Screening for mental disorders in post-conflict regions using computer apps - a feasibility study from Burundi

A high level of psychosocial functioning is essential for survival in many resource-poor countries and is needed for development in these regions. Organized violence, often in combination with other stressors such as poverty and familial conflict, however, result in a range of mental disorders and damage socio-economic progress. An efficient assessment of mental health is a prerequisite for prevention and intervention measures. However, this may require considerable resources that are difficult to obtain in resource-poor countries. We present new methods for the efficient and effective assessment of mental, especially trauma- and stress-related disorders that can easily be administered by trained local paramedics. For decades, Burundi has been a staging ground for armed conflicts leaving behind many survivors with trauma-related illness. In a study with over 900 combatants and veterans from the military as well as former rebels in Burundi, we used a tablet-computer (ipad)-based survey for the assessment of trauma-related syndromes, especially PTSD, in need for treatment. All participants reported the experience of serious traumatic stressors and a substantial portion presented severe symptoms of the trauma-spectrum. Based on the PSS-I and other standardized screening instruments, an ipad app guided the semistructured clinical interviews. Psychologists from the University of Konstanz, the Burundian military as well as psychologist students from the University Lumie` re, Bujumbura, Burundi carried out the interviews. In this contribution, we use the Burundian example to portray the logistics and technology of data acquisition and present respective data. We demonstrate the feasibility of using a computerbased screening approach in the field and in clinical settings. We provide evidence, that the computerized assessment of clinical symptoms can be a useful tool for mental health assessment and screenings, both in research and practice

A generic questionnaire framework supporting psychological studies with smartphone technologies

Many psychological studies are performed with specifically tailored ‘‘paper & pencil’’-questionnaires. Such a paper-based approach usually results in a massive workload for evaluating and analyzing the collected data afterwards, e.g., to transfer data to electronic worksheets or any statistics software. To relieve researchers from such manual tasks and to improve the efficiency of data collection processes, we realized smart device applications for existing psychological questionnaires (e.g., the KINDEX, PDS, or CAPS questionnaire). Based on these applications, we were able to demonstrate the usefulness of smart devices (e.g., smartphones or tablets) for mobile data collection in the context of psychological questionnaires. Although the implemented applications already have shown several advantages in respect to data collection and analysis, they have not been suitable for psychological studies in the large scale yet, e.g., due to the high maintenance efforts for the psychologists. More precisely, changes to a questionnaire or its structure still must be accomplished by computer scientists, since its implementation is hard-coded. What is needed instead is an easy-to-use and self-explaining framework for creating, running, and evolving the questionnaires of psychological studies on mobile and smart devices. In this context, supporting the complete questionnaire lifecycle is essential, i.e., IT support for creating, using, evaluating, and archiving questionnaires is required to assist end-users having no programming background. We present our generic questionnaire framework, which encompasses the following three parts: a questionnaire configurator to create the questions and questionnaires, a way of integrating mobile devices to deploy, run and log questionnaires, and a middleware enabling a secure data exchange. Finally, we discuss how smartphone technology and mobile devices can be used to suitably support psychologists in their daily work with questionnaires. As major benefit of the framework, better data quality, shorter evaluation cycles, and significant decreases in workload will result

Succumbing to the Call of Violence – Sex-Linked Development of Appetitive Aggression in Relation to Familial and Organized Violence

Appetitive aggression is the attraction to violent behavior, which can peak in the experience of a combat high. In various war and conflict scenarios, members of armed groups have reported developing a desire to hunt and even kill humans. More recently, we reported that the phenomenon has also been observed in female ex-combatants with varying participation in warfare. Despite recent investigations on risk factors for appetitive aggression, sex-specific pathways in the development of appetitive aggression have not yet been delineated. This study investigated moderation effects of sex on previously identified risk factors for appetitive aggression by means of regression analyses in a sample of individuals with varying degrees of warfare participation (overall sample, n = 602). First examining a sample characterized by backgrounds heterogeneous in both sociodemographic data and war experiences, the analysis was then replicated in a subsample of fighters active during the civil war (combatant sample, n = 109). In both samples, regression analyses revealed significant moderation effects of sex. Childhood maltreatment and traumatic events had positive associations on the development of appetitive aggression for males but a negative (childhood maltreatment) or no (traumatic events) association for females. Perpetrated events were more strongly correlated with appetitive aggression for females than for males. This pattern was pronounced for the combatant sample. These results are in favor of sex-linked pathways. In both sexes, appetitive aggression may have evolved as a biologically prepared response to cruel environments but might develop along different trajectories. The current study highlights the need for addressing appetitive aggression in order to support peace-building processes and emphasizes sex specific starting-points

The Cycle of Violence in Combatants : The Interaction of Childhood Maltreatment, Mental Health, and Aggression

The present thesis explored the factors fostering and maintaining violence in a post-conflict setting. Therefore, the thesis investigated the sequelae of childhood maltreatment, trauma exposure and violence perpetration with a focus on symptoms of post-traumatic stress disorder (PTSD) and appetitive aggression in Burundian ex-combatants and soldiers. Furthermore, the impact of these factors on self-perpetrated violence during foreign deployment, in the community, and within the family were examined. Violence usually does not cease in communities of post-conflict countries, and an increase in violence within the families of war- affected populations can also be observed (Catani, Jacob, Schauer, Kohila, & Neuner, 2008). Past research has identified war-related PTSD to contribute to violent behavior after war deployment (MacManus et al., 2013; Orcutt, King, & King, 2003). Yet, a pleasure-driven attraction to violent cues, namely appetitive aggression, was as well linked to violent offenses (Hecker, Hermenau, Maedl, Elbert, & Schauer, 2012; Köbach, Schaal, & Elbert, 2014). Often overlooked when exploring the precursors and consequences of violence in war context is the effect of abusive experiences during childhood. Childhood maltreatment is associated with impaired mental health (Margolin, & Gordis, 2000; Teicher, Samson, Polcari, & McGreenery, 2006). The concept of the cycle of violence presumes that a history of child abuse predisposes one to violence perpetration later in life (Widom, Czaja, & DuMont, 2015). The first article investigated predictors of PTSD symptoms and appetitive aggression in two groups of currently active soldiers and demobilized combatants. The building-block effect of traumatic experiences on PTSD (Neuner et al., 2004) was confirmed. Self-committed violence was not significantly associated with PTSD symptoms but was the strongest predictor of appetitive aggression. The results of the first article revealed furthermore that childhood maltreatment was an additional predictor of PTSD. In addition, childhood maltreatment moderated the relationship between the number of traumatic events and PTSD symptoms. This indicates that childhood maltreatment might entail vulnerability for the development of PTSD symptoms after subsequent traumatic events. In interaction with self-committed violence, childhood maltreatment was also positively associated with appetitive aggression. Findings for the specific trauma-potential of self-perpetrated violence are inconsistent (Hecker, Hermenau, Maedl, Hinkel, Schauer, & Elbert, 2013). Violent offending might also be perceived as appealing, therefore particularly fostering appetitive aggression. Köbach and colleagues (2014) have demonstrated in a sample of ex-combatants of the DR Congo, that violent offences are related to appetitive aggression rather than to PTSD symptoms. The second article of this thesis could replicate this finding in the sample of Burundian ex-combatants who presented with a comparable level of violence exposure. Examinations of the relationship between PTSD and appetitive aggression postulated a buffering effect of appetitive aggression on the development of PTSD due to a different perceiving of violent cues (Hecker, Hermenau, Maedl, Schauer, & Elbert, 2013; Weierstall, Castellanos, Neuner, & Elbert, 2013). The results of the third article supported the assumption of the protective influence in the sample of Burundian ex-combatants. PTSD as well as appetitive aggression have been separately linked to violent behavior in past cross-sectional studies (e.g., MacManus et al., 2012; Hecker, et al., 2012). In a longitudinal design, the fourth article could demonstrate the independent contribution of symptoms of the PTSD - hyperarousal cluster as well as appetitive aggression for self-committed violence during deployment in the sample of the currently active soldiers. Correspondingly, the fifth article found PTSD symptoms and appetitive aggression to predict community violence after deployment. Appetitive aggression was not predictive for intimate partner violence and depression symptoms here mediated the effect of PTSD symptoms. Childhood familial violence was linked to appetitive aggression as well as symptoms of PTSD and depression. Moreover, it was the only predictor for the infliction of violent behavior on children and had additionally direct effects on intimate partner and community violence. The present thesis demonstrated that beyond PTSD, appetitive aggression is an important phenomenon amongst combatants, which is constantly promoted though violent experiences. While it has the potential to buffer PTSD symptoms up to a certain degree, it poses a high risk for recurrent violent outbursts. The thesis highlighted the prominent role of childhood maltreatment. First as a vulnerability factor for mental health and appetitive aggression and secondly as a risk factor for violent behavior in adulthood. The present thesis has attained further knowledge about the interplay of mental health, appetitive aggression and violent behavior and pointed out the significant role of childhood maltreatment in maintaining the cycle of violence in post-conflict countries.publishe

Predictors of posttraumatic stress and appetitive aggression in active soldiers and former combatants

Background: During the period between 1993 and 2005, the people of Burundi were trapped within a violent civil war. In post-conflict regions, symptoms of posttraumatic stress disorder (PTSD) were found to be widespread. At the same time, combatants often reported having perceived committing violence as exciting and appealing, an experience referred to as appetitive aggression. Both of these phenomena hamper the building of a functional and peaceful society.Objective: This study aims to investigate the factors that are associated with the level of PTSD and appetitive aggression in former and still active combatants.Methods: Semi-structured interviews were conducted with 948 male Burundians: 556 active soldiers and 392 ex-combatants. PTSD symptom severity was assessed using the PTSD Symptom Scale Interview, while appetitive aggression was assessed using the Appetitive Aggression Scale.Results: Linear regression analyses revealed that the number of traumatic events, childhood maltreatment, and their interaction predicted PTSD symptom severity, whereas self-committed violence did not. The number of traumatic events and self-committed violence were associated with appetitive aggression. Childhood maltreatment alone was not associated with appetitive aggression; however, its interaction with self-committed violence did predict appetitive aggression. When controlling for predictors, ex-combatants reported a higher degree of PTSD symptomatology, whereas active soldiers reported a higher degree of appetitive aggression.Conclusion: We conclude that childhood maltreatment is an additional, significant risk factor that exacerbates the psychological consequences of violent conflicts. Self-committed violence may not necessarily engender trauma-related disorders, but is highly related to appetitive aggression

Appetitive aggression as a resilience factor against Trauma Disorders : appetitive aggression and PTSD in German World War II Veterans

Repeated exposure to traumatic stressors such as combat results in chronic symptoms of PTSD. However, previous findings suggest that former soldiers who report combat-related aggression to be appetitive are more resilient to develop PTSD. Appetitive Aggression should therefore prevent widespread mental suffering in perpetrators of severe atrocities even after decades

Effective Adoption of Tablets for Psychodiagnostic Assessments in Rural Burundi : Evidence for the Usability and Validity of Mobile Technology in the Example of Differentiating Symptom Profiles in AMISOM Soldiers 1 Year After Deployment

Research on the use of mobile technology in health sciences has identified several advantages of so-called mHealth (mobile health) applications. Tablet-supported clinical assessments are becoming more and more prominent in clinical applications, even in low-income countries. The present study used tablet computers for assessments of clinical symptom profiles in a sample of Burundian AMISOM soldiers (i.e., African Union Mission to Somalia; a mission approved by the UN). The study aimed to demonstrate the feasibility of mHealth-supported assessments in field research in Burundi. The study was conducted in a resource-poor setting, in which tablet computers are predestined to gather data in an efficient and reliable manner. The overall goal was to prove the validity of the obtained data as well as the feasibility of the chosen study setting. Four hundred sixty-three soldiers of the AMISOM forces were investigated after return from a 1-year military mission in Somalia. Symptoms of posttraumatic stress disorder (PTSD) and depression were assessed. The used data-driven approach based on a latent profile analysis revealed the following four distinct groups, which are based on the soldiers' PTSD and depression symptom profiles: Class 1: moderate PTSD, Class 2: moderate depression, Class 3: low overall symptoms, and Class 4: high overall symptoms. Overall, the four identified classes of soldiers differed significantly in their PTSD and depression scores. The study clearly demonstrates that tablet-supported assessments can provide a useful application of mobile technology in large-scale studies, especially in resource-poor settings. Based on the data collected for the study at hand, it was possible to differentiate different sub-groups of soldiers with distinct symptom profiles, proving the statistical validity of the gathered data. Finally, advantages and challenges for the application of mobile technology in a resource-poor setting are outlined and discussed.publishe

Violent Offending Promotes Appetitive Aggression Rather than Posttraumatic Stress : A Replication Study with Burundian Ex-Combatants

Research has identified appetitive aggression, i.e., the perception of committed, violent acts as appealing, exciting and fascinating, as a common phenomenon within populations living in precarious and violent circumstances. Investigating demobilized soldiers in the Democratic Republic of Congo (DRC) demonstrated that violent offending is associated with appetitive aggression and not necessarily with symptoms of posttraumatic stress. In the present study, we sought to replicate these results in an independent and larger sample of demobilized soldiers from Burundi. As with the Congolese ex-combatants, random forest regression revealed that the number of lifetime perpetrated violent acts is the most important predictor of appetitive aggression and the number of lifetime experienced traumatic events is the main predictor for posttraumatic stress. Perpetrated violent acts with salient cues of hunting (pursuing the victim, the sight of blood, etc.) were most predictive for perceiving violent cues appealingly after demobilization. Moreover, the association of violent acts and appetitive aggression as well as traumatic events and posttraumatic stress remains strong even years after demobilization. Patterns of traumatic events and perpetrated acts as predictors for posttraumatic stress and appetitive aggression seem to be robust among different samples of ex-combatants who fought in civil wars. Psychotherapeutic interventions that address these complementary facets of combat-related disorders-namely, posttraumatic stress and appetitive aggression-are indispensable for a successful reintegration of those who fought in armed conflicts and to achieve a successful transition to peace.publishe

Appetitive Aggression in Women : Comparing Male and Female War Combatants

Appetitive aggression refers to positive feelings being associated with the perpetration of violent behavior and has been shown to provide resilience against the development of PTSD in combatants returning from the battlefield. Until this point, appetitive aggression has been primarily researched in males. This study investigates appetitive aggression in females. Female and male combatants and civilians from Burundi were assessed for levels of appetitive aggression. In contrast to non-combatants, no sex difference in appetitive aggression could be detected for combatants. Furthermore, each of the female and male combatant groups displayed substantially higher levels of appetitive aggression than each of the male and female civilian control groups. This study demonstrates that in violent contexts, such as armed conflict, in which individuals perpetrate numerous aggressive acts against others, the likelihood for an experience of appetitive aggression increases- regardless of whether the individuals are male or female.publishe

Succumbing to the Call of Violence – Sex-Linked Development of Appetitive Aggression in Relation to Familial and Organized Violence

Appetitive aggression is the attraction to violent behavior, which can peak in the experience of a combat high. In various war and conflict scenarios, members of armed groups have reported developing a desire to hunt and even kill humans. More recently, we reported that the phenomenon has also been observed in female ex-combatants with varying participation in warfare. Despite recent investigations on risk factors for appetitive aggression, sex-specific pathways in the development of appetitive aggression have not yet been delineated. This study investigated moderation effects of sex on previously identified risk factors for appetitive aggression by means of regression analyses in a sample of individuals with varying degrees of warfare participation (overall sample, n = 602). First examining a sample characterized by backgrounds heterogeneous in both sociodemographic data and war experiences, the analysis was then replicated in a subsample of fighters active during the civil war (combatant sample, n = 109). In both samples, regression analyses revealed significant moderation effects of sex. Childhood maltreatment and traumatic events had positive associations on the development of appetitive aggression for males but a negative (childhood maltreatment) or no (traumatic events) association for females. Perpetrated events were more strongly correlated with appetitive aggression for females than for males. This pattern was pronounced for the combatant sample. These results are in favor of sex-linked pathways. In both sexes, appetitive aggression may have evolved as a biologically prepared response to cruel environments but might develop along different trajectories. The current study highlights the need for addressing appetitive aggression in order to support peace-building processes and emphasizes sex specific starting-points.publishe