Traumatic stress and psychopathology: experiences of a trauma clinic

Objective: The study was undertaken to investigate the profile of individuals referred to the psychiatrist for assessment in terms of their demographic features, trauma experienced, diagnosis according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), and recommendations made by the psychiatrist.Method: The trauma clinic, a key component of the Victim Empowerment Programme (VEP) of the Centre for the Study of Violence and Reconciliation (CSVR) in Johannesburg, South Africa is a multidisciplinary unit offering counselling and debriefing services to victims/survivors of violence. The staff consists of trained therapists (clinical, research and educational psychologists), social workers and a psychiatric nurse. Since 1998, a psychiatrist has been consulting at the clinic as well. A retrospective case review of all intake notes and progress notes of the clients was undertaken. The period of the survey was 1999-2002.Results: Of 3668 individuals presenting to the centre, 127 were referred to the resident psychiatrist for assessment. 119 were assessed. The majority were in the age range 15-45, unmarried and unemployed. Children under the age of 15 and refugees constituted 9.9% and 30% respectively. Major Depression was the most commonly diagnosed psychiatric condition (17.6%), with Post Traumatic Stress Disorder (PTSD), diagnosed less than expected (5.9%). Co-morbidity was common. Medication was prescribed for 66.4% of the sample, with a further 5.9% hospitalised.Conclusion: Not all individuals exposed to trauma develop PTSD, with mood disorders possibly being more common. Keywords: traumatic stress, post traumatic stress disorder, refugees, complex trauma, major depression, xenophobia South African Psychiatry Review Vol. 9(2) 2006: 105-10

‘Single’ v. ‘panel’ appointed forensic mental observations: Is the referral process ethically justifiable?

Objective. To compare the outcome and psychiatric morbidity of the forensic mental observation referrals, in the two legally created groups of detainees awaiting trial – the ‘singles’, representing the minor violent and non-violent offenders evaluated by a single-state appointed psychiatrist, v. the ‘panels’, representing the seriously violent offenders evaluated by two or more psychiatrists.Methods. A retrospective record review covered 200 cases, comprising all individuals admitted to the forensic unit of Sterkfontein Hospital for 30 days psychiatric observation from January to August 2010. Pearson’s χ2 test for categorical data were used to determine statistical significance. Results. Of 110 singles, 49 (44.55%) were found fit for trial and 40 (40.4%) were found criminally responsible. Of the 90 ‘panel’ cases 60 (66.67%) were found fit for trial and 57 (64.77%) were found criminally responsible (p=0.002 and p=0.001, respectively) Conclusion. Those charged with seriously violent offences appear more likely to be found both fit and responsible, compared with those charged with less serious offences

Forensic state patients at Sterkfontein Hospital: A 3-year follow-up study

Background. State patients are individuals who have been charged with offences involving serious violence and who have been declared unfit to stand trial and/or who are not criminally responsible because of their mental illness or defect. They are referred by the courts for treatment, rehabilitation and indefinite detention at a forensic psychiatric facility. However, many of these state patients may ultimately be released back into the community. As these individuals may be considered a high-risk group, their rates of relapse and recidivism are of importance. There is a paucity of South African literature on the long-term outcome of state patients.  Objective. To describe the profile of state patients, and to examine their outcomes after 3 years, including recidivism rates.  Methods. A descriptive, retrospective study of the clinical records of 114 state patients admitted to Sterkfontein Hospital in 2004 and 2005 was conducted, and their profile and 3-year outcomes were determined. Results. The majority of state patients were male, single, unemployed, had a past psychiatric history (59%), and substance abuse history (71%). A third reported a past criminal history. The most common offences were assault with the intention to do grievous bodily harm (19%), rape (18%) and murder (13%). Psychotic disorders represented the most common diagnostic category (69%), with schizophrenia being the most frequent diagnosis (44%). Most state patients had been found unfit to stand trial (96%) and not criminally responsible (89%). At the end of the 3-year follow-up, the majority were in the community (69%), of whom most (72%) were out on leave of absence (LOA), while a quarter had absconded and a minority were reclassified (3%). Most absconders (83%) were state patients who had not returned from LOA. The recidivism rate was 4%.  Conclusion. Most state patients were out in the community at the end of the 3-year period. The following recommendations are suggested: improved community psychiatric services, especially for those diagnosed with psychotic disorders and mental retardation, with a focus on improving treatment adherence and early detection of treatment defaulters; improved substance abuse rehabilitation programmes and community facilities, as well as strengthening of systems that manage absconders

Clinical characteristics and treatment outcomes of women with heroin dependence in Johannesburg, South Africa

Background. There has been a steady increase in the number of women with heroin dependence in South Africa (SA). Data from developed countries suggest that women with substance use disorder have unique treatment needs. There are limited SA data on women with heroin dependence and their response to treatment.Objectives. To describe the clinical and psychosocial characteristics of women entering inpatient rehabilitation for heroin dependence, determine the outcomes of treatment 3 and 9 months after rehabilitation, and compare these findings with male heroin users.Methods. We conducted a longitudinal study of 44 women with heroin dependence who were admitted to a rehabilitation facility in the West Rand Municipality of Gauteng Province, SA. The participants were assessed during admission and 3 and 9 months after leaving inpatient rehabilitation. Structured interviews measured changes in drug use, psychopathology, social functioning, injecting and sexual behaviour, criminality and general health. Statistical analysis of these outcomes and comparison between women and men at 3 months and 9 months was performed by a generalised estimating equation. Fixed and time-varying covariates were included in the models.Results. At baseline, 40% of female participants were HIV-positive, 50% engaged in sex work, 27% were injecting heroin users, and 75% were diagnosed with a comorbid mental illness. Thirty-seven (84%) and 30 (68%) were re-interviewed at the 3- and 9-month follow-up points, respectively. Of these, 6 were abstinent from all substances at 3 months and 2 at 9 months. Compared with males, females had a higher prevalence of HIV infection (p=0.006) and mental illness (p=0.0002) at enrolment. At 9 months, women had similar levels of drug use and criminality to men but scored significantly worse in terms of general health, social function and risky sexual behaviour.Conclusions. Women with heroin dependence in Johannesburg have high rates of HIV infection and comorbid mental illness and low rates of abstinence after inpatient detoxification and psychosocial therapy. Women fared worse than men in many domains of treatment outcome. This study builds evidence for the need for gender-sensitive substance rehabilitation facilities in SA.

Post traumatic stress disorder and resilience in veterans who served in the South African border war

Objective: The psychological impact of the South African border war on veterans has received little or no attention. This study determined the prevalence of post-traumatic stress disorder (PTSD), and extent of resilience among a cohort of veterans.Method: Of 1527 former students who matriculated from a Johannesburg high school from 1975 to 1988, only 109 were reachable for convenience and snowballing recruitment into this study. An anonymous, internet-based questionnaire was used to obtain information on demography, combat exposure, drug and alcohol use, traumatic events in later life, and recourse to medication and counselling. The Impact of Event Scale – Revised (IES-R) assessed for PTSD and the Connor Davidson Resilience Scale (CDRISC) measured resilience. Data were processed with STATA; version 11 statistical software package. Analysis included Chi square test and regression analysis.Results: The response rate was 49.5% (n=54). The prevalence of PTSD was 33% and significantly associated with combat exposure (p=.012). Despite high prevalence of PTSD in those exposed to combat, 94% showed normal to above-normal level of resilience. CD-RISC scores showed no association with the IES-R. Only current cannabis use was significantly linked with PTSD (p=.044).Conclusion: Although the prevalence of PTSD found in this sample was higher than in comparable international studies, this cohort of former SA national servicemen, showed high levels of resilience. The current use of cannabis within the context of prior exposure to military national service or combat should prompt clinicians to screen for the presence of PTSD-associated symptoms.Keywords: Combat Exposure; Post-traumatic Stress Disorder; National Service; Border War; South AfricaAfrican Journal of Psychiatry • November 2013, 16(6

Personality style, cortisol secretion and the inflammatory response to trauma exposure in a cohort of South African metro police cadets: a prospective, longitudinal study

Literature investigating trauma exposure, Posttraumatic stress disorder (PTSD) and cortisol secretion has produced conflicting results with regard to whether cortisol is increased or decreased. With trauma there is also a pro- inflammatory response which is intimately linked with the hypothalamic pituitary axis (HPA). The police population can offer useful information in this regard as they represent a sample that will undergo exposure to traumatic events as part of their normal duties. In South Africa few studies have examined biological correlates of the traumatic stress response in the police population. This study sought to determine whether correlations exist between cortisol and the inflammatory response in terms of the cytokines Interleukin 6 (IL6) and Tumour Necrosis Factor (TNF) in response to trauma exposure in a cohort of newly enrolled metro police officers, previously naïve to the duty related trauma exposure. Personality styles were assessed, as coping skills and personality have been suggested as factors determining responses to trauma. The study participants were followed up for one year with repeated measures analysis of urine, blood, and saliva cortisol as well as blood cytokine determination every 3 months. Measures for PTSD [the Clinician Administered Scale for Posttraumatic stress disorder (CAPS) and the revised version of the Impact of Event Scale (IES-R)] as well as for depression [the Hamilton Depression Rating Scale (HAM-D)] were undertaken. 145 new recruits volunteered for the study, of which 120 completed all 5 visits. There were slightly more females than males in the sample and almost 50% of the sample admitted to alcohol abuse. Trauma exposure on entry into the police force was remarkably high with 99% having been exposed to at least one traumatic event in their lives. The majority (61.1 %) had been exposed to more than one traumatic event. There was evidence for the influence of prior trauma on responses to current traumatic events. MVA’s were very common, both duty and non duty related. Certain traumas were associated with greater changes in scores for PTSD and depression in relation to baseline. Over the 5 visits, only a third submitted valid 24 hour urine samples. Of these, the profile of the entire group indicated that 24 hour urine cortisol tended to initially decrease, and then increase with time. Saliva and blood cortisol, which were more reliably measured, tended to decrease with time. Scores for depression and post traumatic stress disorder were generally low in response to duty related traumatic events, and tended to decrease over time. However, the prevalence of lifetime PTSD as measured by the CAPS was high. There was a strong linear correlation between TNF and IL6. Results indicate a proinflammatory response, particularly with regard to IL6. There were no significant correlations between blood cortisol and HAM-D and between blood cortisol and CAPS (lifetime). There was an inverse relationship between CAPS (current scores) and blood cortisol. Cortisol and IES-R scores were significant at visit 3 (inverse relationship). For saliva, there were no significant associations with any of the variables for PTSD and depression. For personality styles, aggressive and antisocial clinical patterns were associated with lower current CAPS scores, while schizoid clinical pattern and the severe syndrome scale of thought disorder showed an association with lower lifetime CAPS score. For the IES-R, only narcissistic clinical pattern was associated with lower scores. A further analysis of those with low (less than 25% of the median) and high (greater than 25% of the median) cortisol responses was undertaken. The results indicate a similar trend to some studies showing lowered cortisol levels with chronic trauma exposure, but this did not correlate with sufficiently high scores for PTSD as measured by the CAPS. Similarly, proinflammatory cytokine increases are evident with trauma exposure, but not with scores for PTSD and depression. There were more variables significantly associated with the low cortisol responders than the high cortisol responders; with a suggestion of cumulative trauma exposure correlating with low cortisol response and a corresponding pro inflammatory response in terms of IL6. The results are discussed with a view to assisting the metro police force with recruitment and counseling strategies and important future research is recommended

Ethical dilemmas in projectivised multisite research

Projectivised multisite research is gaining popularity, but is not without its pitfalls. Presented are eight possible challenges that could be encountered, and strategies to manage them. This article presents valuable information to scholars planning projectivised multisite research endeavours

Depressive and post-traumatic stress symptoms following termination of pregnancy in South African women: A longitudinal study measuring the effects of chronic burden, crisis support and resilience

 Background. Termination of pregnancy (TOP) remains a controversial issue, regardless of legislation. Access to services as well as psychological effects may vary across the world.Objectives and methods. To better understand the psychological effects of TOP, this study describes the circumstances of 102 women who underwent a TOP from two socioeconomic sites in Johannesburg, South Africa, one serving women with few economic resources and the other serving women with adequate resources. The relationship between demographic characteristics, resilience and symptoms of posttraumatic stress disorder (PTSD) and depression before, 1 month after and 3 months after the procedure was also examined.Results. Time since TOP, age, chronic burden, resilience and the interaction of site with religion and site with chronic burden were significant. In addition, site differences were found for religion and chronic burden in predicting depression scores. Women from both sites had significant decreases in depression scores over time. The interaction of time with site was not significant. Higher chronic burden scores correlated with higher depression scores. No variables were significant in the bivariate analysis for PTSD.Conclusion. Resilience, religion and chronic burden emerge as significant variables in women undergoing a first-trimester TOP, and warrant further assessment in studies of this nature

Towards a Conceptual Framework for Interdisciplinary Teaching and Learning Dialogues in Higher Education

This paper explores the development and early validation of a conceptual framework for learning-centred teaching by six Teaching Advancement at Universities (TAU) Fellows and their mentor, each representing a different higher education institution and a different discipline. A grounded theory approach was used to construct the framework and its potential utility value was explored though the use of six teaching innovation projects conducted in undergraduate South African university programmes in law, medicine, education, and the arts. The project revealed that interdisciplinary dialogic spaces can be initiated and nurtured through opportunities offered by communities of practice such as the TAU Fellowship when academics suspend their exclusive disciplinary preoccupations to open up possibilities for a generative, emancipatory scholarship. We argue that the conceptual framework is useful to facilitate and promote dialogues across and between the multiple discipline specific ontologies, epistemologies and methodologies offered in higher education

Adverse childhood experiences, mental illness, HIV and offending among female inmates in Durban, South Africa

Background: Childhood adversities and adult trauma are common among female inmates. Associations have been documented with childhood adversities and mental illness, personality disorders, human immunodeficiency virus (HIV) and violent offending. However, no such study had been conducted in South Africa (SA), despite the high prevalence of HIV and trauma in SA. Aim: To measure the prevalence of childhood adversities and adult trauma; and to determine if there is a relationship between childhood adversities, mental illness, personality disorders, HIV and violent offending among female inmates. Setting: The study was conducted at the largest correctional centre in Durban, KwaZulu-Natal, South Africa. Methods: This cross-sectional, descriptive study randomly recruited 126 female inmates. The World Health Organization’s Adverse Childhood Experiences- International Questionnaire (WHO ACE-IQ) was used to measure childhood adversities; the Structured Clinical Interview for the Diagnostics and Statistical Manual-5 Research Version (SCID 5-RV) was used to diagnose mental illness; and a structured questionnaire was used to measure adult trauma. Human immunodeficiency virus data was confirmed from prison medical records. Results: Elevated rates of individual childhood adversities and adult trauma were found. Associations were found between cumulative childhood adversities and post-traumatic stress disorder (PTSD), alcohol use disorder, substance use disorder, borderline personality disorder, and HIV. Conclusion: Female inmates are a highly traumatised population. Prison mental health services should provide trauma-informed and trauma-focussed care to improve inmates’ mental health outcomes and decrease recidivism. Contribution: This study contributes to the emerging literature on adverse childhood experiences (ACEs) and their associations among incarcerated female populations, in a low- and middle-income, South African setting