Posttraumatic Stress Reactions in Tortured Refugees : Relationship to pain, cognitive impairments, and negative appraisals

Abstract: Refugees, particularly those exposed to torture and other forms of organized violence, often experience a wide range of difficulties, including posttraumatic stress disorder (PTSD), depression, and somatic disturbances, particularly pain. Multimodal treatments have been developed to target this comorbidity in refugees, with evidence suggesting they are moderately effective.The overall aim of this thesis was to identify ways in which we might improve the efficacy of the multimodal treatment provided to tortured refugees seeking treatment for PTSD, depression, anxiety and somatic complaints. This was done by exploring the relationship between pain and PTSD in this population, at a specialist outpatient clinic in Copenhagen; DIGNITY – Danish Institute Against Torture, both at a symptom level, and at the level of two cognitive processes that had previously been shown to be important to the severity, duration, and impact of PTSD (negative trauma-related beliefs) and pain (pain catastrophizing). Another way of identify ways to improve treatment, was to find out to what extent the clients suffered from cognitive impairments based on a brief screening measured developed for this purposes (SDMT), and whether such impairments were related to traumatic brain injury (TBI), severity of PTSD, depression, anxiety, pain and overall functioning. With these aims, we hoped to help fill important informational gaps in the literature regarding the extent of pain, cognitive impairments and TBI in traumatized refugees.Study I: The primary aim of the paper was to explore whether pain and disability levels in tortured refugees seeking treatment at DIGNITY were higher than previously estimated in a Danish validation study, and comparable to or exceeding the levels of pain and disability in mixed pain patients presenting for treatment at specialist pain services in Sweden.Study II: The aim was to explore whether the relationship between pain and PTSD was mediated by pain catastrophizing and negative trauma-related beliefs pre- treatment, and consistent with recommendations from the literature, after controlling for the possible effects of depression on both pain and PTSD.Study III involved an exploration of the impact of pain symptoms on PTSD, depression, and anxiety outcomes in refugees undergoing the multi-disciplinary treatment at the clinic. The primary aim was to test whether pre-treatment levels of pain predicted outcomes.Study IV involved an exploration of the severity of cognitive impairments in refugees treated at the clinic, and their relationship to traumatic brain injury (TBI) and the severity of symptoms of PTSD, depression, anxiety, and pain at pre- treatment.The findings add to a large body of literature suggesting a strong relationship between pain, PTSD, depression, and high levels of disability in traumatized refugees. It shows that interference from pain can lessen the effectiveness of standard multi-modal treatments for refugees. Difficulties in cognitive functioning is also shown to be a significant contributor to overall distress in tortured refugees, suggesting the need for routine screening of head trauma and cognitive impairments.