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Die Posttraumatische Belastungsstörung (PTBS) nach sexueller Gewalt in der Kindheit geht häufig mit komorbiden Symptomen einher. Kognitiv-behaviorale Therapien haben sich als effektiv in der Behandlung der PTBS erwiesen. Die Datenlage zur PTBS nach sexueller Gewalt in der Kindheit ist jedoch gering. In der vorliegenden Dissertation wurden Fragestellungen zur Diagnostik und Therapie der PTBS nach sexueller Gewalt verfolgt. In Schrift 1 werden die Ergebnisse einer ambulanten Assessmentstudie präsentiert, in der 28 Patientinnen wiederholt zum intrusiven Wiederleben befragt wurden. Mit durchschnittlich 75 Intrusionen und 24 Flashbacks pro Woche fand sich eine hohe Symptombelastung. Die Schriften 2, 3 und 4 beziehen sich auf eine randomisiert-kontrollierte Studie. Patientinnen (N=74) wurden randomsiert einer 12-wöchigen stationären DBT-PTBS oder einer treatment-as-usual Warteliste zugewiesen. Die Ergebnisse, die in Schrift 2 beschrieben sind, zeigen eine signifikante Reduktion der posttraumatischen Symptomatik mit einer großen Zwischengruppen-Effektstärke (g=1.35). In Schrift 3 wird dargestellt, dass die Effekte auf die posttraumatische Symptomatik in Bezug auf mehrere traumatische Ereignisse geringer sind als die Effekte in Bezug auf das am stärksten belastende Ereignis. Schrift 4 beinhaltet Ergebnisse zu der Inanspruchnahme psychiatrisch-psychotherapeutischer Behandlung und den assoziierten Kosten. Im Jahr vor der DBT-PTBS fanden sich im Mittel jährliche Pro-Kopf-Kosten von  18100 € und 57 stationäre Tage. Im Jahr nach der DBT-PTBS waren die Inanspruchnahme mit durchschnittlich 14 Tagen und die mittleren Kosten von 7233 € deutlich geringer. Zusammengefasst sprechen die Ergebnisse für eine hohe Effektivität der DBT-PTBS. Zudem scheint die DBT-PTBS mit einer Reduktion stationärer Tage und entsprechender Kosten einherzugehen. Die Ergebnisse zur Diagnostik deuten darauf hin, dass ein Teil der Symptomatik mit dem üblichen diagnostischen Vorgehen nicht erfasst wird. / Posttraumatic stress disorder (PTSD) with co-occurring severe psychopathology is a frequent sequel of childhood sexual abuse (CSA). Cognitive-behavioral therapy has been shown to be efficacious in treating PTSD, but there is only limited data regarding patients with PTSD related to CSA. This dissertation focused on both the assessment and the treatment of PTSD related to CSA. Paper 1 presents data from an ambulatory assessment study. Patients (N=28) were provided with electronic diaries for repeated real-time assessment of intrusions and flashbacks. They reported an average of 75 intrusions and 24 flashbacks during the week of assessment. Papers 2, 3, and 4 present data from a randomized controlled trial. Patients (N=74) were randomized to either a 12-week residential DBT-PTSD program or a treatment-as-usual wait list. The results for primary and secondary outcomes are shown in Paper 2. Data revealed a significant reduction of posttraumatic symptoms with a large between-group effect size (g=1.35). Paper 3 provides results on the impact of the definition of the index trauma. When the index trauma included multiple traumas, PTSD severity scores were significantly higher, and improvements from pre- to post-treatment were significantly lower, compared to when the index trauma was defined as the worst trauma. Paper 4 presents data on the utilization of mental health care. The mean total costs were 18000 €  per patient during the year before and  7233 € during the year after DBT-PTSD. The significant cost reduction was due to large reductions in inpatient treatment days (on average 57 days before and 14 days after DBT-PTSD). To sum up, the findings show clear evidence for the efficacy of the DBT-PTSD program. Data further indicate that DBT-PTSD might contribute to reducing the mental health care costs. Also, the results suggest that the currently applied methods of assessing PTSD in patients with severe symptoms might miss aspects of clinically relevant symptomatology.

Despite a high proportion of the population experiencing traumatic events within their lifetime, the number of individuals who go on to develop posttraumatic stress disorder (PTSD) is comparatively small; herein highlighting the importance of individual differences in imparting risk and resilience towards the development and maintenance of PTSD. Existing literature illustrates that biological and ecological factors are important in predicting PTSD development, with pathological vulnerabilities excepting their effects at pre- peri- and post trauma stages. Whilst cognitive and emotion based models of PTSD account for the role of a minority of known pre-trauma risk factors, individual differences in peri- and post trauma processes are held as critical to the development of PTSD. The broad range of risk factors implicated in the empirical literature, and necessity of traumatic exposure to PTSD, implicates the utility of a diathesis-stress conceptualisation of PTSD development. The current thesis employed an analogue VR-trauma paradigm to investigate the respective importance of vulnerability factors at each stage, in the prediction of analogue PTSD symptoms (memory problems, startle responses, re-exposure fear habituation), whilst measuring affective and electrophysiological concomitance. Findings supported the importance of peri-traumatic responses in the prediction of PTSD, where present, showing increased predictive capacities over pre- and post-trauma factors. Biological and ecological factors also illustrated important predictive associations, with genetic SNPs implicated in reflex startle and cardiac responses towards intrusive memories. Moreover, peri-traumatic HR decelerations and accelerations mediated the association between pre-trauma factors and cued recall inaccuracy and intrusion severity respectively. Results support existing cognitive and emotional models in their emphasis on peri-traumatic processes but suggest the added utility of a diathesis stress conceptualisation of the development of PTSD, in highlighting the importance of pre-trauma biological and ecological risk and resilience factors.

Changing trends within the mental health system treatment practices demand exploration of the cultural context of assessment and treatment of Black/African Americans. Culturally competent assessments include a realistic integration of historical context. Clinicians counseling Black/African Americans must be prepared to assess and address PTSD, racial trauma, micro-aggressions, and other known (or unknown) issues that may affect Black/African Americans. In addition, clinicians must be prepared for the depth and permanence of race-based stress and trauma, as well as the idea that said stress and trauma can result from unaddressed environmental, familial, and/or individual factors. The purpose of this study is to explore cultural competence in the practices of clinicians working with Black/African Americans clients as it relates to assessment, treatment and engagement. Through the exploration of current multicultural counseling and assessment trends, the study explores the origins of stress and trauma in American descendents of African slaves, and proposes an evaluation of clinicians' mental health assessment for PTSD with said clients based on those implications. Exploring to what extent a culturally-proficient clinician engages Black/African Americans clients from initial through on-going assessment and treatment process in conjunction with the professional literature on treatment practices, research suggests that Black/African American clients do suffer from intergenerational trauma and are often mis- or under-diagnosed for mental health issues. With proper assessment of Black/African Americans, the reduction of misdiagnosed or under diagnosed cases of Posttraumatic stress disorder (PTSD), as well as other mental health conditions will occur. / Graduation date: 2012

Anxiety disorders are very common and the primary feature is abnormal or inappropriate anxiety. Fear and anxiety is often mediated by the amygdala, a brain structure rich in substance P (SP) and neurokinin 1 (NK1) receptors. To learn more about how the human amygdala is modulated by fear and anxiety in event-triggered anxiety disorders and to investigate if the SP/NK1 receptor system is affected, regional cerebral blood flow (rCBF) ([15O]-water; Study I and II) and the SP/NK1 receptor system ([11C]GR205171; Study III and IV) were studied with positron emission tomography (PET). In Study I we investigated the neural correlates of affective startle modulation in persons with specific phobia by measuring rCBF during exposure to fearful and non-fearful pictures, paired and unpaired with acoustic startle stimuli. Fear-potentiated startle was associated with activation of the affective part of the anterior cingulate cortex and the left amygdaloid–hippocampal area. In Study II short-term drug treatment effects on rCBF in patients diagnosed with social phobia was evaluated, comparing the NK1 receptor antagonist GR205171 to the selective serotonin reuptake inhibitor citalopram and placebo. Social anxiety and neural activity in the medial temporal lobe including the amygdala was significantly reduced by both drugs but not placebo. In Study III we investigated if activity in the SP/NK1 receptor system in the amygdala would be affected by fear provocation in individuals with specific snake or spider phobia. Fear provocation was associated with a decreased uptake of the NK1 antagonist [11C]GR205171 in the amygdala, possibly explained by an increase in endogenous SP release occupying the NK1 receptors. Study IV was conducted to explore the resting state NK1 receptor availability in PTSD patients as compared to healthy controls. Increased resting state binding of the tracer [11C]GR205171 in the amygdala of patients with PTSD suggested an increased amount of available receptors. In summary, fear and fear-potentiated startle modulates the human amygdala, possibly through the SP/NK1 receptor system.

Providing aid to the inhabitants struck by the stress incentives is on a good level. The findings show that the system of aid providing is set and guarantees its functionality as well as efficiency. Its part is also the preparation of the members of components of the Integrated Rescue System to provide the aid during the stress load of the inhabitants. It is provided on the sufficient level with a significant effort of services bodies and services bodies for its development and structuring. The problem consists in the level of preparedness of the inhabitants. Their behaviour does not correspond to the needs, the people behave in a chaotic way, do not respect the instructions, underestimated the danger. The reason is not that no suitable conditions were created for their preparation or that such a preparation was not performed at all. It was found out that the offer for the substantial education of inhabitants is on the sufficient level and has an adequate scope. Also its forms cover real expectations. The problem is its limited usage by inhabitants for the reason of underestimation of risks and danger. The people are indifferent and persuaded they personally cannot be endangered or struck. The consequence is the state in which neither the individuals nor their communities are prepared on the extraordinary events and they do not know how to behave during them rationally and safely. This leads to the further deepening of the stress load and to the gradation of the initiated psychological problems. As a solution, the creation of a general public meaning is recommended alerting to danger of extraordinary events and to the necessity of a responsible personal preparation on them, including the awareness of the associated psychological endangerment.

Based on longitudinal ethnographic fieldwork in Bosnia and Herzegovina I trace ontologies of posttraumatic stress disorder (PTSD) and their enactments among veterans of the 1992-1995 war. My aim is to problematize and rethink social constructionists' approaches in medical anthropology that discuss war trauma and PTSD in relation to naturalistic models and treat them as constructed realities not determined by the nature of things. I argue that such a standpoint produces a particular epistemological/ontological side-effect: it allows medical anthropologists to craft a purely social ontology of trauma and PTSD by claiming that the realness of these "constructs" is a result of psychiatric discourse, moral economy of contemporary societies or Western (intellectual, political, and medical) hegemony. Considering the ontology of PTSD as an empirical question I analyze the enactments of PTSD in four settings: the ethnographic genre itself, the organization of war veterans with PTSD in the city of Tuzla, the veterans' welfare system in the Federation of Bosnia and Herzegovina, and Bosnian public arena. I argue that PTSD is practiced as a heterogeneous and multiple reality that cannot be situated solely either in the realm of human organism (and explained by naturalistic models) or society and culture (and...