTSS) in caregivers. As an emerging area of research, it is timely to conduct a scoping review to map the existing literature in relation to PTSS among adult caregivers of children and adults with neurodevelopmental disorders (NDD), neurocognitive disorders, and psychiatric disorders. The scoping review was conducted using Preferred Reporting Items of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines and Arksey and O'Malley's five-stage methodology framework. Published and unpublished gray literature between 2005 and 2022 was included in the scoping review. Nine thousand one hundred and twenty-five studies were originally identified for screening and 22 studies were selected for inclusion in the final review. Trauma and PTSS experienced by NDD caregivers were related to news breaking, NDD diagnosis, and behavioral issues, whereas caregivers of individuals with psychosis reported aggression and violence as traumatic events. Studies showed that up to half of caregivers reported PTSS, although no conclusions could be drawn about prevalence rates. A wide variety of tools measuring PTSS were used across the 22 studies. Many symptoms of PTSS were reported by caregivers, and cognitive appraisals were associated with PTSS in caregivers. The findings highlight the importance of recognizing the impact of trauma in caregiver mental health and the potential value of using traumatic stress frameworks with these populations. Research should be expanded to establish prevalence rates and to examine the long-term impact of trauma on caregiving as caregivers and care recipients age.

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

Torture has profound psychological and physiological consequences for survivors. While some brain structures and functions appear altered in torture survivors, it is unclear how torture exposure influences functional connectivity within and between core intrinsic brain networks. In this study, 37 torture survivors (TS) and 62 non-torture survivors (NTS) participated in a resting-state fMRI scan. Data-driven independent components analysis identified active intrinsic networks. Group differences in functional connectivity in the default mode network (DMN), salience network (SN) and central executive network (CEN) of the triple network model, as well any prefrontal network, were examined while controlling for PTSD symptoms and exposure to other potentially traumatic events. The analysis identified 25 networks; eight comprised our networks of interest. Within-network group differences were observed in the left CEN (lCEN), where the TS group showed less spectral power in the low-frequency band. Differential internetwork dynamic connectivity patterns were observed, where the TS group showed stronger positive coupling between the lCEN and anterior dorsomedial and ventromedial DMN, and stronger negative coupling between a lateral frontal network and the lCEN and anterior dorsomedial DMN (when contrasted with the NTS group). Group differences were not attributed to torture severity or dissociative symptoms. Torture survivors showed disrupted dynamic functional connectivity between a laterally-aligned lCEN that serves top-down control functions over external processes and the midline DMN that underpins internal self-referential processes, which may be an adaptive response to mitigate the worst effects of the torture experience. This study provides a critical step in mapping the neural signature of torture exposure to guide treatment development and selection.

Burnout and moral injury within medicine have steadily increased over the last decades, especially among those providing care during the COVID-19 pandemic. The term burnout has been used to describe clinician distress and a syndrome of emotional exhaustion, a diminished sense of personal accomplishment, and depersonalization. Burnout has a significant impact on both job performance and patient care. Moral injury occurs when external circumstances interact with a person's cherished beliefs and standards. When the tension between them cannot be reconciled, the felt integrity of the individual is disrupted and the person experiences distress. The consultative aspect in consultation-liaison psychiatry (CLP) presents challenges that may predispose the young clinician to burnout and moral injury, especially during fellowship training. CLP psychiatrists also have a liaison role that could catalyze systemlevel change to enhance the mental well-being of their colleagues. This article reviews clinically relevant psychodynamic aspects of burnout and moral injury during CLP training. In addition, the authors propose strategies to enhance career growth and prevent and address moral injury during training to generate fulfilling professional development.

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

To identify candidate psychological and non-pharmacological treatments for future research.

Mixed-methods systematic review.

Adults aged ≥ 18 years with a history of complex traumatic events.

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

This study is registered as PROSPERO CRD42017055523.

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Although it is well documented that exposure to severe, cumulative trauma and postdisplacement stress increases the risk for posttraumatic stress symptom disorder (PTSD), less is known about the representation and predictors of complex PTSD (CPTSD) symptoms in refugee populations. We examined PTSD and CPTSD symptom profiles (co-occurring PTSD and disturbances in self-organization [DSO] symptoms) and their premigration, postmigration, and demographic predictors, using latent class analysis (LCA), in a cohort of 112 refugees resettled in Australia. The LCA identified a four-factor model as the best fit to the data, comprising classes categorized as: (a) CPTSD, exhibiting high levels of PTSD and DSO symptoms (29.5%); (b) PTSD only (23.5%); (c) high affective dysregulation (AD) symptoms (31.9%); and (d) low PTSD and DSO symptoms (15.1%). Membership in the CPTSD and PTSD classes was specifically associated with cumulative traumatization, CPTSD OR = 1.56, 95% CI [1.15, 2.12], and PTSD OR = 1.64, 95% CI [1.15, 2.34]; and female gender, CPTSD OR = 14.18, 95% CI [1.66, 121.29], and PTSD OR = 16.84, 95% CI [1.78, 159.2], relative to the low-symptom class. Moreover, CPTSD and AD class membership was significantly predicted by insecure visa status, CPTSD OR = 7.53, 95% CI [1.26, 45.08], and AD OR = 7.19, 95% CI [1.23, 42.05]. These findings are consistent with the ICD-11 model of CPTSD and highlight the contributions of cumulative trauma to CPTSD and PTSD profiles as well as of contextual stress from visa uncertainty to DSO symptom profiles in refugee cohorts, particularly those characterized by AD.

For the 11th version of the International Classification of Diseases, a new stress related diagnosis has been proposed: complex post-traumatic stress disorder (CPTSD). It is described as a chronic condition with several severe and concurrent symptoms. In the literature, these symptoms are discussed as a common reason for seeking psychiatric treatment as they can influence and impair the quality of life not only for affected persons but also for their social and familial system.

This research studies symptom management in everyday life by exploring and reconstructing the views, perceptions, experiences, facilitators and barriers of adults with CPTSD.

A theoretical sampling was used to recruit 18 to 65 years old patients diagnosed with CPTSD from an inpatient setting. The 17 semi-structured interviews were audio recorded and transcribed verbatim. The transcriptions were uploaded into MAXQDA, and a Grounded Theory method based on Corbin and Strauss was used to analyse the data.

We provide a process model with 5 interacting phases: trauma experience, emotional ignorance, overcompensation, paroxysm, and perspectives. Each phase is specified with subcategories.

The participants did not recognise their symptoms as such and were unaware of their diagnosis for many years. Nevertheless, they used various resources and were able to develop skills and techniques to deal with their symptoms and to function on a day-to-day basis. Overall, the process of symptom management was extremely exhausting for the participants and they felt left alone with it. The participants were eager to gain support from healthcare professionals and, when necessary, financial support from the government. Thus, these results indicate an essential need to develop support and tailored interventions for the symptom management of persons with a CPTSD.

Ethical approval was obtained from the Swiss Cantonal Ethic Commission (Nr 201,500,096). This research was also registered at the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial DRKS00012268 .

Human trafficking, also known as modern-day slavery, is an egregious human rights violation associated with wide-ranging medical and mental health consequences. Because of the extensive health problems related to trafficking, health care providers play a critical role in identifying survivors and engaging them in ongoing care. Although guidelines for recognizing affected patients and a framework for developing response protocols in health care settings have been described, survivors' ongoing engagement in health care services is very challenging. High rates of disengagement, lost contact, premature termination, and attrition are common outcomes. For interventions to be effective in this marginalized population, challenges in engaging survivors in long-term therapeutic primary and mental health care must be better understood and overcome. This article uses the socioecological model of public health to identify barriers to engagement; offers evidence- and practice-based recommendations for overcoming these barriers; and proposes an interdisciplinary call to action for developing more flexible, adaptable models of care.

A substantial amount of refugees (10-30%) suffer from Post-Traumatic Stress Disorder (PTSD). In Denmark there are different facilities specialised in psychiatric treatment of trauma-affected refugees. A previously published case report from such a facility in Denmark shows that some patients suffer from secondary psychotic symptoms alongside their PTSD. The aim of this study was to illustrate the characteristics and estimate the prevalence of psychotic features in a clinical population of trauma-affected refugees with PTSD.

Psychiatric records from 220 consecutive patients at Competence Centre for Transcultural Psychiatry (CTP) were examined, and all the PTSD patients were divided into two groups; one group with secondary psychotic features (PTSD-SP group) and one without (PTSD group). A categorisation and description of the secondary psychotic features was undertaken.

One hundred eighty-one patients were diagnosed with PTSD among which psychotic symptoms were identified in 74 (40.9, 95% CI 33.7-48.1%). The majority of symptoms identified were auditory hallucinations (66.2%) and persecutory delusions (50.0%). There were significantly more patients diagnosed with enduring personality change after catastrophic experience in the PTSD-SP group than in the PTSD group (P = 0.009). Furthermore the PTSD-SP group included significantly more patients exposed to torture (P = 0.001) and imprisonment (P = 0.005).

This study provides an estimation of PTSD-SP prevalence in a clinical refugee population with PTSD. The study points to the difficulties distinguishing psychotic features from flashbacks and the authors call for attention to psychotic features in PTSD patients in order to improve documentation and understanding of the disorder.

The ICD-11 proposes different types of prolonged trauma as risk factors for complex PTSD (CPTSD). However, CPTSD's construct validity has only been examined in childhood abuse, and single trauma exposure samples. Thus, the extent to which CPTSD applies to other repeatedly traumatized populations is unknown. This study examined ICD-11's PTSD and CPTSD across populations with prolonged trauma of varying interpersonal intensity and ages of exposure, including: 1) childhood sexual abuse, 2) adulthood trauma of severe interpersonal intensity (refugees and ex-prisoners of war), and 3) adulthood trauma of mild interpersonal intensity (military veterans, and mental health workers). In support of the proposal, latent class analysis (N = 820) identified, a 4-class solution representing "PTSD", "CPTSD", and "non-pathological" classes, but also an "Anxiety symptoms" class, and an alternative 5-class solution, with a "Dissociative PTSD-subtype" class. ICD-11's CPTSD was not exclusively associated with childhood abuse, but also with exposure to adulthood trauma of severe interpersonal intensity. Furthermore, all types of prolonged trauma were equally associated with the "Anxiety symptoms" class. Finally, of all the classes, the "CPTSD" class was associated with the highest frequency of work-related functional impairment, indicating an association between the severity of prolonged trauma exposure and the level of posttraumatic residues.

The effects of treatment in trials with trauma-affected refugees vary considerably not only between studies but also between patients within a single study. However, we know little about why some patients benefit more from treatment, as few studies have analysed predictors of treatment outcome.

The objective of the study was to examine possible psychosocial predictors of treatment outcome for trauma-affected refugees.

The participants were 195 adult refugees with posttraumatic stress disorder (PTSD) who were enrolled in a 6- to 7-month treatment programme at the Competence Centre for Transcultural Psychiatry (CTP), Denmark. The CTP Predictor Index used in the study included 15 different possible outcome predictors concerning the patients' past, chronicity of mental health problems, pain, treatment motivation, prerequisites for engaging in psychotherapy, and social situation. The primary outcome measure was PTSD symptoms measured on the Harvard Trauma Questionnaire (HTQ). Other outcome measures included the Hopkins Symptom Check List-25, the WHO-5 Well-being Index, Sheehan Disability Scale, Hamilton Depression and Anxiety Scales, the somatisation scale of the Symptoms Checklist-90, Global Assessment of Functioning scales, and pain rated on visual analogue scales. The relations between treatment outcomes and the total score as well as subscores of the CTP Predictor Index were analysed.

Overall, the total score of the CTP Predictor Index was significantly correlated to pre- to post treatment score changes on the majority of the ratings mentioned above. While employment status was the only single item significantly correlated to HTQ-score changes, a number of single items from the CTP Predictor Index correlated significantly with changes in depression and anxiety symptoms, but the size of the correlation coefficients were modest.

The total score of the CTP Predictor Index correlated significantly with outcomes on most of the rating scales, but correlations were modest in size, possibly due to the number of different factors influencing treatment outcome.

While studies with survivors of single traumatic experiences highlight individual response variation following trauma, research from conflict regions shows that almost everyone develops posttraumatic stress disorder (PTSD) if trauma exposure reaches extreme levels. Therefore, evaluating the effects of cumulative trauma exposure is of utmost importance in studies investigating risk factors for PTSD. Yet, little research has been devoted to evaluate how this important environmental risk factor can be best quantified.

We investigated the retest reliability and predictive validity of different trauma measures in a sample of 227 Ugandan rebel war survivors. Trauma exposure was modeled as the number of traumatic event types experienced or as a score considering traumatic event frequencies. In addition, we investigated whether age at trauma exposure can be reliably measured and improves PTSD risk prediction.

All trauma measures showed good reliability. While prediction of lifetime PTSD was most accurate from the number of different traumatic event types experienced, inclusion of event frequencies slightly improved the prediction of current PTSD.

As assessing the number of traumatic events experienced is the least stressful and time-consuming assessment and leads to the best prediction of lifetime PTSD, we recommend this measure for research on PTSD etiology.

Complex posttraumatic stress disorder (PTSD) presents with clinical features of full or partial PTSD (re-experiencing a traumatic event, avoiding reminders of the event, and a state of hyperarousal) together with symptoms from three additional clusters (problems in emotional regulation, negative self-concept, and problems in interpersonal relations). Complex PTSD is proposed as a new diagnostic entity in ICD-11 and typically occurs after prolonged and complex trauma. Here we shortly review current knowledge regarding the biological correlates of complex PTSD and compare it to the relevant findings in PTSD. Recent studies provide support to the validity of complex PTSD as a separate diagnostic entity; however, data regarding the biological basis of the disorder are still very limited at this time. Further studies focused on complex PTSD biological correlates and replication of the initial findings are needed, including neuroimaging, neurobiochemical, genetic, and epigenetic investigations. Identification of altered biological pathways in complex PTSD may be critical to further understand the pathophysiology and optimize treatment strategies.