Félagsleg áföll: Þáttur þeirra í þróun áfallastreituröskunar og félagsfælni - verkefni lokið

Fréttatilkynning verkefnisstjóra

11.8.2021

Í þessu verkefni leggjum við til nýja nálgun að áföllum, út frá þeirri ógn sem einstaklingurinn upplifir, sem skilja má út frá þróunarsögu tegundarinnar. Og til viðbótar við lífsógn, sem er velþekkt úr rannsóknum á áföllum, leggjum við til félagslega ógn, sem einkennist af höfnun og/eða niðurlægingu. Kenningar um ÁSR leggja þar að auki til að túlkun fólks á áfalli (t.d. sjálfsásökun) skipti miklu máli fyrir þróun ÁSR.

Í þessu verkefni var algengi og afleiðingar félagslegrar ógnar og túlkunar á henni rannsakað meðal kvenna úr almennu þýði (úr Áfallasögu kvenna), og tengslum slíkrar ógnar í samanburði við lífsógn við áfallastreituröskun (ÁSR) og félagsfælni. Við mátum líka betur slíkar gerðir af ógn og hvernig hún var túlkuð og tengsl við ÁSR og félagsfælni með klínískum viðtölum í klínískri rannsókn þar sem tvö úrtök úr Áfallasögu kvenna (konur með líklega ÁSR í samanburði við konur með lítil eða engin ÁSR einkenni). Niðurstöður úr báðum þessum rannsóknum leiddu í ljós að félagsleg ógn er mun algengari en lífsógn, og líklegri til að tengjast ÁSR einkennum en sú síðarnefnda. Þegar um er að ræða bæði félagslega ógn og lífsógn verða áhrifin mest á ÁSR einkenni. Í klínísku rannsókninni kom einnig fram að túlkun kvennanna sem þróuðu með sér ÁSR einkenni skipti miklu máli, einkum þegar þær lögðu þann skilning í áfallið að þær væru gallaðar á einhvern hátt, og að aðrir væru líklegir til að hafna þeim og niðurlægja þær. Einnig kom í ljós stór hópur af konum sem þróuðu með sér bæði ÁSR og félagsfælni einkenni í kjölfar félagslegrar ógnar, þannig að þær upplifðu áleitnar endurminningar um áfallið, þær voru varar um sig og forðuðust félagslegar aðstæður. Hér er því um að ræða sama heilkennið frekar en tvær aðgreindar geðraskanir.

Við teljum að þessar rannsóknir gætu átt þátt í varpa nýju ljósi á áfallastreituröskun og félagsfælni og haft umtalsverð áhrif á kenningar um áföll og þróun bæði ÁSR og félagsfælni, og á sálræna meðferð hjá þeim einstaklingum sem þróa með sér bæði ÁSR og félagsfælni (sem eina röskun) eftir félagslega ógn.

Fyrir utan þetta kenningarlega framlag, sem við teljum að hafi einnig hagnýtar afleiðingar fyrir meðferð, þá hafa niðurstöðurnar verið kynntar í erindum í Rússlandi og Svíþjóð, og á alþjóðlegri rafrænni ráðstefnu Anxiety and Depression Association of America fyrr á þessu ári. Helstu afurðir eru 3 handrit að greinum sem send verða til birtingar á þessu ári, og eru uppistaðan í doktorsverkefni Jóhanns Pálmars Harðarsonar (doktorsnema sem hefur verið styrktur af verkefninu). 

English:

Ever since post-traumatic stress disorder (PTSD) was first introduced in classification systems of psychiatric disorders around 40 years ago, the trauma literature has depicted trauma in terms of "objectively" defined events. This has led to an unfruitful debate on which types of events should count as traumatic and it remains unclear what it is about trauma, other than experiencing threat to life or sexual violence, that can lead to PTSD symptoms. We have argued for a new approach to conceptualizing trauma as perceived threat rather than objective events. We have proposed that there must be at least two kinds of perceived threat that can lead to PTSS; threat to life and social threat, the latter characterized by humiliation and rejection. Both can be understood with reference to reproductive success in the evolutionary history of our species.

Epidemiological and clinical studies are needed on social threat and its potency in contributing to PTSD and social anxiety disorder (SAD). Theoretical models of PTSD and SAD specify that certain appraisal mechanisms (how individuals make sense of the trauma, such as blaming oneself for what happened) play a key role in the development of these disorders. There is, however, no data on these mechanisms with regard to social threat.

The current project is the first epidemiological study (the SAGA cohort study) on the prevalence of social threat vs. threat to life, and their association with PTSD and SAD. We aimed to determine, through a self-reported web-based questionnaire of the Stress and Gene Analysis (SAGA) cohort of more than 30.000 women from the general Icelandic population, the lifetime prevalence of social threat and life threat and the association with PTSD symptoms. Furthermore, in a clinical study of individuals sampled from the SAGA cohort (with either likely PTSD or little to no PTSD symptoms), we assessed social threat vs. threat to life, and appraisal mechanisms, and their associations with PTSD and SAD, assessed with gold-standard clinical interviews.

Our data from the SAGA cohort strongly indicate that social threat is much more common than life threat, and that women with likely PTSD are most likely to report primarily social threat. Furthermore, when women report both high social threat and high life threat, they are much more likely to report PTSD symptoms. Our findings from the clinical study (comparing women with PTSD or clinically significant PTSD symptoms with women with little or no PTSD symptoms) also suggest that social threat is much more commonly reported than life threat, and that social threat is more strongly associated with PTSD symptoms than threat to life. We have also been able to perform more fine-grained analyses of appraisal mechanisms, in particular that many women feel flawed in some way, and that others are likely to humiliate or reject them. Social threat, and these appraisal mechanisms, appear to be the bridge between PTSD and SAD; two disorders that are known to be highly comorbid but that are usually thought of as separate. Our results suggest, importantly, that there is a group of individuals that develop both PTSD and SAD as one integrated condition (rather than two separate disorders) which consists of a reaction to social threat, and finding oneself flawed in some way and that others are likely to humiliate or reject them, which leads to a sense of constant and serious social threat, involving intrusive memories of the trauma, vigilance and avoidance of social situations. More research is needed, but we believe that this new conceptualization has important implications for theoretical models of both PTSD and SAD, and for the treatment of individuals with the integrated condition of both PTSD and SAD.

We have reported on these inital findings in invited talks at Uppsala University in Sweden and at the National Research University Higher School of Economics in Moscow, Russia in 2019, and during the Anxiety and Depression Association of America virtual conference in 2021. We have written 3 manuscripts addressing all the primary aims of the project that form the doctoral project of Jóhann Pálmar Harðarson (a PhD student who has been supported by the grant). We aim to submit these manuscripts to top journals in the field of mental health later in 2021. In addition to these outputs of the project, the main contributions are both theoretical and (eventually) applied. The theoretical contributions consist of a new approach to trauma (as perceived threat rather than objective events), that can be understood from an evolutionary perspective), in proposing social threat (experiencing peri-traumatic rejection and/or humiliation) as the major determinant of PTSD symptoms, and in proposing new appraisal mechanisms (more nuanced views of the self as flawed and in others as likely to humiliate and/or reject). Finally, we propose that social threat and these appraisal mechanisms may be the bridge between PTSD and SAD, and that there may be a group of individuals who respond to social threat with both PTSD and SAD symptoms (e.g., vigilance and avoidance of social situations) as one integrated condition rather than two separate disorders. These findings are likely to contribute to theoretical models of both disorders, and to treatment for individuals who suffer from both PTSD and SAD after social threat. 

Heiti verkefnis: Félagsleg áföll: Þáttur þeirra í þróun áfallastreituröskunar og félagsfælni/Social trauma and its role in the development of PTSD and SAD: An epidemiological approach
Verkefnisstjóri: Andri Steinþór Björnsson, Háskóla Íslands
Tegund styrks: Verkefnisstyrkur
Styrktímabil: 2018-2020
Fjárhæð styrks: 44,695 millj. kr. alls
Tilvísunarnúmer Rannís: 185323