Survivors of war in northern Kosovo (III): The role of anger and hatred in pain and PTSD and their interactive effects on career outcome, quality of sleep and suicide ideation

Shr-Jie Wang, Feride Rushiti, Xhevdet Sejdiu, Sebahate Pacolli, Besart Gashi, Florentina Salihu, Jens Modvig, Shr-Jie Wang, Feride Rushiti, Xhevdet Sejdiu, Sebahate Pacolli, Besart Gashi, Florentina Salihu, Jens Modvig

Abstract

Background: The management of chronic debilitating health conditions after trauma remains a challenge in post-conflict settings. The study aimed to expand current understanding of the diagnostic overlap of pain and PTSD and explore their independent and interactive effect on career change, sleep disorder and suicide ideation. The role of anger and hatred as contributing factors to the persistence of pain and PTSD were also examined.

Methods: 125 victims of torture and massive violence identified in a household survey took part in the in-depth assessment. Socio-demographic data and information on trauma, emotional disturbance, injuries and medication history were collected. PTSD was diagnosed according to DSM-IV criteria. Pain was assessed using the McGill Pain Questionnaire and the Margolis Pain Diagram.

Results: Nearly 95% participants experienced pain during the last 2 weeks, 47% were diagnosed with PTSD, 50% were taking medication against depression and anxiety. There is substantial overlap of pain, PTSD and emotional disturbance. Injury history, PTSD and negative emotions were related to the pain score and the number of pain locations. Anger, hatred or an inferiority complex particularly amplified pain experience. Headache was constant and especially prevalent in those with recent experience of anger, aggressiveness and hatred. The risk of having chest and abdominal pain within 2 weeks was very high in those who had chest injury and had recently been crying. An increased risk of changing jobs or stopping work or schooling due to depression or injury was observed for those with a higher pain score, and for pain in neck, shoulder and upper limbs. The prevalence of sleep disorders was 80%, that of suicide ideation 70%, and these were found to be associated with greater pain and anger. PTSD was also related to suicide ideation.

Conclusions: The findings provide an overview of pain characteristics in individuals with PTSD and injury and confirm the hypothesized effects on career outcome, sleep disorders and suicide ideation. The study revealed a high level of persistent anger and hatred. The findings suggest the need for new approaches to rehabilitation in a post-war setting, including ways in which to address collective emotional hurt in the society.

Figures

Figure 1
Figure 1
Trend and patterns of incident reporting.
Figure 2
Figure 2
Pain locations on body diagram.

References

    1. Liedl A, Knaevelsrud C. PTSD and chronic pain: development, maintenance and comorbidity–a review. Schmerz. 2008;22(6):644–651. doi: 10.1007/s00482-008-0714-0.
    1. Moeller-Bertram T, Keltner J, Strigo IA. Pain and post traumatic stress disorder - review of clinical and experimental evidence. Neuropharmacology. 2012;62(2):586–597. doi: 10.1016/j.neuropharm.2011.04.028.
    1. Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev. 2003;40(5):397–405. doi: 10.1682/JRRD.2003.09.0397.
    1. Kulich RJ, Mencher P, Bertrand C, Maciewicz R. Comorbidity of post-traumatic stress disorder and chronic pain: implications for clinical and forensic assessment. Curr Rev Pain. 2000;4(1):36–48. doi: 10.1007/s11916-000-0008-4.
    1. Andreski P, Chilcoat H, Breslau N. Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatr Res. 1998;79(2):131–138. doi: 10.1016/S0165-1781(98)00026-2.
    1. Defrin R, Ginzburg K, Solomon Z, Polad E, Bloch M, Govezensky M, Schreiber S. Quantitative testing of pain perception in subjects with PTSD–implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138(2):450–459. doi: 10.1016/j.pain.2008.05.006.
    1. Demyttenaere K, Bonnewyn A, Bruffaerts R, Brugha T, De Graaf R, Alonso J. Comorbid painful physical symptoms and depression: prevalence, work loss, and help seeking. J Affect Disord. 2006;92(2–3):185–193.
    1. Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic pain in torture survivors. Forensic Sci Int. 2000;108(3):155–163. doi: 10.1016/S0379-0738(99)00209-1.
    1. Olsen DR, Montgomery E, Bojholm S, Foldspang A. Prevalent musculoskeletal pain as a correlate of previous exposure to torture. Scand J Publ Health. 2006;34(5):496–503. doi: 10.1080/14034940600554677.
    1. Perera P. Physical methods of torture and their sequelae: a Sri Lankan perspective. J Forensic Leg Med. 2007;14(3):146–150. doi: 10.1016/j.jcfm.2006.05.010.
    1. Wang SJ, Salihu M, Rushiti F, Bala L, Modvig J. Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict. Confl Health. 2010;4:11. doi: 10.1186/1752-1505-4-11.
    1. Melzack R. The McGill pain questionnaire: from description to measurement. Anesthesiology. 2005;103(1):199–202. doi: 10.1097/00000542-200507000-00028.
    1. Menezes Costa Lda C, Maher CG, McAuley JH, Costa LO. Systematic review of cross-cultural adaptations of McGill Pain Questionnaire reveals a paucity of clinimetric testing. J Clin Epidemiol. 2009;62(9):934–943. doi: 10.1016/j.jclinepi.2009.03.019.
    1. Margolis RB, Tait RC, Krause SJ. A rating system for use with patient pain drawings. Pain. 1986;24(1):57–65. doi: 10.1016/0304-3959(86)90026-6.
    1. Wang SJ, Pacolli S, Rushiti F, Rexhaj B, Modvig J. Survivors of war in the Northern Kosovo (II): baseline clinical and functional assessment and lasting effects on the health of a vulnerable population. Confl Health. 2010;4:16. doi: 10.1186/1752-1505-4-16.
    1. United Nations. Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment. The Office of the High Commissioner for Human Rights S: United Nations. 2006.
    1. Wenzel T, Rushiti F, Aghani F, Diaconu G, Maxhuni B, Zitterl W. Suicidal ideation, post-traumatic stress and suicide statistics in Kosovo. An analysis five years after the war. Suicidal ideation in Kosovo. Torture. 2009;19(3):238–247.
    1. Lopes Cardozo B, Kaiser R, Gotway CA, Agani F. Mental health, social functioning, and feelings of hatred and revenge of Kosovar Albanians one year after the war in Kosovo. J Trauma Stress. 2003;16(4):351–360. doi: 10.1023/A:1024413918346.
    1. Lopes Cardozo B, Vergara A, Agani F, Gotway CA. Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA. 2000;284(5):569–577. doi: 10.1001/jama.284.5.569.
    1. United Nations High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. New York and Geneva; 2004.
    1. Meissner JE. McGill-Melzack pain questionnaire. Nursing. 1980;10(1):50–51.
    1. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1(3):277–299. doi: 10.1016/0304-3959(75)90044-5.
    1. Martin AL, Halket E, Asmundson GJ, Flora DB, Katz J. Posttraumatic stress symptoms and the diathesis-stress model of chronic pain and disability in patients undergoing major surgery. Clin J Pain. 2010;26(6):518–527. doi: 10.1097/AJP.0b013e3181e15b98.
    1. Nagai M, Kishi K, Kato S. Insular cortex and neuropsychiatric disorders: a review of recent literature. Eur Psychiatr. 2007;22(6):387–394. doi: 10.1016/j.eurpsy.2007.02.006.
    1. Mickleborough MJ, Daniels JK, Coupland NJ, Kao R, Williamson PC, Lanius UF, Hegadoren K, Schore A, Densmore M, Stevens T. et al.Effects of trauma-related cues on pain processing in posttraumatic stress disorder: an fMRI investigation. J Psychiatr Neurosci. 2011;36(1):6–14. doi: 10.1503/jpn.080188.
    1. Woolf CJ. Evidence for a central component of post-injury pain hypersensitivity. Nature. 1983;306(5944):686–688. doi: 10.1038/306686a0.
    1. Fernandez E, Milburn TW. Sensory and affective predictors of overall pain and emotions associated with affective pain. Clin J Pain. 1994;10(1):3–9. doi: 10.1097/00002508-199403000-00002.
    1. Fernandez E, Turk DC. The scope and significance of anger in the experience of chronic pain. Pain. 1995;61(2):165–175. doi: 10.1016/0304-3959(95)00192-U.
    1. Fernandez E. The relationship between anger and pain. Curr Pain Headache Rep. 2005;9(2):101–105. doi: 10.1007/s11916-005-0046-z.
    1. Rainville P, Bao QV, Chretien P. Pain-related emotions modulate experimental pain perception and autonomic responses. Pain. 2005;118(3):306–318. doi: 10.1016/j.pain.2005.08.022.
    1. Sonnenberg SM. A transcultural observation of posttraumatic stress disorder. Hosp Community Psychiatr. 1982;33(1):58–59.
    1. Kastrup MC. Gender, human rights and cultural diversity: reflections on a career in transcultural psychiatry. Transcult Psychiatr. 2011;48(1–2):66–78.
    1. Kirmayer LJ. Defining and delimiting trauma-related dissociation: a view from cultural psychiatry. J Trauma Dissociation. 2011;12(4):465–468. doi: 10.1080/15299732.2011.570235. discussion 469–473.
    1. Eytan A, Gex-Fabry M. Use of healthcare services 8 years after the war in Kosovo: role of post-traumatic stress disorder and depression. 2011. Aug 3. [Epub ahead of print]
    1. Teh CF, Zaslavsky AM, Reynolds CF, 3rd, Cleary PD. Effect of depression treatment on chronic pain outcomes. Psychosom Med. pp. 61–67.
    1. Clark MR, Cox TS. Refractory chronic pain. Psychiatr Clin North Am. 2002;25(1):71–88. doi: 10.1016/S0193-953X(03)00053-4.
    1. Kinzie JD. Guidelines for psychiatric care of torture survivors. Torture Q J Rehabil Torture Vict Prev Torture. 2011;21(1):18–26.
    1. Drozdek B. Wilson JP: Voices of trauma: treating psychological trauma across cultures. New York, NY: Springer; 2007.
    1. Wilson JP, Drozdek B. Broken spirits: the treatment of traumatized asylum seekers, refugees, war, and torture victims. New York: Brunner-Routledge; 2004.
    1. Basoglu M, Mineka S, Paker M, Aker T, Livanou M, Gok S. Psychological preparedness for trauma as a protective factor in survivors of torture. Psychol Med. 1997;27(6):1421–1433. doi: 10.1017/S0033291797005679.
    1. Jaranson JM, Quiroga J. Evaluating the services of torture rehabilitation programmes: history and recommendations. Torture Q J Rehabil Torture Vict Prev Torture. 2011;21(2):98–140.
    1. Liedl A, Muller J, Morina N, Karl A, Denke C, Knaevelsrud C. Physical activity within a CBT intervention improves coping with pain in traumatized refugees: results of a randomized controlled design. Pain Med. 2011;12(2):234–245. doi: 10.1111/j.1526-4637.2010.01040.x.
    1. Braden JB, Zhang L, Zimmerman FJ, Sullivan MD. Employment outcomes of persons with a mental disorder and comorbid chronic pain. Psychiatr Serv. 2008;59(8):878–885. doi: 10.1176/appi.ps.59.8.878.
    1. O'Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, Robinson ME. Intraindividual variability in daily sleep and pain ratings among chronic pain patients: bidirectional association and the role of negative mood. Clin J Pain. 2011;27(5):425–433. doi: 10.1097/AJP.0b013e318208c8e4.
    1. Llabre MM, Hadi F. War-related exposure and psychological distress as predictors of health and sleep: a longitudinal study of Kuwaiti children. Psychosom Med. 2009;71(7):776–783. doi: 10.1097/PSY.0b013e3181ae6aee.
    1. Rosen J, Reynolds CF 3rd, Yeager AL, Houck PR, Hurwitz LF. Sleep disturbances in survivors of the Nazi Holocaust. Am J Psychiatry. 1991;148(1):62–66.
    1. Shemesh AA, Kohn R, Radomislensky I, Brodsky J, Levav I. Emotional distress and other health-related dimensions among elderly survivors of the Shoa living in the community. Isr J Psychiatry Relat Sci. 2008;45(4):230–238.
    1. Jevtovic S, Gregurek R, Kalenic B, Brajkovic L, Bras M, Loncar M, Germain A. Correlation of sleep disturbances, anxiety and depression in Croatian war veterans with posttraumatic stress disorder. Coll Antropol. pp. 175–181.
    1. Lavie P, Katz N, Pillar G, Zinger Y. Elevated awaking thresholds during sleep: characteristics of chronic war-related posttraumatic stress disorder patients. Biol Psychiatry. 1998;44(10):1060–1065. doi: 10.1016/S0006-3223(98)00037-7.
    1. Bichescu D, Neuner F, Schauer M, Elbert T. Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression. Behav Res Ther. 2007;45(9):2212–2220. doi: 10.1016/j.brat.2006.12.006.
    1. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD) Cochrane Database Syst Rev. 2005;2:CD003388.
    1. Foa EB. Psychosocial therapy for posttraumatic stress disorder. J Clin Psychiatr. 2006;67(Suppl 2):40–45.
    1. Robjant K, Fazel M. The emerging evidence for Narrative Exposure Therapy: a review. Clin Psychol Rev. 2010;30(8):1030–1039. doi: 10.1016/j.cpr.2010.07.004.
    1. Schaal S, Elbert T, Neuner F. Narrative exposure therapy versus interpersonal psychotherapy. A pilot randomized controlled trial with Rwandan genocide orphans. Psychother Psychosom. 2009;78(5):298–306. doi: 10.1159/000229768.
    1. Liedl A, Knaevelsrud C. Chronic pain and PTSD: the Perpetual Avoidance Model and its treatment implications. Torture Q J Rehabil Torture Vict Prev Torture. 2008;18(2):69–76.
    1. Bar-Tal D. Intergroup conflicts and their resolution: a social psychological perspective. New York: Psychology Press; 2011.
    1. Halperin E, Gross JJ. Emotion regulation in violent conflict: reappraisal, hope, and support for humanitarian aid to the opponent in wartime. Cogn Emot. 2011;25(7):1228–1236. doi: 10.1080/02699931.2010.536081.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel