Psychiatric sequelae of posttraumatic stress disorder in women

BACKGROUND

The risk for first-onset major depression, anxiety, and substance use disorders associated with prior posttraumatic stress disorder (PTSD) was estimated in a sample of women.

METHODS

The National Institute of Mental Health Diagnostic Interview Schedule, revised according to DSM-III-R, was used to measure lifetime psychiatric disorders in a stratified random sample of 801 mothers of children, who participated in a study of cognitive and psychiatric outcomes by level of birth weight. Cox proportional hazards models with time-dependent covariates were used to calculate the hazards ratios of first onset of other disorders following PTSD.

RESULTS

The lifetime prevalence of traumatic events was 40% and of PTSD, 13.8%. Posttraumatic stress disorder signaled increased risks for first-onset major depression (hazards ratio, 2.1) and alcohol use disorder (hazards ratio, 3.0). The risk for major depression following PTSD was of the same magnitude as the risk for major depression following other anxiety disorders. Women with preexisting anxiety and PTSD had significantly increased risk for first-onset major depression. Additional analysis showed that preexisting major depression increased women's vulnerability to the PTSD-inducing effects of traumatic events and risk for exposure to traumatic events.

CONCLUSIONS

Posttraumatic stress disorder influences the risk for first-onset major depression and alcohol use disorder. The causal explanation of these temporally secondary disorders is unclear and might involve the effect of PTSD or underlying vulnerabilities exposed by the traumatic experience.

The development of the Pain Management Inventory for patients with arthritis

The initial development of the Pain Management Inventory (PMI), a precise clinical index of pain management methods intended for use with patients with arthritis, is reported. The PMI differs from available instruments in its intent to assess specific methods that the individual is currently using for arthritis pain management and the perceived helpfulness of these methods, thus providing information to be used in combination with other clinical indicators for planning and evaluating ongoing pain self-management. Sixteen of 17 items, or methods, initially demonstrated content validity. Using methods appropriate for an index of independent items, psychometric testing with a sample of 82 persons having a primary diagnosis of osteoarthritis or rheumatoid arthritis then focused on estimating the construct validity and test-retest reliability of each item. Findings assist in better understanding how various methods relate to overall pain management when it is defined as successfully taking care of or handling the pain as viewed within a cognitive-behavioural framework. Findings suggest that there are eight items that represent valid and reliable pain management methods. These items should be used and evaluated with additional arthritis samples to determine whether the findings replicate.

Risk factors for PTSD-related traumatic events: a prospective analysis

OBJECTIVE

The authors previously identified suspected risk factors for traumatic events related to posttraumatic stress disorder (PTSD) on the basis of data gathered retrospectively. In this study, they tested that model prospectively.

METHOD

A random sample of 1,200 persons was drawn from all 21- to 30-year-old members of a large health maintenance organization. In 1989, 1,007 of these persons were interviewed, and suspected risk factors were measured. In 1992, 979 were reinterviewed, and the 3-year incidence of exposure to traumatic events was ascertained.

RESULTS

Nineteen percent of the sample reported traumatic events during the 3-year follow-up. A history of past exposure to traumatic events signaled an increase in the liability to exposure during follow-up, independent of suspected risk factors. Two predictors of exposure, neuroticism and extroversion, identified retrospectively, also predicted exposure prospectively. The odds for exposure among males and persons with less than a college education were marginally significant. Early misconduct and a family history of psychiatric disorder-predictors of exposure in the retrospective data-were not significant predictors at 3-year follow-up. Blacks had a higher incidence of exposure during follow-up than whites. An exploratory reanalysis suggested that the discrepancy between the retrospective and prospective results may be explained by the inclusion of childhood exposure in the lifetime retrospective inquiry.

CONCLUSIONS

The assumption that PTSD-related traumatic events are random phenomena was unsupported. Among young adults, those with less education, blacks, and those with high neuroticism and extroversion scores are more likely than others to be exposed to traumatic events and are thus at greater risk for PTSD.

Joint 1994 Wolff Award Presentation. Migraine and major depression: a longitudinal study

Recent epidemiologic studies have reported an association between migraine and major depression. Little is known about the mechanisms that link the two disorders, or the natural history of their co-occurrence. We examined the association between migraine and major depression in a sample of young adults, using longitudinal data.

METHOD

A random sample of 1,007 young adults (21-30 years of age) members of a large HMO in Southeast Michigan was interviewed in 1989; 97% of the sample were reinterviewed 3.5 years later, in 1992. A structured diagnostic interview was used to elicit information on DSM-III-R major depression and IHS migraine in lifetime (in the 1989 interview) and during the 3.5 year follow-up interval (in the 1992 interview). Using Cox-proportional hazards models with time-dependent covariates, we estimated the relative risk for major depression associated with prior migraine and the relative risk for migraine associated with prior major depression.

RESULTS

In this sample of young adults, the incidence of migraine per 1,000 person years, based on the prospectively gathered data, was 5.0 in males and 22.0 in females. The estimated relative risk for major depression associated with prior migraine, adjusted for sex and education, was 3.2 (95% CI 2.3-4.6). The adjusted relative risk for migraine associated with prior major depression was 3.1 (95% CI 2.0-5.0).

CONCLUSIONS

The study provides the first body of evidence that the previously observed cross-sectional association between migraine and major depression can result from bidirectional influences, with each disorder increasing the risk for first onset of the other. The explanation that major depression in persons with migraine represents a psychologic response to migraine attacks would have been more plausible had we found an influence only from migraine to depression. By diminishing the plausibility of a simple causal explanation for the migraine-depression comorbidity, the findings favor the shared mechanisms explanation.

Measurement and clinical decision making: focus on instrument development

Valid and reliable instruments are essential to responsible and accurate diagnosis, planning, and evaluation by professional nurses working independently or collaboratively with other healthcare professionals. The author provides an overview of the instrument development process and emphasizes the importance of measurement as an intrinsic part of the clinical decision-making process. Discussion focuses attention on the differences between an index and a scale, both of which are needed as part of assessment protocols. Some differences in strategies required for estimating validity and reliability for scales and indexes are highlighted.

Post-traumatic stress disorder in victims of civilian trauma and criminal violence

Many individuals in the community suffer from PTSD and other stress reactions. Physicians, however, tend to diagnose post-traumatic symptoms as anxiety or depressive disorders rather than PTSD. Contacting and engaging patients after a disaster can be quite difficult. The chronic PTSD patient has been described as elusive and difficult to detect within the health care system. In one study, the time interval from trauma to psychiatric consultation was well over 3 years. A history of PTSD is often obscured by comorbid disorders or adjustment difficulties, such as depression, aggressive behavior, and drug and alcohol abuse. PTSD is a common problem, particularly in populations that are at high risk for exposure to traumatic events, such as the homeless, drug abusers, and those of specific professions. Although research on treatment of PTSD has revealed only modest benefits, early detection and intervention are important and might prevent poor adjustment and a chronic outcome. Clinicians should routinely inquire about history of unpleasant events and distasteful and unspeakable experiences, both recent and lifetime. Studies of various traumatic events consistently demonstrated that the presence of significant symptoms between 6 weeks to 6 months after exposure predicts chronic PTSD. Although early intervention might lead to the prevention of PTSD or its chronic course, there have been no randomized or controlled studies to support this hypothesis. Research on PTSD in victims of civilian trauma has only recently begun. Rape is the most extensively studied civilian trauma. Most studies reported that PTSD following rape is common. Further, characteristics of the rape event, such as rape by a stranger, use of physical force, display of weapons, and victim injury, are associated with a greater likelihood of PTSD, and symptoms at 3 months after the rape are predictive of a chronic course. Interest in the consequences of MVAs has increased dramatically, perhaps owing to the frequency of such accidents and the large number of PTSD damage claims. There is a great need to understand work environments better and the special risks associated with dangerous occupations, such as police, firefighters, rescue workers, and body handlers. Clinicians commonly attribute symptoms to a particular stressor, usually the most recent stressor or the stressor that represents the content of the symptoms. For example, nightmares about a recent auto accident and avoidance of expressways are interpreted as evidence that a recent auto accident is the cause of PTSD symptoms.(ABSTRACT TRUNCATED AT 400 WORDS)

Migraine, physical health and psychiatric disorder: a prospective epidemiologic study in young adults

In a prospective study of a random sample of 1,007 young adults, we examined the association between migraine and psychiatric disorder, physical complaints, indicators of functional impairment, and use of mental health services. A history of migraine was associated with increased lifetime rates of major depression, anxiety disorders, illicit drug use disorders, nicotine dependence, and suicide attempts. Compared with subjects without a history of migraine, those with such a history had significantly more physical symptoms and were more likely to report job absenteeism, assess their general health as fair or poor, and use mental health services. Follow-up data, gathered 14 months after the baseline interview, revealed that subjects with a history of migraine at the baseline had significantly increased rates of first incidence major depression and panic disorder during the interval period (odds ratio (OR) for major depression = 4.2, 95% confidence interval (CI) 2.0-9.2; and OR for panic disorder = 12.8, 95% CI 4.1-39.8). The risk for these psychiatric disorders in persons with prior history of migraine was unrelated to the recentness of their migraine attacks. These findings suggest that the link between migraine, major depression and anxiety might reflect a common predisposition.

The meaning of pain management: a concept analysis

As it relates to the person experiencing chronic nonmalignant pain, the conceptual meaning of pain management has not been clarified previously. This article describes a concept analysis of pain management that resulted in a definition of the term and three defining attributes: pain relief, pain modulation, and self-efficacy. A model case is provided with examples of borderline and related cases. The findings of this analysis will contribute to instrument development, theory testing, and an understanding that should positively impact the self-management of persons experiencing chronic nonmalignant pain.

Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity

OBJECTIVE

Despite progress in epidemiologic research on posttraumatic stress disorder (PTSD), little is known about factors that distinguish chronic from nonchronic PTSD. In a previous report, the authors identified a set of personal predispositions associated with PTSD following traumatic events in a general population sample of young adults. The purpose of this analysis was to identify characteristics of chronic PTSD and examine whether any of the suspected risk factors for PTSD was associated specifically with chronic PTSD.

METHOD

A random sample of 1,007 21- to 30-year-old members of a large health maintenance organization in the Detroit area was interviewed, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS), revised for DSM-III-R. The analysis was performed on data from 394 respondents who reported traumatic events, of whom 93 met criteria for PTSD. Chronic PTSD was defined as duration of symptoms for 1 year or more.

RESULTS

Persons with chronic PTSD (N = 53) had, on the average, a significantly higher total number of PTSD symptoms and higher rates of overreactivity to stimuli that symbolized the stressor and interpersonal numbing than persons with nonchronic PTSD. The rates of one or more additional anxiety or affective disorders and a variety of medical conditions were higher in persons with chronic than nonchronic PTSD. Family history of antisocial behavior and female sex were associated specifically with chronic PTSD.

CONCLUSIONS

The findings suggest that chronic PTSD may be associated with specific risk factors and clinical features. Longitudinal data on the course of PTSD are needed to determine whether the distinct features and the medical and psychiatric histories of persons with chronic PTSD are complications attendant on a chronic course or coexisting disturbances that inhibit recovery.

Migraine, major depression and panic disorder: a prospective epidemiologic study of young adults

We examined prospectively the risk for major depression (MDD) and panic disorder in persons with prior history of migraine. A random sample of 995 young adults was interviewed in 1989 and reinterviewed in 1990. A history of migraine at baseline increased fourfold the risk for MDD during the follow-up interval. A history of any anxiety disorder exacerbated the risk for MDD in persons with migraine. Persons with a history of migraine were twelve times more likely to become cases of panic disorder than those with no history of migraine. The risk for MDD and/or panic disorder was unrelated to whether or not migraine was active during the year preceding the baseline interview or in remission for more than one year. The findings suggest that migraine, major depression and anxiety disorders might share common predispositions.

Migraine, psychiatric disorders, and suicide attempts: an epidemiologic study of young adults

To determine the prevalence of migraine and the risks for psychiatric disorders and suicide attempts associated with it, we studied a random sample of 1,007 young adults from a large Health Maintenance Organization in the Detroit, MI area. The lifetime prevalence of migraine was 7% in males and 16.3% in females. The rate of migraine was higher in persons with lower education and was equal in whites and blacks. Persons with migraine were at increased risk for affective and anxiety disorders, nicotine dependence, and alcohol or illicit drug abuse or dependence. There was a consistent trend toward higher psychiatric comorbidity in migraine with aura than in migraine without aura. Coexisting anxiety, which generally preceded migraine, was associated with a marked increase in the odds of major depression. Persons with migraine had higher rates of suicide attempts than persons without migraine. The odds ratio for suicide attempts, adjusted for coexisting major depression and other psychiatric and substance use disorders, in migraine with aura was 3.0 (95% confidence interval, 1.4-6.6). The coexistence of migraine with major depression, anxiety disorders, and suicide attempts has important clinical and research implications.

Traumatic events and posttraumatic stress disorder in an urban population of young adults

To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population.

Pain management in the older adult with rheumatoid arthritis or osteoarthritis

The study's major purpose was to explore the pain management of the older adult with rheumatic disease. Medication, rest, heat, distraction, exercise, and talking with others were methods most often used by older adults (n = 31). Methods identified by them as most helpful included medication, rest, and heat. When the pain management techniques of those adults 65 and over were compared with those of younger adults (n = 51), several differences were noted. The combined number of methods used by the younger group was significantly greater, and they rated relaxation techniques as being significantly more helpful. Increasing the elderly arthritis patient's repertoire of pain management modalities and measuring the ongoing individual effectiveness of the individual and combined methods used are identified as needs to be addressed in improving pain management.

Measurement of the chronic pain experience: development of an instrument

Development and testing of the Chronic Pain Experience Instrument (CPEI) were initiated to address the need for a valid and reliable instrument for the accurate clinical assessment of, as well as for the empirical investigation of, the chronic pain experience, that is, the personal response to living with nonmalignant persistent pain. When tested with persons with rheumatic disease (N = 160), the 16-item CPEI demonstrated high internal consistency, adequate stability, and moderate construct validity. Analysis included coefficient alpha, interitem correlations, item-scale correlations, Pearson r, factor analysis, and predictive modeling. Additional testing of the CPEI is suggested prior to its clinical application.

The clinical assessment of chronic pain in rheumatic disease: evaluating the use of two instruments

Health care professionals are becoming increasingly aware of the complex nature of chronic pain. Measurement instruments are needed which will assist in better understanding the patient's response to the pain. The McGill Pain Questionnaire (MPQ) and an expanded version useful in comprehensive clinical assessment, the McGill Comprehensive Pain Questionnaire (MCPQ), are currently-available tools for assessing chronic pain. The major purposes of this study were to test the discriminant and concurrent validity of the MPQ and to describe the major responses of the person with rheumatic disease to chronic pain using both instruments. Two sample groups were used: (1) 30 patients with chronic pain related to rheumatic disease, and (2) 30 patients with acute pain related to a surgical procedure. The MPQ's Affective Subscale discriminated between acute and chronic pain, and its Present Pain Intensity (PPI) Scale correlated moderately with the Visual Analogue Scale (VAS), another commonly-used scale for measuring pain intensity. While the MCPQ was useful in describing the patient's response to chronic pain, administration was time-consuming, and its open-ended format makes validity and reliability testing impossible. The information gained through the use of the MCPQ was helpful in determining what living with chronic pain means to the individual. Such information should be useful in the future development of a valid and reliable instrument for more efficiently measuring the chronic pain experience. Such an instrument would be useful in coordination with the MPQ which focuses on pain description.

Learning about nursing management

Summaries of the discussions were compiled in a booklet. The group then expressed an interest in getting some feedback on their decisions from nurse managers, so a meeting was arranged in the hospital where they were completing their nursing management practicum. The prepared booklet was distributed to each nurse manager attending the meeting: several head nurses, the director of medical/surgical nursing, and the assistant vice president for nursing. The resulting discussion provided a good summary and an opportunity for testing ideas. The interest and feedback of these nurses were very encouraging to the students. Overall, the mix of fantasy and realism provided a successful way of helping students gain a realistic view of nursing management. An understanding of and identification with the issues faced by today's nurse manager should help new graduates to appreciate and adapt to the realities of the clinical setting, regardless of their position.

Depressed mothers as informants in family history research--are they accurate?

A sample of 333 mother-child dyads was used to examine the association between major depression in mothers and children's symptoms. Findings based on children's self-reports were compared to findings based on mothers' reports about the children. Children's data support a depression-specific transmission. In contrast, mothers' data show an increased risk for all psychiatric syndromes covered in the study (including depression, anxiety, oppositionalism, inattention, hyperactivity, impulsivity, and antisocial acts). Results from multivariate analysis support the hypothesis that the discrepancy between mothers and children is in part a function of the tendency of depressed mothers to view their children as more symptomatic. The use of probands as informants may lead to an overestimation of familial aggregation, if the affected probands suffer from major depression or depressive symptoms.

Keeping the focus on nursing

Keeping the curriculum focused on nursing will take the best efforts of nursing educators, administrators, and practitioners. Nursing knowledge based on systematic study has expanded and is now developing more quickly than ever. This, along with the recognized need for general education courses in the curriculum, has helped nursing move into the mainstream of higher education. New approaches to curriculum organization and to teaching nursing should be considered in the effort to provide the best possible education. The many advances made by nursing education and practice in the past century now challenge us to consider curriculum changes that could significantly alter our traditional approaches.

Posttraumatic stress disorder: the etiologic specificity of wartime stressors

The authors examined the effects of wartime stressors in a sample of 69 Vietnam veterans who were psychiatric inpatients in a Veterans Administration hospital. Participation in atrocities and the cumulative exposure to combat stressors, each independently of the other, conferred a significant risk for posttraumatic stress disorder. In contrast, the effect of these war experiences on the onset of panic, major depression, and mania was not significant. The results indicate that extreme stressors are uniquely linked with posttraumatic stress disorder's characteristic cluster of symptoms but challenge DSM-III's implicit assumption that the reexperienced trauma is the stressor responsible for posttraumatic stress disorder.

Posttraumatic stress disorder. The stressor criterion

Posttraumatic stress disorder (PTSD) was officially introduced into psychiatric nomenclature in 1980, when it was incorporated into DSM-III. There is as yet little empirical research on the validity of the diagnosis. Literature on disasters, civilian and wartime, and on more ordinary stressful life events does not support the view that extreme stressors form a discrete class of stressors in terms of the probability of psychiatric sequelae or the distinctive nature of subsequent psychopathology. Extraordinary stressors are like more ordinary stressful events with respect to their complex differential effects upon individuals. Personal characteristics and the nature of the social environment modify the likelihood and form of the response of individuals to all types of stressors.

Searching for evidence on the validity of generalized anxiety disorder: psychopathology in children of anxious mothers

The diagnostic validity of generalized anxiety disorder (GAD) is tested by examining the relationship between GAD in mothers and children's overanxious disorder (OAD), separation anxiety (SA), and anxious symptoms in 331 mother-child dyads from a geographically based probability sample. Data on the relationship between mothers' major depressive disorder (MDD) and children's depression are presented for comparison. The National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) was used in mothers and the NIMH Diagnostic Interview Schedule for Children (DISC), in children. Children of mothers with GAD were not at increased risk for OAD, SA, or anxious symptoms. In contrast, MDD in mothers conferred a risk for OAD in younger children and of MDD in older children. Additionally, older children of depressed mothers exhibited significantly more depressive symptoms. The presence of diffuse anxiety in children of mothers with MDD may represent a nonspecific response pattern in psychiatrically vulnerable children. Like GAD in adults, these anxiety symptoms in children may constitute a prodromal manifestation of other disorders and transient responses to life stressors.

Evaluation of immunosorbents for the analysis of small molecules. Isolation and purification of cytokinins

This paper describes the preparation and evaluation of immunosorbents for the isolation of cytokinins. The nature of both the solid support and the linkage chemistry affected the non-specific adsorption of sample contaminants and the characteristics of the immobilized antibody. All the immunosorbents investigated provided sufficient purification of cytokinins for high-performance liquid chromatographic analysis with no further clean-up. This demonstrates a rapid and powerful purification method for small molecules for which antibodies can be generated. As a consequence, the procedures described for the immobilization of cytokinin antibodies are generally applicable to the preparation of immunosorbents.