On the relation of injury to pain. The John J. Bonica lecture

Pain is better classified as an awareness of a need-state than as a sensation. It serves more to promote healing than to avoid injury. It has more in common with the phenomena of hunger and thirst than it has with seeing or hearing. The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.

Reaction to trauma: A cognitive processing model

We integrated existing cognitive processing models of posttrauma reactions into a longitudinal model. Data were obtained after a multiple shooting in a city office block. The subject group comprised 158 office workers who were in the building at the time of the shootings. The methodology of this research was a repeated measures survey, with data collection at 4, 8, and 14 months posttrauma. Measures included the Impact of Events Scale (IES) and the Symptom Checklist-90-Revised. A path analysis was performed with the IES as an indication of cognitive processing. Intrusion and avoidance were shown to mediate between exposure to trauma and symptom development. Intrusion was also found to be negatively related to subsequent symptom levels. The findings provide provisional support for a cognitive processing model.

Malignant memories: PTSD in children and adults after a school shooting

Sixty-four children and 66 adults were screened for post-traumatic stress disorder 6 to 14 months after a school shooting. Although there were no differences in overall frequencies of DSM-III-R diagnoses or cluster endorsements, there were developmental influences. Post-traumatic stress disorder was associated more with emotional states recalled from the disaster than with proximity. Emotional states mediated the formation of malignant memories leading to symptomatology, suggesting that postdisaster intervention be offered on the basis of degree of emotional reaction as well as proximity.

Long-term Functional, Psychological, Emotional, and Social Outcomes in Survivors of Firearm Injuries

Importance

The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied.

Objective

To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries.

Design, Setting, and Participants

This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019.

Exposures

A GSW sustained from January 1, 2008, through December 31, 2017.

Main Outcomes and Measures

Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Results

Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P < .001), Global Mental Health (48 [11]; P = .03), and Physical Function (45 [12]; P < .001) PROMIS metrics. Eighty-nine participants (48.6%) had a positive screen for probable PTSD. Patients who required intensive care unit admission (n = 64) had worse mean (SD) Physical Function scores (42 [13] vs 46 [11]; P = .045) than those not requiring the intensive care unit. Survivors no more than 5 years after injury had greater PTSD risk (38 of 63 [60.3%] vs 51 of 119 [42.9%]; P = .03) but better mean (SD) Global Physical Health scores (47 [11] vs 43 [11]; P = .04) than those more than 5 years after injury.

Conclusions and Relevance

This study's results suggest that the lasting effects of firearm injury reach far beyond mortality and economic burden. Survivors of GSWs may have negative outcomes for years after injury. These findings suggest that early identification and initiation of long-term longitudinal care is paramount.

Wisconsin Card Sorting Test performance based on location and size of neuroanatomical lesion in Vietnam veterans with penetrating head injury

We examined Wisconsin Card Sorting Test performance in a large group of brain-damaged patients and controls. No differences were found between patients with frontal lesions only and those with nonfrontal lesions. Patients with left dorsofrontal and anterior temporal lobe lesions committed the most perseverative errors. More analyses regarding requirements for information processing on the Wisconsin Card Sorting Test are needed.

Self-inflicted gunshot wounds: lethality of method versus intent

The authors studied 30 patients treated at an urban trauma center for self-inflicted gunshot wounds, most or all of which would have been fatal without emergency treatment. About half the patients had used alcohol or drugs immediately before wounding themselves, and slightly more than half had experienced interpersonal conflict just before the incident. Thirteen of the 30 were women. Only nine were given diagnoses of major depressive episode or dysthymia; none of the patients had written suicide notes. These data indicate that the reported demographic and clinical characteristics of impulsive, violent self-injury must be reexamined.

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

The long-term consequences of exposure to firearm injury-including suicide, assault, and mass shootings-on children's mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Physical and psychological outcomes 8 months after serious gunshot injury

BACKGROUND

The purpose of this study was to determine the health status and psychological distress of gunshot injury victims 8 months after hospital discharge.

METHODS

Sixty patients admitted to a Level I trauma center for firearm-related injuries were interviewed during their hospitalization and again 8 months postdischarge. Health status was measured using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Symptoms of posttraumatic stress (avoidance and intrusion) were assessed using the Impact of Event Scale.

RESULTS

Subjects were predominantly young (mean age, 30 years), male (92%), and African-American (95%). Mean SF-36 scores at follow-up were significantly worse than preinjury scores for all subscales (p < 0.05). Symptoms of posttraumatic stress were common; 39% of respondents reported severe intrusive thoughts and 42% reported severe avoidance behaviors. Admission Injury Severity Scores did not predict poor health status 8 months postdischarge, but intrusion symptoms were strongly associated with lower SF-36 scores.

CONCLUSION

Many hospitalized survivors of gunshot injuries report significant long-term declines in physical and/or mental health. Injury severity at hospital admission may not be predictive of long-term health status.

Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks

OBJECTIVE

This study examined emotional and behavioral effects on hospital staff after a series of sniper shootings in the Washington, D.C., area.

METHODS

Employees of a large tertiary care military hospital were anonymously surveyed about their perceptions of safety and threat, changes in activities, and peritraumatic dissociation as possible risk factors for acute stress disorder, depression, and increased alcohol use the week after the sniper suspects were captured.

RESULTS

Of 382 study participants, whose average age was 39 years, 24 (6 percent) met criteria for acute stress disorder, 13 (3 percent) reported increased alcohol use, and 31 (8 percent) met criteria for depression. Risk factors for acute stress disorder were female sex (odds ratio [OR]=2.59), increased alcohol use (OR=5.1), comorbid depression (OR=7.28), lower perceived safety, higher perceived threat, higher levels of peritraumatic dissociation, and greater numbers of decreased activities. Risk factors for increased alcohol use were comorbid depression (OR=4.02), lower perceived safety, higher perceived threat, and higher levels of peritraumatic dissociation. Risk factors for depression were lower perceived safety and higher levels of peritraumatic dissociation.

CONCLUSIONS

The sniper shootings were associated with substantial changes in perceived safety and threat assessment as well as decreased activities outside the home among highly educated hospital employees. Levels of acute stress disorder were similar to levels of posttraumatic stress disorder in New York City after the terrorist attacks of September 11, 2001. Peritraumatic dissociation was associated not only with acute stress disorder but also with depression and increased alcohol use after the attacks.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression

OBJECTIVE

To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial.

METHOD

The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up.

RESULTS

Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition.

CONCLUSIONS

Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Teaching firearm safety to children: failure of a program

The present study investigated the effectiveness of a skills-based firearm safety program on reducing children's play with firearms. In a randomized control study, 34 children aged 4 to 7 years participated in a week-long firearm safety program; the Control Group was composed of 36 children. After the program, pairs of children were observed playing in a structured setting in which they had access to a semiautomatic pistol. A total of 53% of the pairs played with the gun, and there was no difference in gun-play behavior between those children who did and did not receive the intervention. Interview data revealed significant discrepancies in parent and child reports of parental gun ownership and inaccurate parental predictions of their children's interest in guns. The results of the current study cast doubt on the potential effectiveness of skills-based gun safety programs for children.

Complex suicides by self-incineration

Among the few cases of suicidal self-incineration primary or secondary complex suicides are a rarity. Accordingly the number of reports on this subject in the forensic literature is small. In a retrospective analysis of the Freiburg and Berlin autopsy material, four cases were found within an observation period of 11 years. These are described together with seven other cases reported in the literature. Altogether most of these suicides are primary combinations, especially with falls from a height. Other combinations include hanging or the infliction of stabs, cuts or gunshot injuries. The sex and age distribution is similar to that found for suicide by self-incineration alone.

Cognitive processing in post-trauma reactions: some preliminary findings

The current study investigated a model of post-trauma reactions proposed initially by McFarlane (1988 a). Two separate data sets, one obtained following a multiple shooting and the other reported by McFarlane following a natural disaster, were examined. The findings of both studies provide support for a cognitive processing conceptualization of the development of post-trauma reactions.

Post-Discharge Needs of Victims of Gun Violence in Chicago: A Qualitative Study

The purpose of this study was to understand the post-discharge needs of violently injured patients and their families to improve health outcomes and reduce the impact of gun violence. We recruited 10 patients from the trauma registry of a Midwestern university hospital with a Level 1 Trauma Center (L1TC). After obtaining the informed consent, semi-structured, face-to-face, in-depth interviews were conducted. Discussions focused on post-discharge needs and resources to facilitate the recovery and rehabilitation process, and aid in community reintegration. Interviews were audiotaped and transcribed verbatim. Transcripts were analyzed thematically in stages of open, axial, and selective coding methods. Seven main themes were identified at the hospital and community level. These included the following: (a) feeling stigmatized by hospital personnel, (b) patient-provider communication, (c) feeling discharged too soon, (d) issues in obtaining medicines, (e) challenges with Chicago Police Department, (f) transportation to trauma center for follow-up care, and (g) concerns with returning back to the community. Patients reported the need for mental health counseling for themselves and their family, more follow-up, and help with financial paperwork among others. For the victims of gun violence, there exists a chasm between injury and care, and an even wider one between care and rehabilitation. The findings can inform health care, social workers, and rehabilitation professionals in their efforts to better address the myriad of unmet needs pre- and post-discharge. For trauma centers, the identified needs provide a template for developing an individualized- and community-centered resource pathway to improve outcomes and reduce suffering for this particularly vulnerable subset of patients.

Management of Close-Range, High-Energy Shotgun and Rifle Wounds to the Face

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

Development and factor analysis of a measure of youth attitudes toward guns and violence

Administered the Attitudes Toward Guns and Violence Questionnaire (AGVQ) to 1,619 students in Grades 3, 5, 6, 7, 9, 11, and 12 from four demographically diverse school systems. Fifty-two of the 61 items exhibited satisfactory part-whole correlation and correlation with a validity criterion. Factor analysis revealed four main factors: Aggressive Response to Shame, Comfort With Aggression, Excitement, and Power/Safety. The instrument was reduced to 23 items by deleting items with high cross-loadings. Construct validity was similar for the longer and shorter versions. Youth who self-reported owning a gun produced scores 1.5 SD higher than nonowners. Low scores were associated with a 1 in 125 chance of gun ownership, and high scores were associated with a 1 in 3 chance. Congruency coefficients indicated similar factor structure for the present sample and a separate sample of 5th-, 7th- and 9th-grade students. These results indicate that the AGVQ is a reliable and valid measure of violence-related attitudes in young people.

Pre-Vietnam contents of posttraumatic stress disorder veterans' service medical and personnel records

We reviewed the pre-Vietnam contents of the service medical and personnel records of 250 Vietnam combat veterans, in an attempt to identify factors predisposing to the development of posttraumatic stress disorder (PTSD). PTSD and non-PTSD veterans did not differ significantly on self-reported medical history items, sick call visits, or military efficiency and conduct ratings. There were trends for PTSD veterans to have lower arithmetic aptitude, more self-reported school difficulties, and (paradoxically) lower pulse rate at military induction.

Effect of the incident at Columbine on students' violence- and suicide-related behaviors

BACKGROUND

This study examined the impact that the violent incident at Columbine High School may have had on reports of behaviors related to violence and suicide among U.S. high school students.

METHODS

Nationally representative data from the 1999 Youth Risk Behavior Survey (YRBS) were analyzed using logistic regression analyses.

RESULTS

Students who completed the 1999 YRBS after the Columbine incident were more likely to report feeling too unsafe to go to school and less likely to report considering or planning suicide than were students who completed the 1999 YRBS before the incident.

CONCLUSIONS

These results highlight how an extreme incident of school violence can affect students nationwide.

Learning and forgetting during posttraumatic amnesia in head injured patients

To investigate forgetting during recovery from head injury, colour slides were initially projected for long durations to ensure acquisition on a recognition test given 10 minutes later. Patients tested during posttraumatic amnesia (PTA) exhibited accelerated forgetting over 32 hours as compared with head trauma patients studied after the period of PTA and normal controls.

Posttraumatic distress and physical functioning: a longitudinal study of injured survivors of community violence

This study examines the cross-lagged relationships between posttraumatic distress symptoms and physical functioning, using a sample of 413 persons who were hospitalized for injuries resulting from community violence. Posttraumatic distress was assessed at 1 week, 3 months, and 12 months postinjury, and posttraumatic physical functioning was assessed at 3 months and 12 months. Structural equation modeling was used to assess the prospective relationship between posttraumatic distress symptoms and physical functioning while controlling for demographic characteristics and objective measures of injury severity. Results indicate that posttraumatic distress and physical functioning are reciprocally related. Individuals with high levels of psychological distress at 1 week posttrauma have worse physical functioning at 3 months. Psychological distress at 3 months was not significantly associated with subsequent change in physical functioning at 12 months. Individuals with poor physical functioning at 3 months had higher than expected levels of psychological distress at 12 months. These findings demonstrate a reciprocal relationship between physical and mental health following traumatic injury. Interventions targeting physical recovery may influence subsequent mental health, and therapies aimed at improving early mental health may also have long-term benefits for physical recovery.

Treatment of posttraumatic stress disorder with eye movement desensitization

This case report describes the successful treatment of a posttraumatic stress disorder (PTSD) using eye movement desensitization (EMD). The client, a 40-year-old male, presented with an 8-year history of PTSD following an incident in which he was shot with a hand gun and left dying. Using EMD treatment, this trauma was quickly desensitized. Two earlier traumas with similar themes then emerged and they too were desensitized. Test results, taken pre-treatment and posttreatment, along with the client's verbatim account of cognitive and behavioral changes 8 months later, converged to document the successful treatment outcome.

Methods of suicide and implications for suicide prevention

Examined annual variations in the methods used for suicide in the United States in recent years (1962-1975) by sex and ethnic groups (white males, white females, nonwhite males, nonwhite females). Virtually all of the increase in United States suicide rates between 1962 and 1975 can be attributed to the increase in suicides by firearms. The increase in suicides by firearms, which occurred in all sex-ethnic groups, accompanied marked increases in the availability of firearms, which is a preferred, socioculturally accepted method of suicide in the United States. These results present a mirror image of the reductions in suicide rates in Great Britain and Vienna when the availability of the most preferred method of suicide in those locales (toxic domestic gas) was reduced. The data from this and other studies suggest that the physical availability of the more culturally accepted methods of suicide is a major determinant of suicide rates and that suicides may be prevented by decreasing the availability of the most common methods of suicide to suicidal individuals.

Development and factor analysis of a measure of youth attitudes toward guns and violence

Administered the Attitudes Toward Guns and Violence Questionnaire (AGVQ) to 1,619 students in Grades 3, 5, 6, 7, 9, 11, and 12 from four demographically diverse school systems. Fifty-two of the 61 items exhibited satisfactory part-whole correlation and correlation with a validity criterion. Factor analysis revealed four main factors: Aggressive Response to Shame, Comfort With Aggression, Excitement, and Power/Safety. The instrument was reduced to 23 items by deleting items with high cross-loadings. Construct validity was similar for the longer and shorter versions. Youth who self-reported owning a gun produced scores 1.5 SD higher than nonowners. Low scores were associated with a 1 in 125 chance of gun ownership, and high scores were associated with a 1 in 3 chance. Congruency coefficients indicated similar factor structure for the present sample and a separate sample of 5th-, 7th- and 9th-grade students. These results indicate that the AGVQ is a reliable and valid measure of violence-related attitudes in young people.

Prospective psychosocial, interpersonal, and behavioral predictors of handgun carrying among adolescents

OBJECTIVES

This study identified behavioral and psychosocial/interpersonal factors in young adolescence that are associated with handgun carrying in later adolescence.

METHODS

A sample of 2200 high school students was surveyed at 9th grade and again at 12th grade.

RESULTS

Multivariate logistic regression analyses indicated that measures of risk-taking preference, depression, stress, temper, and drug use assessed while the students were in 9th grade were predictive of handgun carrying in 12th grade for both male and female students.

CONCLUSIONS

These findings suggest the need for a comprehensive approach to prevention that focuses on both individual and interpersonal factors associated with adolescents' decision to carry a handgun.

Firearm-related experiences and perceptions among United States male veterans: A qualitative interview study

BACKGROUND/OBJECTIVE

Male veterans ages 55-74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans.

METHODS

We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50-70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach.

RESULTS

Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using "common sense;" 3) Firearms serve an important social function across veterans' lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in which they acted to limit others' access during unsafe situations; and 6) Veterans have preferences for who is involved in firearm safety discussions.

CONCLUSIONS

We identified themes relevant to developing firearm-specific lethal means safety interventions among older male veterans. Findings suggest potential obstacles (e.g., sociocultural value of firearms) to affecting changes in firearm behaviors, and factors that could potentially facilitate interventions (e.g., family involvement). Consideration of these findings may be important for developing personalized, effective interventions for this population.