Eating Disorders and Treatment from Different Perspectives

Eating disorders (EDs) are rare, but very serious psychiatric disorders, with a low recovery rate (1,2). This warrants studies on treatment quality to improve the course and consequences of EDs and enhance recovery rates. Despite the increasing recognition of the value of patient input, few studies address how ED patients evaluate the illness, its consequences and treatment, and how their views are related to scientific evidence and expert opinions.This thesis investigates eating disorders (EDs) and treatment from the patients’ perspective and compares the patients’ perspective as a body of knowledge with the scientific evidence and the therapists’ perspective. EDs, namely anorexia nervosa, bulimia nervosa, and the EDs not otherwise specified, are rare, but very serious psychiatric disorders, with a low recovery rate. Mortality in anorexia nervosa and bulimia nervosa is high in comparison to other mental disorders. The physical, psychological and social consequences are also severe. Optimal treatment is imperative. Evidence-based medicine (EBM) has increasingly become the accepted means to offering optimal treatment of EDs, although the evidence on treatment of EDs, as described in the Dutch multidisciplinary guidelines on EDs, is limited. In EBM, a therapist, when confronted with specific problems, seeks to integrate scientific research with clinical expertise and a patient’s preferences. The growing importance of the patients’ preferences arises from the changing attitudes towards (and of) patients. Today patients are considered to be emancipated citizens or consumers, who want to have a say in their treatment. Although a patient’s preferences are considered important in an individual’s encounter with a clinician, the patients’ views are rarely considered to be a body of knowledge. This thesis investigates if and how the patients’ perspective - as a body of knowledge - contributes to an understanding of EDs, the consequences of EDs and what should be regarded optimal treatment of EDs and how the patients’ perspective is related to other bodies of knowledge. The following questions are addressed: 1. What are the patients’ views on eating disorders, their consequences and treatment? 2. In what ways can the patients’ perspective contribute to a better understanding of eating disorders, their consequences and optimal treatment? 3. How is the patients’ perspective related to other bodies of knowledge, namely the scientific evidence and the therapists’ perspective

The impact of morally injurious events in a refugee sample: A quantitative and qualitative study

Background: Posttraumatic Stress Disorder (PTSD) is often reported by refugees that faced violence and persecution. Some stressful events may also entail moral conflicts or dilemmas, described as “potentially morally injurious events” (PMIE). Very few studies have yet investigated the nature of these PMIEs in traumatized refugees, using both quantitative and qualitative data. Method: For this retrospective study, secondary data analysis was used to examine the traumatic events of 183 patients. Based on established definitions of a PMIE, participants were allocated to a Moral Injury (MI) group if they reported lasting distress after exposure to an event of which they indicated that it transgressed their moral beliefs. The remaining participants were allocated to the No-MI group. The type of PMIEs was categorized using qualitative analysis. The groups were compared in terms of PTSD severity, feelings of guilt, and general mental health symptoms. Results: Of the total sample, 55 participants reported one or more acts of transgression (MI group) and 128 reported no acts of transgression (No-MI group). Analyses of PMIEs revealed six themes 1) failing to prevent harm to others, 2) not giving aid to people in need, 3) leaving family members behind that consequently lead to injury or death of others, 4) making indirect and direct moral decisions leading to injury or death of others, 5) betrayal, and 6) engaging in the harm of others. No differences were found between groups on the clinical outcomes, except for feelings of guilt. Conclusion: A considerable number of traumatized refugees reported confrontation with PMIEs. Experiencing PMIEs appeared unrelated to elevated posttraumatic mental health issues

Feasibility and predictors of change of narrative exposure therapy for displaced populations:a repeated measures design

Background: Displaced victims of interpersonal violence, such as refugees, asylum seekers, and victims of sexual exploitation, are growing in numbers and are often suffering from a post-traumatic stress disorder (PTSD). At the same time, these victims are known to benefit less from trauma-focused therapy (TFT) and to be less compliant to treatment. The objective of this paper is to describe the rationale and research protocol of an ongoing trial that aims to evaluate different variables that might influence the feasibility of TFT for the study population. Specifically, perceived daily stress, emotion regulation, and mood are investigated as predictors of change in PTSD symptoms during a trauma-focused therapy (narrative exposure therapy (NET)). The feasibility of administering measures tapping these constructs repeatedly during treatment will also be evaluated. Methods/design: Using an observational treatment design, 80 displaced victims of interpersonal violence will be measured before, during, and after partaking in NET. Several questionnaires tapping PTSD plus the aforementioned possible predictors of PTSD change will be administered: Post-traumatic Stress Disorder Checklist-5, Perceived Stress Scale, Difficulties in Emotion Regulation Scale-18 (pre-test, post-test, and follow-up),subscale impulsivity of the Difficulties in Emotion Regulation Scale-18, Perceived Stress Scale short version, Primary Care Post-traumatic Stress Disorder and a single Mood item (each session). Multilevel modelling will be used to examine the relation between the possible predictors and treatment outcome. Discussion: The present study is the first to examine the interplay of facilitating and interfering factors possibly impacting treatment feasibility and effectiveness in displaced victims of interpersonal violence with PTSD receiving NET, using repeated measures. The current study can help to improve future treatment based on individual characteristics. Trial registration: Netherlands Trial Register: NTR7353, retrospectively registered. Date of registration: July 11, 2018

Stronger Than My Ghosts: Narrative Exposure Therapy and Cognitive Recovery in Later Life

Background: To explore cognitive recovery during and after Narrative Exposure Therapy from the patient’s perspective, autobiographical material and interview responses were qualitatively analyzed.  Method: Using a framework of cognitive development, patient-reported outcomes from four senior Dutch citizens (57–81 years of age) were examined. All participants reported multiple traumatic experiences, including adverse childhood experiences.  Results: During and after treatment, the participants reported gradual changes in posttraumatic feelings, cognitions, and treatment-related perceptions toward increased self-awareness and self-esteem.  Conclusions: A framework of cognitive development provides a comprehensive understanding of how older adults deal with childhood trauma and its consequences

The impact of torture on mental health in the narratives of two torture survivors

Introduction: Torture survivors risk developing Posttraumatic Stress Disorder (PTSD) as well as other mental health problems. This clinical case study describes the impact of torture on two survivors who were treated for their PTSD with Narrative Exposure Therapy. Methods: The reports of the narratives of two torture survivors were qualitatively analyzed. It was hypothesized that torture yields overaccommodating cognitions, as well as mental defeat, which in turn, are related to severity of psychological complaints. Results: Both patients have experienced an accumulation of traumatic events. The psychological and physical torture they experienced lead to increased anticipation anxiety, loss of control and feelings of hopelessness, as well as overaccommodating cognitions regarding self and others. Conclusions: Cognitions, culture and beliefs, as well as issues of confidence and a more long-term perspective affect therapeutic work. Building trust, pacing the therapeutic process, and applying tailor-made interventions that focus on cognitions regarding self-esteem, trust in relationships, as well as safety and control are warranted

Culturally Sensitive Assessment of Traumatic Grief

Background: Migrants and refugees are at increased risk of traumatic loss of loved ones that may cause specific psychopathology. Ways of dealing with bereavement and grief are influenced by the norms of one’s cultural identity. Cultural assessment of bereavement and grief is therefore needed for a comprehensive evaluation of grief-related psychopathology and for negotiating appropriate treatment (Smid et al., 2018). Objective: To evaluate the risk of psychopathology related to traumatic and multiple loss in refugees and to describe a culturally sensitive assessment of traumatic grief. Method: We evaluated the effects of traumatic and multiple losses of family members and friends on psychopathology, disability and quality of life in Iraqi asylum seekers in the Netherlands (Hengst et al., 2018). To facilitate clinical exploration of cultural aspects of bereavement and grief, we developed a set of brief, person-centred and open-ended questions as a draft supplementary module to the DSM-5 Cultural Formulation Interview (CFI; Smid et al., 2018).> Results: The loss of a loved one was reported by 87.6% of the sample. Traumatic and multiple losses of family members independently predicted psychopathology (Hengst et al., 2018). Cultural ways of dealing with bereavement and grief include cultural traditions related to death, bereavement and mourning as well as help-seeking and coping (Smid et al., 2018). Conclusions: Clinicians need to assess psychopathology related to traumatic loss in a culturally sensitive way, especially when working with migrants and refugees. The proposed supplementary module bereavement and grief to the DSM-5 CFI supports such assessment

Toward Cultural Assessment of Grief and Grief-Related Psychopathology

Ways of dealing with bereavement and grief are influenced by the norms of one's cultural identity. Cultural assessment of bereavement and grief is therefore needed for a comprehensive evaluation of grief-related psychopathology and for negotiating appropriate treatment. Cultural aspects of bereavement and grief include cultural traditions related to death, bereavement, and mourning as well as help seeking and coping. To facilitate clinical exploration of cultural aspects of bereavement and grief, the authors propose a set of brief, person-centered, and open-ended questions as a draft supplementary module to the DSM-5 Cultural Formulation Interview

Culturele evaluatie van verlies en rouw

Omgaan met verlies en rouw wordt beïnvloed door de normen van iemands culturele identiteit.Culturele evaluatie van verlies en rouw is daarom nodig voor diagnostiek van rouwgerelateerde psychiatrische aandoeningen en het opstellen van een behandelplan. Culturele aspecten van verlies en rouw omvatten culturele tradities in verband met de dood, verlies en rouw, evenals hulpzoekgedrag en coping. Om de klinische evaluatie van culturele aspecten van verlies en rouw te vergemakkelijken,beschrijven wij een instrument, bestaande uit korte, persoonsgerichte en open vragen, dat we voorstellen als aanvullende module voor hetdsm-5Cultural Formulation Interview.Drie casusvignetten maken inzichtelijk hoe culturele evaluatie van verlies en rouw kan bijdragen aan diagnostiek,behandeling en versterking van de behandelrelatie bij patiënten die hulp zoeken na het verlies van dierbaren