Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008

OBJECTIVES

We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans.

METHODS

We determined the prevalence and predictors of mental health diagnoses among 289,328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from 2002 to 2008 using national VA data.

RESULTS

Of 289,328 Iraq and Afghanistan veterans, 106,726 (36.9%) received mental health diagnoses; 62,929 (21.8%) were diagnosed with posttraumatic stress disorder (PTSD) and 50 432 (17.4%) with depression. Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD.

CONCLUSIONS

Mental health diagnoses increased substantially after the start of the Iraq War among specific subgroups of returned veterans entering VA health care. Early targeted interventions may prevent chronic mental illness.

Low expression of catecholamine-O-methyl-transferase gene in obsessive-compulsive disorder

This study examined peripheral catecholamine-O-methyl-transferase (COMT) gene expression in obsessive-compulsive disorder (OCD) patients and healthy controls. Participants included 35 first episode OCD patients and 31 age- and sex-matched healthy controls. Relative COMT gene expression levels were examined by real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) in peripheral blood of all the subjects. COMT gene expression levels, normalized by glyceraldehyde-3-phosphate dehydrogenase (GAPDH), were significantly decreased in the OCD group compared with healthy controls (F=6.244, p=0.015). OCD patients showed a 32% down-regulation. We also found lower COMT gene expression levels in female in comparison to male participants (F=5.366, p=0.024) in the sample as a whole. COMT gene expression down-regulation of male OCD patients relative to male controls is 38%, and that of female OCD patients relative to female controls is 27%. These results suggest that COMT gene expression down-regulation might play an important role in the development of OCD and that there may be gender differences in this alteration.

The latent structure of the Peritraumatic Dissociative Experiences Questionnaire

This paper has been retracted due to a publisher's error: the order of the authors was incorrect. The Editor and Publisher of the Journal of Traumatic Stress apologize to the authors and our readership. The Peritraumatic Dissociative Experiences Questionnaire (PDEQ) is a widely used measure of peritraumatic dissociation, and is presumably a unidimensional construct. Two hundred forty-seven individuals admitted to five hospitals after traumatic injury were administered the Clinician Administered PTSD Scale, the Hospital Anxiety and Depression Scale, and the PDEQ. Factor analysis indicated that the PDEQ involved two factors containing four items each: one factor (altered awareness) indexes alterations in awareness and the other (derealization) reflects distortions in perceptions of the self and the world. Only the derealization factor was associated with acute stress, anxiety, and depression symptoms. Cross-validation with independent data provided only partial support for the 2-factor structure model. These data indicate that peritraumatic dissociation may involve two distinct constructs.

Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review

The selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for PTSD. However, even when treated with this class of drugs, response rates rarely exceed 60% and less than 20-30% of the patients achieve full remission. The aim of this study was to address this limitation by systematically reviewing the options left for the treatment of PTSD when patients do not respond satisfactorily to or tolerate SSRIs. A systematic review covering all original articles, letters and brief reports published in any language until October 2008 was conducted through searches in the ISI/Web of Science, PubMed and PILOTS databases. The search terms included the pharmacological class of each agent or its generic name plus "PTSD" or "stress disorder" in the title, in the abstract or as a keyword. Sixty-three articles were selected, covering the following categories: antipsychotics, anticonvulsants, adrenergic-inhibiting agents, opioid antagonists, benzodiazepines and other agents. None of the identified agents reached the level A of scientific evidence, 5 reached level B, 7 level C and 13 level D. The non-antidepressant agent with the strongest scientific evidence supporting its use in PTSD is risperidone, which can be envisaged as an effective add-on therapy when patients did not fully benefit from previous treatment with SSRIs. Prazosin, an adrenergic-inhibiting agent, is a promising alternative for cases of PTSD where nightmares and insomnia are prominent symptoms. So far, there is no consistent empirical support for using benzodiazepines in the prevention or in the treatment of PTSD, although these drugs could alleviate some associated non-specific symptoms, such as insomnia or anxiety. Further controlled clinical trials and meta-analysis are needed to guide clinicians in their search of effective pharmacological alternatives to antidepressants in PTSD.

Prospective prediction of posttraumatic stress disorder symptoms using fear potentiated auditory startle responses

BACKGROUND

Posttraumatic stress disorder (PTSD) has been most consistently associated with exaggerated physiologic reactivity to startling sounds when such sounds occur in threatening contexts. There is conflicting evidence about whether startle hyperreactivity is a preexisting vulnerability factor for PTSD or an acquired result of posttrauma neural sensitization. Until now, there have been no prospective studies of physiologic reactivity to startling sounds in threatening contexts as predictors of PTSD symptoms.

METHODS

One hundred and thirty-eight police academy cadets without current psychopathology were exposed to repeated 106-dB startling sounds under increasing (low, medium, or high) threat of mild electric shock while their eye-blink electromyogram, skin conductance, heart rate, and subjective fear responses were recorded. Measures of response habituation were also calculated. Following 1 year of exposure to police-related trauma, these participants were assessed for PTSD symptom severity.

RESULTS

After accounting for other baseline variables that were predictive of PTSD symptom severity (age and general psychiatric distress), more severe PTSD symptoms were prospectively and independently predicted by the following startle measures: greater subjective fear under low threat, greater skin conductance under high threat, and slower skin conductance habituation.

CONCLUSIONS

These results imply that hypersensitivity to contextual threat (indexed by greater fear under low threat), elevated sympathetic nervous system reactivity to explicit threat (indexed by larger responses under high threat), and failure to adapt to repeated aversive stimuli (evidenced by slower habituation) are all unique preexisting vulnerability factors for greater PTSD symptom severity following traumatic stress exposure. These measures may eventually prove useful for preventing PTSD.

The latent structure of the Peritraumatic Dissociative Experiences Questionnaire

The Peritraumatic Dissociative Experiences Questionnaire (PDEQ) is a widely used measure of peritraumatic dissociation, and is presumably a unidimensional construct. Two hundred forty-seven individuals admitted to five hospitals after traumatic injury were administered the Clinician Administered PTSD Scale, the Hospital Anxiety and Depression Scale, and the PDEQ. Factor analysis indicated that the PDEQ involved two factors containing four items each: one factor (altered awareness) indexes alterations in awareness and the other (derealization) reflects distortions in perceptions of the self and the world. Only the derealization factor was associated with acute stress, anxiety, and depression symptoms. Cross-validation with independent data provided only partial support for the 2-factor structure model. These data indicate that peritraumatic dissociation may involve two distinct constructs.

A prospective study of trait anger and PTSD symptoms in police

It is unknown whether anger is a risk factor for the development of posttraumatic stress disorder ( PTSD) symptoms, arises as a consequence of PTSD, or both. Two hypotheses were tested in 180 police recruits: Greater trait anger during training will predict greater PTSD symptoms at one year; greater PTSD symptoms at one year will predict greater state anger at one year. Both hypotheses were confirmed, suggesting that trait anger is a risk factor for PTSD symptoms, but that PTSD symptoms are also associated with an increase of state anger. Increased anger is important not only because of the impact it has on individual distress and physical health, but also because of its potential public health impact.

Abnormal serum lipid profile in Brazilian police officers with post-traumatic stress disorder

BACKGROUND

To measure the serum lipid composition of a sample of Brazilian police officers with and without PTSD regularly exposed to potentially traumatic situations.

METHODS

A cross-sectional survey was conducted with 118 active duty male police officers. Serum concentrations for total cholesterol, LDL-C, HDL-C, and triglycerides were enzymatically determined. Body mass index (BMI) was obtained for each participant.

RESULTS

Officers with PTSD exhibited significantly higher serum total cholesterol, LDL-C and triglycerides levels than those without PTSD. Total cholesterol and triglycerides, but not LDL-C, remained associated with PTSD diagnosis after controlling for confounding influences (i.e. socio-demographics, BMI, and tobacco, alcohol and medication use).

LIMITATIONS

The sample size was small. A nutritional interview was employed instead of established scales to assess alimentary habits, tobacco or alcohol consumption. A self-report screening tool was used to assess the prevalence of PTSD.

CONCLUSIONS

The association between PTSD and abnormal serum lipid profile and a tendency to exhibit higher BMI suggests that individuals with PTSD may be at increased risk for developing metabolic syndrome, a condition that by itself could account for many of the most serious PTSD-related physical health problems.

Getting beyond "Don't ask; don't tell": an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan

OBJECTIVES

We sought to evaluate outcomes of the Veterans Administration (VA) Afghan and Iraq Post-Deployment Screen for mental health symptoms.

METHODS

Veterans Administration clinicians were encouraged to refer Iraq or Afghanistan veterans who screened positive for posttraumatic stress disorder, depression, or high-risk alcohol use to a VA mental health clinic. Multivariate methods were used to determine predictors of screening, the proportions who screened positive for particular mental health problems, and predictors of VA mental health clinic attendance.

RESULTS

Among 750 Iraq and Afghanistan veterans who were referred to a VA medical center and 5 associated community clinics, 338 underwent postdeployment screening; 233 (69%) screened positive for mental health problems. Having been seen in primary care (adjusted odd ratio [AOR]=13.3; 95% confidence interval [CI]=8.31, 21.3) and at a VA community clinic (AOR=3.28; 95% CI=2.03, 5.28) predicted screening. African American veterans were less likely to have been screened than were White veterans (AOR=0.45; 95% CI=0.22, 0.91). Of 233 veterans who screened positive, 170 (73%) completed a mental health follow-up visit.

CONCLUSIONS

A substantial proportion of veterans met screening criteria for co-occurring mental health problems, suggesting that the VA screens may help overcome a "don't ask, don't tell" climate that surrounds stigmatized mental illness. Based on data from 1 VA facility, VA postdeployment screening increases mental health clinic attendance among Iraq and Afghanistan veterans.

Abnormal N-acetylaspartate in hippocampus and anterior cingulate in posttraumatic stress disorder

Magnetic resonance spectroscopic imaging (MRSI) studies suggest hippocampal abnormalities in posttraumatic stress disorder (PTSD), whereas findings of volume deficits in the hippocampus, as revealed with magnetic resonance imaging (MRI), have been inconsistent. Co-morbidities of PTSD, notably alcohol abuse, may have contributed to the inconsistency. The objective was to determine whether volumetric and metabolic abnormalities in the hippocampus and other brain regions are present in PTSD, independent of alcohol abuse. Four groups of subjects, PTSD patients with (n=28) and without (n=27) alcohol abuse and subjects negative for PTSD with (n=23) and without (n=26) alcohol abuse, were enrolled in this observational MRI and MRSI study of structural and metabolic brain abnormalities in PTSD. PTSD was associated with reduced N-acetylaspartate (NAA) in both the left and right hippocampus, though only when normalized to creatine levels in the absence of significant hippocampal volume reduction. Furthermore, PTSD was associated with reduced NAA in the right anterior cingulate cortex regardless of creatine. NAA appears to be a more sensitive marker for neuronal abnormality in PTSD than brain volume. The alteration in the anterior cingulate cortex in PTSD has implications for fear conditioning and extinction.

The psychological risks of Vietnam: the NVVRS perspective

In recent years, controversy concerning the psychological consequences of service in the Vietnam war has rearisen. In this article, the Co-Principal Investigators of the National Vietnam Veterans Readjustment Study (NVVRS) provide a perspective on new findings reported by B. P. Dohrenwend et al. (2006) that addresses criticisms of the NVVRS PTSD (posttraumatic stress disorder) prevalence findings, and on a perspective that was provided by R. J. McNally (2006) in an accompanying commentary. They find that Dohrenwend et al.'s study, which evaluated empirically a variety of the critics' alternative explanations and found little support for any of them, represents a landmark contribution to the trauma field. However, they found that McNally's commentary misrepresented the history and context of the NVVRS, and then misinterpreted Dohrenwend et al.'s findings and their importance.

Associations between childhood trauma and emotion-modulated psychophysiological responses to startling sounds: a study of police cadets

Childhood trauma may confer risk for adult psychopathology by altering emotional and physiological responses to subsequent stressors. Few studies have distinguished effects of childhood trauma from effects of current Axis I psychopathology on adult psychophysiological reactivity. The authors exposed 90 psychiatrically healthy police cadets to startling sounds under increasing threat of shock while assessing their eyeblink electromyogram (EMG), skin conductance (SC), and heart rate responses. When compared with those who did not endorse early trauma (n = 65), cadets reporting childhood trauma (n = 25) reported less positive emotion and showed greater SC responses across all threat levels. They also showed threat-dependent elevations in reported negative emotions and EMG responses. Results suggest that childhood trauma may lead to long-lasting alterations in emotional and psychophysiological reactivity even in the absence of current Axis I psychopathology.

Crewmember and mission control personnel interactions during International Space Station missions

INTRODUCTION

Reports from astronauts and cosmonauts, studies from space analogue environments on Earth, and our previous research on the Mir Space Station have identified a number of psychosocial issues that can lead to problems during long-duration space missions. Three of these issues (time effects, displacement, leader role) were studied during a series of long-duration missions to the International Space Station (ISS).

METHODS

As in our previous Mir study, mood and group climate questions from the Profile of Mood States or POMS, the Group Environment Scale or GES, and the Work Environment Scale or WES were completed weekly by 17 ISS crewmembers (15 men, 2 women) in space and 128 American and Russian personnel in mission control.

RESULTS

The results did not support the presence of decrements in mood and group cohesion during the 2nd half of the missions or in any specific quarter. The results did support the predicted displacement of negative feelings to outside supervisors in both crew and mission control subjects on all six questionnaire subscales tested. Crewmembers related cohesion in their group to the support role of their commander. For mission control personnel, greater cohesion was linked to the support role as well as to the task role of their leader.

DISCUSSION

The findings from our previous study on the Mir Space Station were essentially replicated on board the ISS. The findings suggest a number of countermeasures for future on-orbit missions, some of which may not be relevant for expeditionary missions (e.g., to Mars).

Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting

OBJECTIVE

To evaluate the efficacy of sertraline in the treatment of posttraumatic stress disorder (PTSD) in a Veterans Affairs (VA) clinic setting involving patients with predominantly combat-related PTSD.

METHOD

169 outpatient subjects with a DSM-III-R diagnosis of PTSD and who scored 50 or higher on Part 2 of the Clinician-Administered PTSD Scale (CAPS-2) at the end of a 1-week placebo run-in period participated. Patients recruited from 10 VA medical centers were randomly assigned to 12 weeks of flexibly dosed sertraline (25-200 mg/day) (N = 86; 70% with combat-related PTSD; 79% male) or placebo (N = 83; 72% combat-related PTSD; 81% male) between May 1994 and September 1996. The primary efficacy measures were the mean change in CAPS-2 total severity score from baseline to endpoint, in the total score from the Impact of Event Scale, and in the Clinical Global Impressions-Severity of Illness and Improvement scales.

RESULTS

There were no significant differences between sertraline and placebo on any of the primary or secondary efficacy measures at endpoint. In order to understand the results, gender, duration of illness, severity of illness, type of trauma, and history of alcohol/substance abuse were explored as potential moderators of outcome, but no consistent effects were uncovered. Sertraline was well tolerated, with 13% of patients discontinuing due to adverse events.

CONCLUSION

Sertraline was not demonstrated to be efficacious in the treatment of PTSD in the VA clinic settings studied.

Effects of metyrapone on hypothalamic-pituitary-adrenal axis and sleep in women with post-traumatic stress disorder

BACKGROUND

Metyrapone blocks cortisol synthesis which results in removal of negative feedback, a stimulation of hypothalamic corticotropin releasing factor (CRF) and a reduction in delta sleep. We previously reported a diminished delta sleep and hypothalamic-pituitary-adrenal (HPA) response to metyrapone in men with post-traumatic stress disorder (PTSD). In this study, we aimed to extend these findings to women.

METHODS

Three nights of polysomnography were obtained in 17 women with PTSD and 16 controls. On day 3, metyrapone was administered throughout the day up until bedtime. Plasma adrenocorticotropic hormone (ACTH), cortisol, and 11-deoxycortisol were obtained the morning following sleep recordings the day before and after metyrapone administration.

RESULTS

There were no significant between-group differences in hormone concentration and delta sleep at baseline. Relative to controls, women with PTSD had decreased ACTH and delta sleep responses to metyrapone. Decline in delta sleep was associated with the magnitude of increase in ACTH across groups.

CONCLUSIONS

Similar to our previous findings in men, the ACTH and sleep electroencephalogram response to metyrapone is attenuated in women with PTSD. These results are consistent with a model of downregulation of CRF receptors in an environment of chronically increased CRF activity or with enhanced negative feedback regulation in PTSD.

Post-traumatic stress symptoms in an elite unit of Brazilian police officers: prevalence and impact on psychosocial functioning and on physical and mental health

BACKGROUND

Frequent exposure to traumatic situations put police officers under an increased risk for developing post-traumatic stress disorder (PTSD). The goals of this study were to determine the current prevalence of post-traumatic stress symptoms (PTSS) in Brazilian police officers and to compare groups with and without PTSS in terms of associated morbidity.

METHODS

Police officers from an elite unit (n=157) were asked to fill out a socio-demographic questionnaire, the 12-item General Health Questionnaire and the Post-Traumatic Stress Disorder Checklist-Civilian Version. The latter's scores were used to establish the diagnoses of "full PTSD" and of "partial PTSD".

RESULTS

Prevalence rates of "full PTSD" and "partial PTSD" were 8.9% and 16%, respectively. Compared with the "no PTSD" group, police officers with "full PTSD" were five times more likely to be divorced (21.6% vs. 4.3%, p=0.008), felt that their physical health was poorer (64.3% vs. 6%, p<0.001), had more medical consultations during the last 12 months [2.00 (+/-1.62) vs. 1.09 (+/-1.42), p=0.03] and reported more often lifetime suicidal ideation (35.7% vs. 5.2%, p=0.002).

LIMITATIONS

The sample was relatively small. A screening tool was employed instead of a semi-structured interview. The cross-sectional design is unsuitable for ascertaining cause-effect relations.

CONCLUSIONS

PTSD prevalence in our sample was comparable to those reported for North American and Dutch policemen. The presence of "full PTSD" was associated with evidences of considerable morbidity. These findings may contribute to the development of effective policies aimed at the prevention and treatment of PTSD in law enforcement agents.

Peritraumatic fear, helplessness and horror and peritraumatic dissociation: Do physical and cognitive symptoms of panic mediate the relationship between the two?

The goal of this study was to examine whether panic mediates the relationship between fear, helplessness, and horror (PTSD criterion A2) and dissociation at the time of trauma. The study sample included 709 police officers and 317 peer-nominated civilians who had been exposed to a variety of critical incidents. Participants filled out measures of critical incident exposure, PTSD criterion A2, panic, and dissociation. Results indicate that together, physical and cognitive symptoms of panic completely mediate the relationship between criterion A2 and dissociation in civilians, and partially mediate that relationship in police. These results provide support for the idea that panic mediates the relationship between fear, helplessness, and horror (criterion A2) and dissociation at the time of trauma. The results also raise the possibility, however, that the mediational role of panic may be further moderated by additional variables.

No improvement of posttraumatic stress disorder symptoms with guanfacine treatment

OBJECTIVE

The authors report an 8-week, double-blind, randomized controlled trial of guanfacine versus placebo for posttraumatic stress disorder (PTSD).

METHOD

Veterans with chronic PTSD who were medication-free or receiving stable pharmacotherapy were randomly assigned to guanfacine (N=29) versus placebo (N=34).

RESULTS

Guanfacine had no effect on PTSD symptoms, subjective sleep quality, or general mood disturbances. Guanfacine was associated with a number of side effects.

CONCLUSIONS

These results do not support the use of alpha 2 agonists in veterans with chronic PTSD.

Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse

Studies have shown differences in neuropsychological functioning between groups with posttraumatic stress disorder (PTSD) and control participants. Because individuals with PTSD often have a history of comorbid alcohol abuse, the extent to which an alcohol confound is responsible for these differences remains a concern. The current study compares neuropsychological testing scores in 4 groups of veterans with and without PTSD (PTSD+ and PTSD-, respectively) and with and without a history of alcohol abuse (ETOH+ and ETOH-, respectively): n for PTSD+/ETOH- = 30, n for PTSD+/ETOH- = 37, n for PTSD-/ETOH+ = 30, and n for PTSD-/ETOH- = 31. Results showed that PTSD, when alcohol, educational level, vocabulary, and depression are controlled for, was associated with decreased verbal memory, attention, and processing speed performance. Alcohol abuse history was associated with decreased visual memory performance. By controlling for alcohol and depression, the authors can more conclusively demonstrate that verbal memory and attention differences are associated with PTSD.

The impact of personal threat on police officers' responses to critical incident stressors

The relationship of type of critical incident (CI) stressor with peritraumatic responses and posttraumatic stress disorder symptoms was examined in police. Officers (N = 662) provided narratives of their most distressing CI experienced during police service and completed measures of related peritraumatic responses and posttraumatic stress disorder symptoms. Narratives were reliably rated (kappa = .80-1.0) on seven categories emerging from a series of factor analyses of a measure of critical incident stressors. Additional analysis revealed that the classification of primary narrative features required only five categories (personal life threat, duty-related violence, encountering physical or sexual assault victims, exposure to civilian death, other). When analyzed by further collapsing these five categories into high versus low personal threat, officers whose narratives contained high personal threat reported more peritraumatic dissociation, peritraumatic emotional distress, and current hyperarousal symptoms. Results suggest that greater personal threat during a CI may place an officer at greater risk for subsequent distress.

Increased cortisol in women with intimate partner violence-related posttraumatic stress disorder

BACKGROUND

Alterations of hypothalamic-pituitary-adrenal (HPA) axis function and sympathetic-adrenal activity have been proposed as key factors in biological models of posttraumatic stress disorder (PTSD).

METHODS

We examined neuroendocrine function in female survivors of intimate partner violence (IPV) with lifetime (current or remitted) PTSD (n=29) and in women who were exposed to IPV but never developed PTSD (n=20). Salivary cortisol was collected as a marker of HPA axis function at 1, 4, 9, and 11 h after awakening. Platelet epinephrine and norepinephrine were assayed as markers of sympathetic-adrenal activation.

RESULTS

Women with lifetime PTSD had significantly higher cortisol levels across the day compared to abuse-exposed participants without PTSD, after controlling for age, depression, severity, and latency of abuse. There were no significant group differences in levels of platelet catecholamines.

CONCLUSIONS

Elevated cortisol levels may be a biomarker of IPV-related lifetime PTSD, reflecting long-lasting changes associated with trauma-exposure or possibly a reflection of risk for PTSD in women.

Association Between Alexithymia and Neuroendocrine Response to Psychological Stress in Police Academy Recruits

Alexithymia has been associated with both posttraumatic stress disorder and neuroendocrine responses to stress. This study examined the relationship of alexithymia to salivary cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG) in a sample of police academy recruits exposed to a video stress challenge. Alexithymia scores were negatively associated with catecholamine response to the video challenge but no association was found between alexithymia scores and cortisol reactivity.

Predictors of Posttraumatic Stress in Police and Other First Responders

We provide an overview of previous research conducted by our group on risk and resilience factors for PTSD symptoms in police and other first responders. Based on our work, the findings of other investigators on individual differences in risk for PTSD, and drawing on preclinical studies fear conditioning and extinction, we propose a conceptual model for the development of PTSD symptoms emphasizing the role of vulnerability and resilience to peritraumatic panic reactions. We tested this conceptual model in a cross-sectional sample of police officers (n = 715). Utilizing an hierarchical linear regression model we were able to explain 39.7% of the variance in PTSD symptoms. Five variables remained significant in the final model; greater peritraumatic distress (beta = 0.240, P < .001), greater peritraumatic dissociation (beta = 0.174, P < .001), greater problem-solving coping (beta = 0.103, P < .01), greater routine work environment stress (beta = 0.182, P < .001), and lower levels of social support (beta = -0.246, P < .001). These results were largely consistent with the proposed conceptual model. Next steps in this line of research will be to test this model prospectively in a sample of 400 police academy recruits assessed during training and currently being followed for the first 2 years of police service.

Neuroendocrine Regulation of Sleep Disturbances in PTSD

Studies that have conducted quantitative analysis of the sleep electroencephalogram (EEG) have demonstrated decreased delta sleep in PTSD. Elevations in both hypothalamic (neurohormonal) and extrahypothalamic (neurotransmitter) corticotropin releasing factor (CRF) release is associated with decreased delta sleep activity. We present data from several studies examining the effect of metyrapone administration on the sleep EEG in PTSD and control subjects. Plasma ACTH, cortisol, and 11-deoxycorticol were obtained the morning following polysomnographic sleep recordings before and after metyrapone administration. Delta sleep was measured by period amplitude analysis. The results demonstrate: a) decreased delta sleep in male subjects with PTSD; b) metyrapone administration resulted in an activation of the sleep EEG and a robust decrease in quantitative delta sleep; c) the sleep and endocrine (increase in ACTH) responses to metyrapone were significantly decreased in PTSD in two different study samples; and d) the metyrapone-related disruption to sleep in both samples was predicted by the increase in ACTH measured the following morning. These findings strongly suggest that the delta sleep response to metyrapone is a measure of the brain response to a hypothalamic CRF challenge. The attenuated delta sleep and endocrine response to metyrapone challenge in PTSD is consistent with a model of enhanced negative feedback regulation or downregulation of CRF receptors in an environment of chronically increased CRF activity.

Increased Cortisol in Women With Intimate Partner Violence-Related Posttraumatic Stress Disorder

Intimate partner violence (IPV) is a chronic and recurrent traumatic stressor associated with PTSD; however, its biological correlates are not well understood. This study examined diurnal salivary cortisol and platelet catecholamines in women with lifetime IPV-related PTSD and in women exposed to IPV who did not develop PTSD. Cortisol was elevated in women with lifetime PTSD compared to controls. No differences were found for platelet catecholamines.

Alexithymia and PTSD symptoms in urban police officers: cross-sectional and prospective findings

The relationship of alexithymia to posttraumatic stress disorder (PTSD) symptomatology was examined cross-sectionally in 166 urban police officers surveyed between 1998 and 1999 and prospectively in 54 of these officers who participated in a follow-up survey after the September 11, 2001 (9/11) terrorist attacks. In cross-sectional analyses, alexithymia scores were positively associated with PTSD symptom levels and self-reported childhood emotional abuse--neglect, but not with cumulative level of critical incident exposure. Alexithymia scores accounted for 11.2% of the variance in PTSD symptoms prior to accounting for additional predictors, but did not retain significance in the final model. In prospective analyses, alexithymia scores significantly predicted 9/11-related PTSD symptom severity over and above pre-9/11 PTSD symptoms.

Hypothalamic-pituitary-adrenal axis activity and sleep in posttraumatic stress disorder

Alterations of the hypothalamic-pituitary-adrenal (HPA) axis and sleep disturbances have been described separately in post-traumatic stress disorder (PTSD). It is not known if HPA alterations and sleep disturbances are associated in PTSD. This study examined sleep and HPA activity in 20 male medication-free subjects with PTSD and 16 matched healthy controls. Two nights of polysomnography were obtained and 24-h urinary cortisol was collected during day 2. Subjects self-administered a low-dose (0.5 mg) salivary dexamethasone test at home. Compared with controls, PTSD subjects had higher 24-h urinary microg cortisol/g creatinine (mean+/-SD 40+/-17 vs 28+/-12, p=0.03) but not significantly higher 24-h urinary cortisol (mean+/-SD 52+/-15 microg/day vs 43+/-23, p=0.19). PTSD subjects showed a trend towards less cortisol suppression after dexamethasone (73%+/-18 vs 83%+/-10, p=0.06). In the combined sample, delta sleep was significantly and negatively correlated with 24-h urinary cortisol (r=-0.36, p=0.04), and with 24-h urinary cortisol/g creatinine on a trend level (r=-0.34, p=0.06). Our results suggest that increased cortisol is negatively associated with delta sleep. This may contribute to sleep abnormalities in conditions associated with elevated cortisol, possibly including PTSD. Future studies should explore the temporal relationship between HPA activity, sleep disturbances, and psychopathology after a traumatic event.

PTSD symptoms predict waking salivary cortisol levels in police officers

This study examines whether pre- or post-dexamethasone salivary cortisol is related to cumulative critical incident exposure, peritraumatic responses, or post-traumatic stress disorder (PTSD) symptom severity. Thirty active duty police officers completed the study protocol, which included measures of peritraumatic emotional distress, peritraumatic dissociation, duty-related trauma exposure, and PTSD symptoms. Salivary cortisol was consolidated into three outcome variables: (1) pre-dexamethasone free cortisol levels at 1, 30, 45, and 60 min after awakening, (2) post-dexamethasone cortisol levels at the identical wake times, and (3) percentage of cortisol suppression. Control variables included age, gender, average daily alcohol use, night shift work, routine work environment stressors, and salivary dexamethasone levels. Zero order correlations showed that greater levels of PTSD symptoms, peritraumatic distress, and peritraumatic dissociation were associated with lower levels of pre-dexamethasone cortisol levels on awakening, but were not associated with the other two cortisol variables. A trend was also noted for older subjects to have lower pre-dexamethasone cortisol on awakening. When these four predictors were entered simultaneously in a regression analysis, only age and PTSD symptom severity significantly predicted pre-dexamethasone awakening cortisol levels. These results replicate previous research indicating a relationship between greater PTSD symptoms and lower levels of basal cortisol on awakening, and extend this finding to a previously unstudied non-treatment seeking population, urban police.

Why Are Hispanics at Greater Risk for PTSD?

Several studies have found that Hispanic Americans have higher rates of posttraumatic stress disorder (PTSD) than non-Hispanic Caucasian and Black Americans. The authors identified predictors of PTSD symptom severity that distinguished Hispanic police officers (n=189) from their non-Hispanic Caucasian (n=317) and Black (n=162) counterparts and modeled them to explain the elevated Hispanic risk for PTSD. The authors found that greater peritraumatic dissociation, greater wishful thinking and self-blame coping, lower social support, and greater perceived racism were important variables in explaining the elevated PTSD symptoms among Hispanics. Results are discussed in the context of Hispanic culture and may be important for prevention of mental illness in the fastest growing ethnic group in the United States.

Comparisons between high and low peritraumatic dissociators in cardiovascular and emotional activity while remembering trauma

Peritraumatic dissociation (PD) is one of the best predictors of posttraumatic stress disorder (PTSD). In this pilot study, we examined cardiovascular psychophysiology and negative emotions in 19 adults who, retrospectively, reported experiencing high or low levels of PD during the worst trauma of their lives. In a contiguous series of ten-minute phases, they rested, thought about, talked about, and recovered from talking about their index trauma. We hypothesized that greater PD would be associated with more negative emotion, lower cardiovascular activity, and greater discordance between negative emotions and cardiovascular activity. Our main findings were that PD was associated with lower blood pressure prior to talking about the trauma, greater negative emotion while talking about the trauma, and greater emotional and cardiovascular discordance throughout the experiment. These findings add to the very limited empirical data on physiological concomitants of peritraumatic dissociation and may aid in developing preventive interventions for PTSD.

Association between childhood trauma and catecholamine response to psychological stress in police academy recruits

BACKGROUND

Childhood trauma is a risk factor for anxiety disorders in adulthood. One possible mechanism for this association is an increased neuroendocrine response to stress in adults with a history of childhood trauma.

METHODS

In a cross-sectional study, 76 police academy recruits (mean [+/-SD] age 28 +/- 5 years, 10 female) were exposed to a video depicting real-life officers exposed to highly stressful incidents. Salivary cortisol and 3-methoxy-4-hydroxy-phenylglycol (MHPG, the major metabolite of norepinephrine) were collected at baseline, immediately after the video, and 20 min after the video. Childhood trauma before age 14 was assessed with an interview (Life Stressor Checklist-Revised).

RESULTS

Exposure to the video elicited significant MHPG and cortisol responses in both groups. Recruits with childhood trauma histories (n = 16) had a significantly greater MHPG response, as evidenced by a group effect (F = 8.0, p < .01), and a group x time interaction (F = 4.1, p < .05). The cortisol response did not differ between groups.

CONCLUSIONS

Police academy recruits with childhood trauma histories have an increased catecholamine response to psychological stress. This might serve as a risk factor for anxiety disorders in recruits, and these findings might generalize to other groups with a history of childhood trauma.

A meta-analysis of cortisol response to challenge in human aging: importance of gender

An increased cortisol response to challenge is associated with a variety of age-related disorders such as Alzheimer's disease, depression, diabetes, metabolic syndrome, and hypertension. Among the healthy elderly, an increased cortisol response to challenge may be a risk factor for developing these age-related disorders. We searched Pubmed, Embase, PsychInfo, Biosis, and Digital Dissertations (January 1966-June 2003) and included 45 parallel-group (young vs. old subjects) studies that used either a pharmacological or psychological challenge in healthy volunteers and measured cortisol response to challenge. We calculated effect sizes (Cohen's d) for the standardized mean differences between groups. Compared to younger controls (n=670, mean age 28 years +/-5), older subjects (n=625, 69+/-6) showed a larger cortisol response to challenge defined as stronger response to stimulation or less inhibition after a suppression test (d=0.42, 95% confidence interval (CI), 0.26-0.57). The effect of age on cortisol release was significantly stronger in women (d=0.65, 95% CI 0.34-0.97) than men (d=0.24, 95% CI 0.02-0.47). Our results demonstrate that aging increases the cortisol response to challenge. This effect of age on cortisol response is almost three-fold stronger in women than men. Prospective studies should explore whether the higher cortisol response in the elderly is a risk factor for developing neuropsychiatric and medical disorders.

Depression and 24-hour urinary cortisol in medical outpatients with coronary heart disease: The Heart and Soul Study

BACKGROUND

In patients with coronary heart disease (CHD), depression leads to worse cardiovascular outcomes. Depression has been associated with increased cortisol in medically healthy patients, suggesting that cortisol may act as a mediator in the pathway between depression and cardiovascular events. However, it is not known whether depression is associated with elevated cortisol levels in patients with CHD.

METHODS

We examined the association between depression (assessed by the Computerized Diagnostic Interview Schedule) and 24-hour urinary cortisol in 693 medical outpatients with known CHD.

RESULTS

Of 693 participants, 138 (20%) had current depression. Depressed participants had greater mean cortisol levels than those without depression (42 +/- 25 vs. 36 +/- 20 microg/day, p <.01). With each increasing quartile of cortisol concentration the frequency of depression increased (p <.01). Participants in the highest quartile of cortisol had a twofold increased odds of having depression, compared with those in the lowest quartile (odds ratio [OR] 2.1, 95% confidence interval [CR] 1.2-3.6, p =.01). This association remained strong after adjusting for potential confounding variables (OR 2.4, 95% CI 1.3-4.4, p <.01). In this cross-sectional analysis, elevated cortisol was not associated with worse cardiac function.

CONCLUSIONS

In patients with CHD,depression is associated with elevated cortisol levels.

Current concepts in pharmacotherapy for posttraumatic stress disorder

OBJECTIVE

This article describes current approaches to the pharmacologic treatment of posttraumatic stress disorder (PTSD) and reviews the classes of pharmacologic agents used in the treatment of PTSD. Pharmacotherapy for PTSD that is comorbid with other psychiatric disorders is highlighted.

METHODS

The primary-source literature was reviewed by using a MEDLINE search. Secondary-source review articles and chapters were also used. Results from studies of the psychophysiology of PTSD are outlined in the review to help inform treatment choices. The review gives more consideration to controlled studies than to open clinical trials. Recommendations for treatment are evidence based.

RESULTS AND DISCUSSION

A growing body of evidence demonstrates the efficacy of pharmacologic treatment for PTSD. The effectiveness of the selective serotonin reuptake inhibitors sertraline and paroxetine in large-scale, well-designed, placebo-controlled trials resulted in their being the first medications to receive approval from the U.S. Food and Drug Administration for the treatment of PTSD. Observation of psychophysiologic alterations associated with PTSD has led to the study of adrenergic-inhibiting agents and mood stabilizers as therapeutic agents. Controlled clinical trials with these classes of medication are needed to determine their efficacy for treating PTSD. Finally, the choice of medication for treating PTSD is often determined by the prominence of specific PTSD symptoms and the pattern of comorbid psychiatric conditions.

Attention, learning, and memory in posttraumatic stress disorder

This study compared attention and declarative memory in a sample of combat veterans with posttraumatic stress disorder (PTSD, n = 24) previously reported to have reduced concentrations of the hippocampal neuronal marker N-acetyl aspartate (NAA), but similar hippocampal volume compared to veteran normal comparison participants (n = 23). Healthy, well-educated males with combat-related PTSD without current depression or recent alcohol/drug abuse did not perform differently on tests of attention, learning, and memory compared to normal comparison participants. Further, hippocampal volume, NAA, or NAA/Creatine ratios did not significantly correlate with any of the cognitive measures when adjustments for multiple comparisons were made. In this study, reduced hippocampal NAA did not appear to be associated with impaired declarative memory.

Stress response syndromes in women undergoing mammography: a comparison of women with and without a history of breast cancer

OBJECTIVE

The purpose of this study was to assess the incidence, severity, and correlates of acute stress responses in women undergoing diagnostic mammographic surveillance and to explore the moderating impact of physician support on these symptoms.

METHODS

Sixty-six female breast cancer outpatients (at least 12 months after diagnosis and primary treatment) and 69 healthy women undergoing mammographic surveillance completed measures of: acute stress response, somatization, trauma history, psychiatric history, social support, and physician satisfaction.

RESULTS

Previous cancer, pre-mammography breast complaints, lower income, previous psychiatric medication use, greater instrumental support, greater somatization, greater perceived physician disengagement, and less perceived physician support were all associated with increased stress responses. Among women with a previous cancer diagnosis, those with greater distress reported higher levels of physician support. In contrast, among those without a previous cancer diagnosis, those with greater perceived physician support reported less distress.

CONCLUSIONS

These findings suggest that cancer-related cues, such as follow-up surveillance, may trigger a sensitizing response in women with a previous cancer diagnosis. The association of distress with physician support may arise from the responsiveness of physicians to identified distress, from increased help-seeking behavior by those who are distressed, or both. The benefit of support provided by health care professionals to those at risk of developing stress response syndromes deserves further study.

Cortisol levels are positively correlated with hippocampal N-acetylaspartate

BACKGROUND

This study examined the relationship of hypothalamic-pituitary-adrenal measures and hippocampal N-acetylaspartate (NAA) in posttraumatic stress disorder (PTSD) patients and control subjects.

METHODS

Eleven patients with combat-related PTSD and 11 control subjects were evaluated with magnetic resonance spectroscopy as well as by morning salivary cortisol samples before and after administration of low-dose dexamethasone (.5 mg).

RESULTS

Left hippocampal NAA was strongly associated with both pre-dexamethasone cortisol levels (n = 22, r =.53, p =.013) and post-dexamethasone cortisol levels (n = 22, r =.63, p =.002). After accounting for clinical symptom severity and hippocampal volume, cortisol levels accounted for 21.9% of the variance (F = 5.6, p =.004) in left hippocampal NAA and 12.6% of the variance (F = 3.2, p =.035) in right hippocampal NAA.

CONCLUSIONS

This study shows a positive relationship between cortisol levels and hippocampal NAA in subjects without hypercortisolemia. Within the range of values seen in our subjects, cortisol may have a trophic effect on the hippocampus.

Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma

BACKGROUND

This study investigated the efficacy of propranolol prescribed shortly after trauma exposure in the prevention of posttraumatic stress disorder (PTSD) symptoms and diagnosis.

METHODS

Eleven patients received 40 mg of propranolol 3 times daily for 7 days, followed by a taper period of 8-12 days. They were compared with eight patients who refused propranolol but agreed to participate in the study. Though nonrandomized, the two groups did not differ on demographics, exposure characteristics, physical injury severity, or peritraumatic emotional responses.

RESULTS

Posttraumatic stress disorder rates were higher in the group who refused propranolol (3/8) compared with those who received the medication (1/11), as were the levels of PTSD symptoms (U = 85, p =.037).

CONCLUSIONS

Our results are consistent with earlier findings and suggest that propranolol may be useful for mitigating PTSD symptoms or perhaps even preventing the development of PTSD.

Fear-potentiated startle and posttraumatic stress symptoms in urban police officers

We studied the effects of increasing threat conditions on self-reported emotion, eyeblink electromyogram, and skin conductance responses to startling sounds in 55 police officers who endorsed a range of PTSD (posttraumatic stress disorder) symptoms. We found that contextual threat affected both physiologic and self-reported emotional responses. Greater PTSD symptom severity was related to greater physiologic responses under the low and medium but not under the high threat condition. The relationship between PTSD symptoms and physiologic responses was neither explained by self-reported emotional responses nor preexisting reported exaggerated startle symptoms. Our results emphasize the importance of contextual threat and suggest that laboratory measures of startle improve upon self-reported exaggerated startle alone in indexing PTSD symptom severity in urban police officers.

Delta sleep response to metyrapone in post-traumatic stress disorder

Metyrapone blocks cortisol synthesis, which results in the stimulation of hypothalamic cortiocotropin-releasing factor (CRF) and a reduction in delta sleep. We examined the effect of metyrapone administration on endocrine and sleep measures in male subjects with and without chronic PTSD. We hypothesized that metyrapone would result in a decrease in delta sleep and that the magnitude of this decrease would be correlated with the endocrine response. Finally, we utilized the delta sleep response to metyrapone as an indirect measure of hypothalamic CRF activity and hypothesized that PTSD subjects would have decreased delta sleep at baseline and a greater decrease in delta sleep induced by metyrapone. Three nights of polysomnography were obtained in 24 male subjects with combat-related PTSD and 18 male combat-exposed normal controls. On day 3, metyrapone was administered during normal waking hours until habitual sleep onset preceding night 3. Endocrine responses to metyrapone were measured in plasma obtained the morning following sleep recordings, the day before and after administration. Repeated measures ANOVAs were conducted to compare the endocrine and sleep response to metyrapone in PTSD and controls. PTSD subjects had significantly less delta sleep as indexed by stages 3 and 4, and total delta integrated amplitude prior to metyrapone administration. There were no differences in premetyrapone cortisol or ACTH levels in PTSD vs controls. PTSD subjects had a significantly decreased ACTH response to metyrapone compared to controls. Metyrapone caused an increase in awakenings and a marked decrease in quantitative measures of delta sleep that was significantly greater in controls compared to PTSD. The decline in delta sleep was significantly associated with the magnitude of increase in both 11-deoxycortisol and ACTH. The results suggest that the delta sleep response to metyrapone is a measure of the brain response to increases in hypothalamic CRF. These data also suggest that the ACTH and sleep EEG response to hypothalamic CRF is decreased in PTSD.

The mediating effects of sleep in the relationship between traumatic stress and health symptoms in urban police officers

OBJECTIVE

Posttraumatic stress symptoms have been associated with increased health problems across numerous studies. Sleep disruption, one of the principal symptoms resulting from traumatic stress, has also been shown to produce health problems. This study explored the hypothesis that the relationship between posttraumatic stress symptoms and health is mediated by sleep problems.

METHOD

A sample of 741 police officers were administered measures of traumatic stress symptoms, sleep, health functioning, and somatic symptoms.

RESULTS

Traumatic stress symptoms were significantly related to both somatic symptoms (R2 = 0.18, p <.001) and health functioning (R2 = 0.02, p <.01). The relationship between somatic symptoms and traumatic stress symptoms was partially mediated by sleep (p <.001). The relationship between traumatic stress symptoms and health functioning was fully mediated by sleep.

CONCLUSIONS

Although design characteristics, such as cross-sectional sampling, limit the inferences that can be drawn, these findings suggest that sleep may serve as an important mediator between traumatic stress and somatic symptoms.

The effect of nefazodone on subjective and objective sleep quality in posttraumatic stress disorder

BACKGROUND

This study assesses the efficacy of nefazodone treatment (target dose of 400-600 mg/day) on objective and subjective sleep quality in Vietnam combat veterans with chronic DSM-IV posttraumatic stress disorder (PTSD).

METHOD

Medically healthy male Vietnam theater combat veterans with DSM-IV PTSD (N = 10) completed a 12-week open-label trial. Two nights of ambulatory polysomnography were obtained at baseline and at the end of the trial. PTSD and depressive symptoms and subjective sleep quality were assessed at baseline and after 12 weeks. Data were collected in 1999 and 2000.

RESULTS

Nefazodone treatment led to a significant decrease in PTSD and depressive symptoms (p <.05), an improvement in global subjective sleep quality, and a reduction in nightmares. Nefazodone also resulted in a substantial improvement in objective measures of sleep quality, particularly increased total sleep time, sleep maintenance, and delta sleep as measured by period amplitude analysis.

CONCLUSION

Nefazodone therapy results in an improvement of both subjective and objective sleep quality in subjects with combat-related PTSD.

Temporal instability of auditory and visual event-related potentials in posttraumatic stress disorder

BACKGROUND

We examined P300 measures in patients with posttraumatic stress disorder (PTSD) and control subjects at two different time points to determine event-related potential (ERP) stability over time and the relationship of changes in ERPs to changes in symptom levels.

METHODS

Auditory and visual P300 was recorded in a three-condition novelty oddball task in 25 male subjects with combat-related PTSD and 15 male combat-exposed normal control subjects at two time points separated by 6-12 months. Regression analyses were conducted to compare the temporal stability of ERP measures in PTSD and control subjects. Variability in ERP measures over time within PTSD subjects was examined for association with changes in symptom levels.

RESULTS

There were no significant differences in P300 amplitude or latency in PTSD versus control subjects at either time point, regardless of stimulus type (target, novel) or modality (auditory, visual). Nine of 24 P300 measures were significantly less predictable over time in the PTSD group compared to control subjects. Variability of P300 measures over time was not associated with fluctuations in symptoms of depression or PTSD.

CONCLUSIONS

P300 ERPs are more variable cross-sectionally and over time in PTSD subjects compared to trauma exposed control subjects. Measures of variability about the group mean appear to be more informative about the cognitive electrophysiology of PTSD than measures of central tendency.

Lessons learned from Shuttle/Mir: psychosocial countermeasures

BACKGROUND

During future long-duration space missions, countermeasures need to be developed to deal with psychosocial issues that might impact negatively on crewmember performance and well-being.

METHODS

In our recently completed NASA-funded study of 5 U.S. astronauts, 8 Russian cosmonauts, and 42 U.S. and 16 Russian mission control personnel who participated in the Shuttle/Mir program, we evaluated a number of important psychosocial issues such as group tension, cohesion, leadership role, and the displacement of negative emotions from crewmembers to people in mission control and from mission control personnel to management.

RESULTS

Based on our findings, which are reviewed, a number of psychosocial countermeasures are suggested to help ameliorate the negative impact of potential psychosocial problems during future manned space missions.

CONCLUSIONS

Crewmembers should be selected not only to rule out psychopathology but also to select-in for group compatibility and facility in a common language. Training should include briefings and team building related to a number of psychosocial issues and should involve both crewmembers and mission control personnel. During the mission, both experts on the ground and the crewmembers themselves should be alert to potential interpersonal problems, including the displacement of negative emotions from the crew to the ground. Supportive activities should consist of both individual and interpersonal strategies, including an awareness of changing leisure time needs. Finally, attention should be given to postmission readjustment and to supporting the families on Earth.

Critical incident exposure and sleep quality in police officers

OBJECTIVE

Police officers face many stressors that may negatively impact sleep quality. This study compares subjective sleep quality in police officers with that in control subjects not involved in police or emergency services. We examined the effects of critical incident exposure (trauma exposure) and routine (nontraumatic) work environment stressors on sleep quality after controlling for the effects of work shift schedule.

METHODS

Subjective sleep disturbances were measured by the Pittsburgh Sleep Quality Index in police officers (variable-shift workers, N = 551; stable day-shift workers, N = 182) and peer-nominated comparison subjects (variable-shift workers, N = 98; stable day-shift workers, N = 232). The main predictor variables were 1) duty-related critical incident exposure to on-line policing and 2) work environment stress related to routine administrative and organizational aspects of police work.

RESULTS

Police officers on both variable and stable day shifts reported significantly worse sleep quality and less average sleep time than the two corresponding control groups. Within police officers, cumulative critical incident exposure was associated with nightmares but only weakly associated with poor global sleep quality. In contrast, the stress from officers' general work environment was strongly associated with poor global sleep quality. Sleep disturbances were strongly associated with posttraumatic stress symptoms and general psychopathology.

CONCLUSIONS

A large percentage of police officers report disturbances in subjective sleep quality. Although the life-threatening aspects of police work are related to nightmares, the routine stressors of police service seem to most affect global sleep quality in these subjects. These findings may have implications for health and occupational performance.

New directions in the pharmacotherapy of posttraumatic stress disorder

Advances in psychopharmacology of PTSD are presented, focusing on antidepressants, adrenergic agents, antianxiety agents, and mood stabilizers. Treatment recommendations are related to recent advances in the understanding of the biology of PTSD. Pharmacotherapy of PTSD in children and adolescents is discussed, including recommended dose ranges. Recommendations are specified for pharmacotherapy of trauma survivors in the immediate aftermath of traumatic exposure, and for those with acute and chronic posttraumatic stress disorders.

Decreased hippocampal N-acetylaspartate in the absence of atrophy in posttraumatic stress disorder

BACKGROUND

Previous magnetic resonance imaging studies of posttraumatic stress disorder reported hippocampal volume loss. The goals of this study were 1) to determine the relationship between hippocampal atrophy and posttraumatic stress disorder in the absence of alcohol abuse, and 2) to test if loss of N-acetylaspartate (a neuron marker) in the hippocampus of posttraumatic stress disorder occurs separate from atrophy. In addition, volume changes in the entorhinal cortex were also explored.

METHODS

Eighteen male patients with combat-related posttraumatic stress disorder (mean age 51.2 +/- 2.5 years) and 19 male control subjects (mean age 51.8 +/- 3.2 years) were studied using magnetic resonance imaging and Proton magnetic resonance spectroscopic imaging. Both groups had no alcohol and drug abuse during the past 5 years.

RESULTS

Posttraumatic stress disorder and control subjects had similar volumes of hippocampus and entorhinal cortex. In contrast to volume, N-acetylaspartate was significantly reduced by about 23% bilaterally in the hippocampus of posttraumatic stress disorder when compared with control subjects, and creatine-containing compounds were reduced by 26% in the right hippocampus of posttraumatic stress disorder.

CONCLUSIONS

N-acetyl asparate and creatine reductions imply that there are hippocampal abnormalities in posttraumatic stress disorder. Furthermore, these metabolite changes seem to be better indicators of posttraumatic stress disorder pathology than volume losses.