Using clinical expertise and empirical data in constructing networks of trauma symptoms in refugee youth

Background: In recent years, many adolescents have fled their home countries due to war and human rights violations, consequently experiencing various traumatic events and putting them at risk of developing mental health problems. The symptomatology of refugee youth was shown to be multifaceted and often falling outside of traditional diagnoses. Objective: The present study aimed to investigate the symptomatology of this patient group by assessing the network structure of a wide range of symptoms. Further, we assessed clinicians’ perceptions of symptoms relations in order to evaluate the clinical validity of the empirical network. Methods: Empirical data on Post-Traumatic Stress Disorder (PTSD), depression and other trauma symptoms from N = 366 refugee youth were collected during the routine diagnostic process of an outpatient centre for refugee youth in Germany. Additionally, four clinicians of this outpatient centre were asked how they perceive symptom relations in their patients using a newly developed tool. Separate networks were constructed based on 1) empirical symptom data and 2) clinicians’ perceived symptom relations (PSR). Results: Both the network based on empirical data and the network based on clinicians’ PSR showed that symptoms of PTSD and depression related most strongly within each respective cluster (connected mainly via sleeping problems), externalizing symptoms were somewhat related to PTSD symptoms and intrusions were central. Some differences were found within the clinicians’ PSR as well as between the PSR and the empirical network. Still, the general PSR-network structure showed a moderate to good fit to the empirical data. Conclusion: Our results suggest that sleeping problems and intrusions play a central role in the symptomatology of refugee children, which has tentative implications for diagnostics and treatment. Further, externalizing symptoms might be an indicator for PTSD-symptoms. Finally, using clinicians’ PSR for network construction offered a promising possibility to gain information on symptom networks and their clinical validity

Using Clinical Expertise and Empirical Data in Constructing Networks of Trauma Symptoms in Refugee Youth

Background In recent years, many adolescents have fled their home countries due to war and human rights violations, consequently experiencing various traumatic events and putting them at risk of developing mental health problems. The symptomatology of refugee youth was shown to be multifaceted and often falling outside of traditional diagnoses. The present study aims to investigate the symptomatology of this patient group by assessing the network structure of a wide range of symptoms. Further, we assess clinicians’ perceptions of symptoms relations in order to evaluate the clinical validity of the empirical network. Methods Empirical data on Post-Traumatic Stress Disorder (PTSD), depression and other trauma symptoms from N=366 refugee youth was collected during the routine diagnostic process of an outpatient centre for refugee youth in Germany. Additionally, four clinicians of this outpatient centre were asked how they perceive symptom relations in their patients using a newly developed tool. Separate networks were constructed based on 1) empirical symptom data and 2) clinicians’ perceived symptom relations (PSR). Results Both the network based on empirical data and the network based on clinicians’ PSR showed that symptoms of PTSD and depression related most strongly within each respective cluster, externalizing symptoms were weakly connected to the network and intrusions were central. Some differences were found within the clinicians’ PSR as well as between the PSR and the empirical network. Still, the general PSR-network structure showed a moderate to good fit to the empirical data. Conclusion Our results suggest that due to their limited connectedness, both central PTSD symptoms and central depression symptoms need to be targeted in treatment, with a focus on intrusions. Further, using clinicians’ PSR for network construction offered a promising possibility to gain information on symptom networks and their clinical validity

Summary of events post NTCU.

<p>A graphical representation of change in cell type frequencies in the trachea (solid line) and bronchial epithelium (dashed line) during NTCU time-course. Time points where changes are statistically significant are shown by * symbol.</p

Molecular phenotype of the cells present in NTCU-induced bronchial dysplasia.

<p>Bronchial epithelium from mice treated for 32 weeks with vehicle <b>(A-B)</b> or NTCU <b>(C-F).</b> Tissues were stained with antibodies against <b>(A)</b> CCSP (green), ACT (red) and <b>(B & C)</b> K5 (green). Expression of other basal cell markers was detected by staining with <b>(D</b>) K14 (red), <b>(E)</b> p63 (red) and K5 (green), and <b>(F)</b> nerve growth factor receptor (NGFR, red). DAPI staining (blue) in all images depicts nuclei. Representative images from 10 mice treated with vehicle or NTCU.</p

NTCU treatment increased the mitotic index of tracheal basal cells.

<p><b>(A-B</b>) Tracheal tissue sections from mice treated with vehicle or NTCU for 32 weeks were stained for K5 (green), BrdU (red) and DAPI (blue). Representative pictures from n = 4 mice per group was used. <b>(C)</b> Quantification was performed by counting BrdU⁺ nuclei throughout the trachea from proximal to distal axis and represented as % of DAPI⁺ nuclei. Statistical analyses were performed as described in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122823#pone.0122823.g005" target="_blank">Fig 5</a>.</p

NTCU induced squamous dysplasia of the tracheal epithelium: Tracheal epithelium of vehicle (left column) and NTCU treated (right column) mice at 32 weeks.

<p><b>(A&B)</b> H&E stained picture showing high-grade dysplasia of the tracheal epithelium induced by NTCU. <b>(C&D)</b> Dual staining with K5 (green) and K14 (red), <b>(E&F)</b> K5 (green) and p63 (red) and arrows show dual positive cells. Nonspecific staining under the epithelium are shown by white * symbol. <b>(G&H)</b> Staining for nerve growth factor receptor NGFR and <b>(I &J)</b> squamous differentiation marker, involucrin. DAPI staining (blue) in all images indicates nuclei and scale bar is indicated in each panel. Representative images from 10 mice each for vehicle and NTCU group.</p

Development of bronchial dysplasia over time.

<p><b>(A)</b> Study design for time-course analysis of NTCU exposure. Arrows indicate the time-points when tissues were collected. <b>(B-C)</b> H & E stained bronchial tissues after 25 weeks of NTCU treatment. Immunofluorescence staining of dysplastic bronchial epithelium <b>(D-G)</b>. <b>(E)</b> Amplified image of the boxed area shown in <b>(D).</b> Antigens used and scale bars are mentioned in the respective panel. Representative images are from 5 NTCU treated mice.</p