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Conflict and Health

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Open Access 01-12-2012 | Research

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

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

Published in: Conflict and Health | Issue 1/2012

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.

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Liedl A, Knaevelsrud C: PTSD and chronic pain: development, maintenance and comorbidity–a review. Schmerz. 2008, 22 (6): 644-651. 10.1007/s00482-008-0714-0.PubMed

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. 10.1016/j.neuropharm.2011.04.028.PubMed

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. 10.1682/JRRD.2003.09.0397.PubMed

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. 10.1007/s11916-000-0008-4.PubMed

Andreski P, Chilcoat H, Breslau N: Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatr Res. 1998, 79 (2): 131-138. 10.1016/S0165-1781(98)00026-2.

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. 10.1016/j.pain.2008.05.006.PubMed

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.PubMed

Thomsen AB, Eriksen J, Smidt-Nielsen K: Chronic pain in torture survivors. Forensic Sci Int. 2000, 108 (3): 155-163. 10.1016/S0379-0738(99)00209-1.PubMed

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. 10.1080/14034940600554677.

10.

Perera P: Physical methods of torture and their sequelae: a Sri Lankan perspective. J Forensic Leg Med. 2007, 14 (3): 146-150. 10.1016/j.jcfm.2006.05.010.PubMed

11.

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: 11-10.1186/1752-1505-4-11.PubMedCentralPubMed

12.

Melzack R: The McGill pain questionnaire: from description to measurement. Anesthesiology. 2005, 103 (1): 199-202. 10.1097/00000542-200507000-00028.PubMed

13.

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. 10.1016/j.jclinepi.2009.03.019.PubMed

14.

Margolis RB, Tait RC, Krause SJ: A rating system for use with patient pain drawings. Pain. 1986, 24 (1): 57-65. 10.1016/0304-3959(86)90026-6.PubMed

15.

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: 16-10.1186/1752-1505-4-16.PubMedCentralPubMed

16.

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

17.

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.PubMed

18.

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. 10.1023/A:1024413918346.PubMed

19.

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. 10.1001/jama.284.5.569.PubMed

20.

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. 2004, New York and Geneva

21.

Meissner JE: McGill-Melzack pain questionnaire. Nursing. 1980, 10 (1): 50-51.

22.

Melzack R: The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975, 1 (3): 277-299. 10.1016/0304-3959(75)90044-5.PubMed

23.

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. 10.1097/AJP.0b013e3181e15b98.PubMed

24.

Nagai M, Kishi K, Kato S: Insular cortex and neuropsychiatric disorders: a review of recent literature. Eur Psychiatr. 2007, 22 (6): 387-394. 10.1016/j.eurpsy.2007.02.006.

25.

Mickleborough MJ, Daniels JK, Coupland NJ, Kao R, Williamson PC, Lanius UF, Hegadoren K, Schore A, Densmore M, Stevens T: Effects of trauma-related cues on pain processing in posttraumatic stress disorder: an fMRI investigation. J Psychiatr Neurosci. 2011, 36 (1): 6-14. 10.1503/jpn.080188.

26.

Woolf CJ: Evidence for a central component of post-injury pain hypersensitivity. Nature. 1983, 306 (5944): 686-688. 10.1038/306686a0.PubMed

27.

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. 10.1097/00002508-199403000-00002.PubMed

28.

Fernandez E, Turk DC: The scope and significance of anger in the experience of chronic pain. Pain. 1995, 61 (2): 165-175. 10.1016/0304-3959(95)00192-U.PubMed

29.

Fernandez E: The relationship between anger and pain. Curr Pain Headache Rep. 2005, 9 (2): 101-105. 10.1007/s11916-005-0046-z.PubMed

30.

Rainville P, Bao QV, Chretien P: Pain-related emotions modulate experimental pain perception and autonomic responses. Pain. 2005, 118 (3): 306-318. 10.1016/j.pain.2005.08.022.PubMed

31.

Sonnenberg SM: A transcultural observation of posttraumatic stress disorder. Hosp Community Psychiatr. 1982, 33 (1): 58-59.

32.

Kastrup MC: Gender, human rights and cultural diversity: reflections on a career in transcultural psychiatry. Transcult Psychiatr. 2011, 48 (1–2): 66-78.

33.

Kirmayer LJ: Defining and delimiting trauma-related dissociation: a view from cultural psychiatry. J Trauma Dissociation. 2011, 12 (4): 465-468. 10.1080/15299732.2011.570235. discussion 469–473PubMed

34.

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]

35.

Teh CF, Zaslavsky AM, Reynolds CF, Cleary PD: Effect of depression treatment on chronic pain outcomes. Psychosom Med. 72 (1): 61-67.

36.

Clark MR, Cox TS: Refractory chronic pain. Psychiatr Clin North Am. 2002, 25 (1): 71-88. 10.1016/S0193-953X(03)00053-4.PubMed

37.

Kinzie JD: Guidelines for psychiatric care of torture survivors. Torture Q J Rehabil Torture Vict Prev Torture. 2011, 21 (1): 18-26.

38.

Drozdek B: Wilson JP: Voices of trauma: treating psychological trauma across cultures. 2007, New York, NY: Springer

39.

Wilson JP, Drozdek B: Broken spirits: the treatment of traumatized asylum seekers, refugees, war, and torture victims. 2004, New York: Brunner-Routledge

40.

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. 10.1017/S0033291797005679.PubMed

41.

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.

42.

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. 10.1111/j.1526-4637.2010.01040.x.PubMed

43.

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. 10.1176/appi.ps.59.8.878.PubMedCentralPubMed

44.

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. 10.1097/AJP.0b013e318208c8e4.PubMed

45.

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. 10.1097/PSY.0b013e3181ae6aee.PubMed

46.

Rosen J, Reynolds CF, Yeager AL, Houck PR, Hurwitz LF: Sleep disturbances in survivors of the Nazi Holocaust. Am J Psychiatry. 1991, 148 (1): 62-66.PubMed

47.

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.PubMed

48.

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. 35 (1): 175-181.

49.

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. 10.1016/S0006-3223(98)00037-7.PubMed

50.

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. 10.1016/j.brat.2006.12.006.PubMed

51.

Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2005, 2: CD003388.PubMed

52.

Foa EB: Psychosocial therapy for posttraumatic stress disorder. J Clin Psychiatr. 2006, 67 (Suppl 2): 40-45.

53.

Robjant K, Fazel M: The emerging evidence for Narrative Exposure Therapy: a review. Clin Psychol Rev. 2010, 30 (8): 1030-1039. 10.1016/j.cpr.2010.07.004.PubMed

54.

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. 10.1159/000229768.PubMed

55.

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.

56.

Bar-Tal D: Intergroup conflicts and their resolution: a social psychological perspective. 2011, New York: Psychology Press

57.

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. 10.1080/02699931.2010.536081.PubMed

Title: 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
Authors: Shr-Jie Wang
Feride Rushiti
Xhevdet Sejdiu
Sebahate Pacolli
Besart Gashi
Florentina Salihu
Jens Modvig
Publication date: 01-12-2012
Publisher: BioMed Central
Published in: Conflict and Health / Issue 1/2012
Electronic ISSN: 1752-1505
DOI: https://doi.org/10.1186/1752-1505-6-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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