Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway

Teodorescu et al. Health and Quality of Life Outcomes 2012, 10:84 http://www.hqlo.com/content/10/1/84 RESEARCH Open Access Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway Dinu-Stefan Teodorescu1*, Johan Siqveland2, Trond Heir3, Edvard Hauff4,5, Tore Wentzel-Larsen3,6,7 and Lars Lien1,4,5 Abstract Background: Psychiatric outpatients with a refugee background have often been exposed to a variety of potentially traumatizing events, with numerous negative consequences for their mental health and quality of life. However, some patients also report positive personal changes, posttraumatic growth, related to these potentially traumatic events. This study describes posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, post-migration stressors, and their association with quality of life in an outpatient psychiatric population with a refugee background in Norway. Methods: Fifty five psychiatric outpatients with a refugee background participated in a cross-sectional study using clinical interviews to measure psychopathology (SCID-PTSD, MINI), and four self-report instruments measuring posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, and quality of life (PTGI-SF, IES-R, HSCL-25-depression scale, and WHOQOL-Bref) as well as measures of social integration, social network and employment status. Results: All patients reported some degree of posttraumatic growth, while only 31% reported greater amounts of growth. Eighty percent of the patients had posttraumatic stress symptoms above the cut-off point, and 93% reported clinical levels of depressive symptoms. Quality of life in the four domains of the WHOQOL-Bref levels were low, well below the threshold for the’life satisfaction’ standard proposed by Cummins. A hierarchic regression model including depressive symptoms, posttraumatic stress symptoms, posttraumatic growth, and unemployment explained 56% of the total variance found in the psychological health domain of the WHOQOL-Bref scale. Posttraumatic growth made the strongest contribution to the model, greater than posttraumatic stress symptoms or depressive symptoms. Post-migration stressors like unemployment, weak social network and poor social integration were moderately negatively correlated with posttraumatic growth and quality of life, and positively correlated with psychopathological symptoms. Sixty percent of the outpatients were unemployed. * Correspondence: 1 Innlandet Hospital Trust, PO Box 104, Brumunddal N-2381, Norway Full list of author information is available at the end of the article © 2012 Teodorescu et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Teodorescu et al. Health and Quality of Life Outcomes 2012, 10:84 http://www.hqlo.com/content/10/1/84 Page 2 of 16 Conclusions: Multi-traumatized refugees in outpatient clinics reported both symptoms of psychopathology and posttraumatic growth after exposure to multiple traumatic events. Symptoms of psychopathology were negatively related to the quality of life, and positively related to post-migration stressors such as unemployment, weak social network and poor social integration. Posttraumatic growth was positively associated with quality of life, and negatively associated with post-migration stressors. Hierarchical regression modeling showed that posttraumatic growth explained more of the variance in quality of life than did posttraumatic stress symptoms, depressive symptoms or unemployment. It may therefore be necessary to address both positive changes and psychopathological symptoms when assessing and treating multi-traumatized outpatients with a refugee background. Introduction Many refugees in Norway have been exposed to multiple traumatic events in their home countries, such as imprisonment in concentration camps, torture or multiple rapes [1]. As a consequence of this they can suffer from a variety of psychiatric problems for many years after resettlement. In spite of exposure to such overwhelming traumatic events, some refugees also report positive personal changes related to these highly negative events, often referred to as posttraumatic growth. This phenomenon of benefiting or growing psychologically from traumatic events has been long recognized throughout human history, and in the 19th century Nietzsche famously said “That which does not kill us makes us stronger” [2], indicating the potential for personal growth after a traumatic event. After the Second World War, Victor Frankl began the modern inquiry of perceived positive changes [3] and later several researchers have empirically identified the same phenomenon, some calling it “benefit finding” [4], “stress-related growth” [5], “adversial growth” [6], and “posttraumatic growth” [7]. Tedeschi and Calhoun defined posttraumatic growth (PTG) as a “positive psychological change experienced as a result of the struggle with highly challenging life circumstances” ([8] page1). According to Tedeschi and Calhoun, positive changes can be divided into five sub-domains: relating to others, new possibilities, personal strength, spiritual change and appreciation of life. There is a growing volume of research providing evidence for psychological growth in a variety of populations (children, adolescents, and adults) exposed to diverse traumatic events. Posttraumatic growth has been identified in refugees and immigrants [9-13], adult civilians exposed to war [14,15], civilians exposed to terrorism [16-18],veterans of war [19,20], former child soldiers [21], former war prisoners [22-25], former political prisoners [26], and in victims of interpersonal violence [27-30]. For PTG to be more than an interesting concept for academic psychology, its relation to health, both physical and mental, and quality of life are essential, and research thus far has been inconclusive about these relationships [31-33]. Posttraumatic growth and posttraumatic stress symptoms PTG is related to the dramatic impact of a traumatic event, which is followed by symptoms of psychological distress and PTSD symptoms. It is not essential to the development of PTG that the person experiences a full diagnosis of PTSD, but some psychological distress is essential [8]. Tedeschi and Calhoun proposed that posttraumatic growth and posttraumatic stress may be largely two different dimensions, thus, it is possible to report both growth experiences and distress in trauma survivors [8,34]. There are conflicting results from empirical studies on posttraumatic growth theory. Many studies report a positive relationship between PTG and posttraumatic stress (...truncated)