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Phd by Public Works School of Health and Social Sciences January 2012 Acknowledgements Middlesex University Research Repository An open access repository of Middlesex University research http://eprints.mdx.ac.uk Powell, Stephen (2012) The psychosocial consequences of the 1992-5 war in Bosnia & Herzegovina. [Doctorate by Public Works] This version is available at: https://eprints.mdx.ac.uk/8402/ Copyright: Middlesex University Research Repository makes the University’s research available electronically. Copyright and moral rights to this work are retained by the author and/or other copyright owners unless otherwise stated. The work is supplied on the understanding that any use for commercial gain is strictly forbidden. A copy may be downloaded for personal, non-commercial, research or study without prior permission and without charge. Works, including theses and research projects, may not be reproduced in any format or medium, or extensive quotations taken from them, or their content changed in any way, without first obtaining permission in writing from the copyright holder(s). They may not be sold or exploited commercially in any format or medium without the prior written permission of the copyright holder(s). Full bibliographic details must be given when referring to, or quoting from full items including the author’s name, the title of the work, publication details where relevant (place, publisher, date), pag- ination, and for theses or dissertations the awarding institution, the degree type awarded, and the date of the award. If you believe that any material held in the repository infringes copyright law, please contact the Repository Team at Middlesex University via the following email address: [email protected] The item will be removed from the repository while any claim is being investigated. See also repository copyright: re-use policy: http://eprints.mdx.ac.uk/policies.html#copy Middlesex University Research Repository: an open access repository of Middlesex University research Powell, Stephen, 2012. The psychosocial consequences of the 1992-5 war in Bosnia & Herzegovina. Available from Middlesex University’s Research Repository. Copyright: Middlesex University Research Repository makes the University’s research available electronically. Copyright and moral rights to this thesis/research project are retained by the author and/or other copyright owners. The work is supplied on the understanding that any use for commercial gain is strictly forbidden. A copy may be downloaded for personal, non-commercial, research or study without prior permission and without charge. Any use of the thesis/research project for private study or research must be properly acknowledged with reference to the work’s full bibliographic details. This thesis/research project may not be reproduced in any format or medium, or extensive quotations taken from it, or its content changed in any way, without first obtaining permission in writing from the copyright holder(s). If you believe that any material held in the repository infringes copyright law, please contact the Repository Team at Middlesex University via the following email address: [email protected] The item will be removed from the repository while any claim is being investigated. The psychosocial consequences of the 1992-5 war in Bosnia & Herzegovina. Stephen Powell A Context Statement submitted to Middlesex University in partial fulfilment of the requirements for the degree of PhD by Public Works School of Health and Social Sciences January 2012 Acknowledgements All of the research in the submitted papers was carried out as part of a cooperation program initiated by the Institute for Clinical Psychology and Psychotherapy, LMU (University of Mu- nich) and funded by the Volkswagen-Stiftung Program, grant number II/73301, and by the Deutscher Akademischer Austauschdienst (DAAD; German Academic Exchange Service: Son- derausschreibung 2.12.96). This program involved formal cooperation with the Departments of Psychology at the University of Sarajevo and later in Banja Luka and other Universities in the region. The research program was led from Munich by Prof. Dr. Willi Butollo and Dr1. Rita Rosner. Elma Pašić was Program Manager during the fieldwork in 1999 and 2000. The fieldwork in 1999 (Table 1.3 on page 20) was also supported by the GTZ (Deutsche Gesell- schaft für Technische Zusammenarbeit, Office of the Federal Government Commissioner Hans Koschnick). The fieldwork in Sarajevo and Banja Luka was carried out by advanced students of psychology in cooperation with their respective Departments of Psychology. The Psychology Department of the University of Banja Luka was also involved in helping to develop the questions for the research carried out in 1999. Ema Kapetanović gave valuable assistance to the fieldwork in 2000. Heartfelt thanks are due to all of the above, and especially to those citizens of Bosnia & Herzegovina who answered the sometimes exhausting batteries of questions. 1Now Prof. Dr. Rosner 1 Abstract a) The research carried out Eight different samples of citizens of Bosnia and Herzegovina were assessed in 1998 and 1999, two to four years after the end of the 1992-5 war, covering a wide range of variables including traumatic and stressful experiences and various measures of psychosocial adaptation including PTSD. b) Main results and conclusion The results were published in nine papers which are described in this Context Statement, and which are also included as Appendices. Taken together, the specific (and sometimes tragic) features of the conflict in B&H, and some strengths of the research design, enabled the papers to make a significant contribution to three key psychological themes. The first theme was PTSD concept and measurement. The psychometric performance of meas- ures of PTSD in B&H were found to be similar to other published results, suggesting that the construct is as valid for the B&H population as for the comparison populations on which the instrument was developed. The case is also made for dropping Criterion A from the DSM PTSD diagnosis altogether, on the grounds of overwhelming practical and conceptual problems with assessing it using populations with multiple stressors. The second theme was epidemiology and aetiology of PTSD and other symptom groups. Quite apart from PTSD, the war had a very significant impact on general mental health across the population. Current PTSD prevalences in the non-treatment samples ranged from 11% amongst returned refugees to 36% amongst internally displaced persons (IDPs) in camps, which are in line with the literature. Beyond PTSD, impact was concentrated in particularly high levels of somatisation, paranoid ideation, and aggression. PTSD prevalences amongst returned refugees are clearly lower than those of their peers who stayed in host countries, and much lower than all known reports in refugee samples abroad. Analysis of persons in treatment suggests that those who seek treatment for PTSD (as opposed to other medical problems) do have high levels of PTSD symptoms specifically, but not necessarily because they experienced a larger number of traumatic events. The third theme looked beyond psychopathology. Findings suggest that the concept of post- traumatic growth can be validly extended to this population, but levels were considerably lower than reported in most other studies on other kinds of traumatic event. Finally PTSD and the PTSD diagnosis are discussed in a broader social context and it is concluded that while the war had many different kinds of consequences beyond the purely clinical, this should not divert attention from the fact that individual, clinically-relevant suffering was prevalent in the population at levels warranting urgent attention from public health care. Contents 1 Context Statement: Introduction 6 1.1 Abbreviations . .6 1.2 Structure . .7 1.3 The historical and research context . .8 1.4 Positive and negative reactions to traumatic events: PTSD and PTG . 12 1.5 The research project and methods . 19 1.6 Ethical issues . 32 2 Findings on PTSD: concept and measurement 34 2.1 The construct of PTSD . 34 2.2 Structure and reliability in B&H context . 35 2.3 DSM vs ICD . 35 2.4 Problem of symptom overlap . 36 2.5 Diagnostic inflation . 37 2.6 The problem of Criterion A and multiple trauma . 37 3 Findings on PTSD and other symptom groups: epidemiology and aetiology in different contexts 40 3.1 Background . 40 3.2 Findings and recent developments . 40 4 Findings on consequences beyond PTSD 47 4.1 Background . 47 4.2 Post-Traumatic Growth and other positive outcomes after stressful events . 48 4.3 Maintenance and long-term trajectories . 52 4.4 Cultural and situational validity of the PTSD concept from a public health per- spective . 55 1 5 Limitations 58 5.1 Appropriateness of methods . 58 5.2 Statistical issues . 59 5.3 Additional relevant materials not covered here . 60 6 Conclusion of the findings: the value and impact of the research 62 6.1 The potential of the research project in the research context to make a contri- bution to the main themes. 62 6.2 Chapter 2: PTSD concept and measurement . 63 6.3 Chapter 3: PTSD and other symptom groups: epidemiology and aetiology in different contexts . 63 6.4 Chapter 4: Beyond PTSD . 64 6.5 Future work . 65 Bibliography 66 A The published works 77 A.1 Paper 1: Rosner, R., Powell, S. & Butollo, W. (2003). Post-traumatic Stress Disorder three years after the Siege of Sarajevo. Journal of Clinical Psychology . 77 A.2 Paper 2: Powell, S., Rosner, R., & Butollo, W. (2000). Flight Paths: Report to the Office of the (German) Federal Government Commissioner for the Return of Refugees, Reintegration and related Reconstruction in Bosnia and Herzegovina. Sarajevo: GTZ-Büro. 93 A.3 Paper 3: Powell, S., & Rosner, R. (2005). The Bosnian version of the interna- tional self-report measure of post-traumatic stress disorder, the Post-traumatic Stress Diagnostic Scale, is reliable and valid in a variety of different adult samples affected by war. BMC Psychiatry, 5(1), 11. doi:10.1186/1471-244X-5-11 .
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