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      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

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          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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          Most cited references31

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          Evidence for a central component of post-injury pain hypersensitivity.

          C J Woolf (2015)
          Noxious skin stimuli which are sufficiently intense to produce tissue injury, characteristically generate prolonged post-stimulus sensory disturbances that include continuing pain, an increased sensitivity to noxious stimuli and pain following innocuous stimuli. This could result from either a reduction in the thresholds of skin nociceptors (sensitization) or an increase in the excitability of the central nervous system so that normal inputs now evoke exaggerated responses. Because sensitization of peripheral receptors occurs following injury, a peripheral mechanism is widely held to be responsible for post-injury hypersensitivity. To investigate this I have now developed an animal model where changes occur in the threshold and responsiveness of the flexor reflex following peripheral injury that are analogous to the sensory changes found in man. Electrophysiological analysis of the injury-induced increase in excitability of the flexion reflex shows that it in part arises from changes in the activity of the spinal cord. The long-term consequences of noxious stimuli result, therefore, from central as well as from peripheral changes.
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            Insular cortex and neuropsychiatric disorders: a review of recent literature.

            The insular cortex is located in the centre of the cerebral hemisphere, having connections with the primary and secondary somatosensory areas, anterior cingulate cortex, amygdaloid body, prefrontal cortex, superior temporal gyrus, temporal pole, orbitofrontal cortex, frontal and parietal opercula, primary and association auditory cortices, visual association cortex, olfactory bulb, hippocampus, entorhinal cortex, and motor cortex. Accordingly, dense connections exist among insular cortex neurons. The insular cortex is involved in the processing of visceral sensory, visceral motor, vestibular, attention, pain, emotion, verbal, motor information, inputs related to music and eating, in addition to gustatory, olfactory, visual, auditory, and tactile data. In this article, the literature on the relationship between the insular cortex and neuropsychiatric disorders was summarized following a computer search of the Pub-Med database. Recent neuroimaging data, including voxel based morphometry, PET and fMRI, revealed that the insular cortex was involved in various neuropsychiatric diseases such as mood disorders, panic disorders, PTSD, obsessive-compulsive disorders, eating disorders, and schizophrenia. Investigations of functions and connections of the insular cortex suggest that sensory information including gustatory, olfactory, visual, auditory, and tactile inputs converge on the insular cortex, and that these multimodal sensory information may be integrated there.
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              Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo.

              The 1998-1999 war in Kosovo had a direct impact on large numbers of civilians. The mental health consequences of the conflict are not known. To establish the prevalence of psychiatric morbidity associated with the war in Kosovo, to assess social functioning, and to identify vulnerable populations among ethnic Albanians in Kosovo. Cross-sectional cluster sample survey conducted from August to October 1999 among 1358 Kosovar Albanians aged 15 years or older in 558 randomly selected households across Kosovo. Nonspecific psychiatric morbidity, posttraumatic stress disorder (PTSD) symptoms, and social functioning using the General Health Questionnaire 28 (GHQ-28), Harvard Trauma Questionnaire, and the Medical Outcomes Study Short-Form 20 (MOS-20), respectively; feelings of hatred and a desire for revenge among persons surveyed as addressed by additional questions. Of the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%) reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for PTSD; total mean score on the GHQ-28 was 11.1 (95% CI, 9.9-12.4). Respondents reported a high prevalence of traumatic events. There was a significant linear decrease in mental health status and social functioning with increasing amount of traumatic events (P
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                Author and article information

                Journal
                Confl Health
                Confl Health
                Conflict and Health
                BioMed Central
                1752-1505
                2012
                30 July 2012
                : 6
                : 4
                Affiliations
                [1 ]Rehabilitation and Research Centre for Torture Victims (RCT), Copenhagen, Denmark
                [2 ]Kosova Rehabilitation Centre for Torture Victims (KRCT), Pristina, Kosovo
                [3 ]Department of Psychology, University of Pristina, Pristina, Kosovo
                [4 ]Faculty of Medicine, University of Pristina, Pristina, Kosovo
                Article
                1752-1505-6-4
                10.1186/1752-1505-6-4
                3492011
                22846511
                e7d5aaac-3ef0-49ca-8c5f-fbf1e3f196ed
                Copyright ©2012 Wang 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.

                History
                : 13 August 2011
                : 12 July 2012
                Categories
                Research

                Health & Social care
                Health & Social care

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