Prospective study of externalizing and internalizing subtypes of posttraumatic stress disorder and their relationship to mortality among Vietnam veterans

Posttraumatic stress disorder (PTSD) can be a complex disorder, and some studies have found that samples of individuals with PTSD contain subtypes that may relate to health outcomes. The goals were to replicate previously identified PTSD subtypes and examine how subtype membership relates to mortality. Data from the Vietnam Experience Study and a clinical sample of Vietnam veterans were combined (n = 5248) to address these research questions. Consistent with previous studies, 3 PTSD subtypes emerged: externalizers (n = 317), internalizers (n = 579), and low pathology (n = 280). Posttraumatic stress disorder diagnosis was associated with increased risk of all-cause and behavioral-cause (eg, homicide, suicide) mortality. Both externalizing and internalizing subtypes had higher mortality and were more likely to die from cardiovascular causes than those without PTSD. Externalizers were more likely to die from substance-related causes than those without PTSD. The value of considering possible PTSD subtypes is significant in that it may contribute to identifying more specific targets for treatment and rehabilitation in veterans with PTSD.

Diagnostic alterations for post-traumatic stress disorder: examining data from the National Comorbidity Survey Replication and National Survey of Adolescents

BACKGROUND

Two alternative models of post-traumatic stress disorder (PTSD) appear to represent the disorder's latent structure better than the traditional Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) three-factor PTSD model. The present study examines the impact of using these structural models for the diagnosis of lifetime PTSD while retaining the DSM-IV PTSD's six-symptom diagnostic requirement.

METHOD

Data were gathered from large-scale, epidemiological datasets collected with adults (National Comorbidity Survey Replication) and adolescents (National Survey of Adolescents). Two alternative, empirically supported four-factor models of PTSD were compared with the DSM-IV three-factor PTSD diagnostic model.

RESULTS

Results indicated that the diagnostic alterations resulted in substantially improved structural validity, downward adjustments of PTSD's lifetime prevalence (roughly 1 percentage point decreases in adults, 1-2.5 percentage point decreases in adolescents), and equivalent psychiatric co-morbidity and sociodemographic associations.

CONCLUSIONS

Implications for modifying PTSD diagnostic criteria in future editions of DSM are discussed.

[Analysis on factors affecting the severity of post-traumatic stress disorder in transferred casualty after Earthquake]

OBJECTIVE

To investigated the related factors which affecting the severity degrees of post-traumatic stress disorder (PTSD) in transferred casualty after Wenchuan Earthquake.

METHODS

Taking PTSD symptoms self-assessment scale (PCL-C) to involve 386 wounded who suffered 40 days after the earthquake disaster, from 11 hospitals and were transferred to Chongqing city. Multi-stage cluster sampling method was used. 354 valid questionnaires were recovered to explore the relevant factors affecting the severity on the symptoms of PTSD.

RESULTS

This survey contains 354 subjects, with male 154 (43.6%), female 200 (56.4%), age 43.76 +/- 21.22, nation alities: Han people 236 (66.7%), Qiang people 114 (32.2%), others 4 (1.1%), and marriage status as unmarried 92 (26.1%), married 253 (71.7%), others 9 (2.2%). The wounded women PTSD have more serious symptoms than men, and there were differences between them in repeated and disturbing dreams of this stressful experience (t = 2.46, P = 0.014), a strong sense of psychological suffering annoyance (t = 2.02, P = 0.044), having difficulty concentrating (t = 2.04, P = 0.042), being "super-alert" (t = 2.465, P = 0.014) etc, also in the total scores (t = 2.489, P = 0.013) (P < 0.05). The PTSD symptoms of wounded degree in who had been buried in Earthquake were more serious than those not been buried. There were significant differences between them in the items as: avoid thinking about or talking about a stressful experience (t = 2.661, P = 0.008), avoid activities or situations that could recall the stressful experience (t = 2.705, P = 0.007), trouble remembering important parts of a stressful experience (t = 2.775, P = 0.006), feeling emotionally numb or being unable to have loving feelings for those close to you (t = 3.017, P = 0.003), feeling as if your future will somehow be cut short (t = 2.979, P = 0.003) and total scores (t = 3.175, P = 0.002). The wounded that witnessed someone be buried or died in earthquake, in PTSD symptoms, were more serious than those without. In the items of feeling distant or cut off from other people, feeling emotionally numb or being unable to have loving feelings for those close to you, feeling irritable or having angry outbursts, there were significant difference (P < 0.05 - 0.01). There were significant differences among the average score of the three core symptoms (F = 3.350, P < 0.001), among the three core symptoms as well as between the three core symptoms and total score respectively.

CONCLUSION

There were differences in the severity degrees of PTST in transferred casualty under different exposed conditions. Correlations were also found between each of the symptoms.

Six-year longitudinal predictors of posttraumatic growth in parentally bereaved adolescents and young adults

Using the Posttraumatic Growth Inventory, we examined posttraumatic growth in a sample of 50 adolescents and young adults who had experienced parental death in childhood or adolescence. Longitudinal relations were examined between baseline measures of contextual and intraindividual factors and scores on the posttraumatic growth subscales (i.e., New Possibilities, Relating to Others, Personal Strengths, Spiritual Changes, and Appreciation of Life) six years later. Controlling for time since death, threat appraisals, active coping, avoidant coping, seeking support from parents or guardians, seeking support from other adults, internalizing problems, and externalizing problems were significant predictors of posttraumatic growth. The implications of these findings for research and clinical practice are discussed.

[Diagnostic criteria of posttraumatic stress disorder]

The authors consider historical and diagnostic aspects of the origin of the posttraumatic stress disorder diagnosis (PTSD). Different criteria of PTSD presented in diagnostic systems ICD-10 and DSM (from DSM-III to DSM-IV-TR) are analyzed. Attention is drawn to diagnostic definition of "acute stress disorder" (ASD) and its place in the dynamics of PTSD: ASD, acute PTSD, chronic PTSD. The authors claim the existence of PTSD as a distinct diagnostic entity and note that there are substantial differences in the clinical interpretation of distinct psychopathological phenomena involved in the PTSD structure by different authors.

[The problem of the nosological independence of posttraumatic stress disorder]

The author considers the problem of the nosological independence and diagnosis of posttraumatic stress disorder (PTSD) in the theoretical aspect from the position of multifactor character of the disease development. The corresponding issues are discussed on example of consequences of combat trauma (PTSD in combatants). The author presents original conceptions on the consequent development of pathos and nosos with regard to "combat" PTSD.

[Assessment of posttraumatic stress disorders]

Trauma, traumatization, Acute stress reaction, Posttraumatic stress disorder and other disorders following exposure to traumatic stress are described. Classification according to ICD and DSM are presented and critically valued. The complex Posttraumatic Stress disorder is introduced in its symptoms and with a proposal for a classification. Problems in assessing traumatized individuals are referred and recommendations for interviews and testing procedure are presented. Structured interviews and tests in german language are described. Due to control stress load by the process of assessing the economic choice of instruments is recommended.

Acute stress responses: A review and synthesis of ASD, ASR, and CSR

Toward the development of a unifying diagnosis for acute stress responses this article attempts to find a place for combat stress reaction (CSR) within the spectrum of other defined acute stress responses. This article critically compares the diagnostic criteria of acute stress disorder (ASD), acute stress reaction (ASR), and CSR. Prospective studies concerning the predictive value of ASD, ASR, and CSR are reviewed. Questions, recommendations, and implications for clinical practice are raised concerning the completeness of the current acute stress response diagnoses, the heterogeneity of different stressors, the scope of expected outcomes, and the importance of decline in function as an indicator of future psychological, psychiatric, and somatic distress.

Reliability and validity of the SCL-90-R PTSD subscale

Two studies examined the psychometric properties of the Posttraumatic Stress Disorder (PTSD) subscale of the SCL-90-R. Study 1 examined SCL-90-R responses from 2,361 college women to determine whether this subscale can appropriately assess the three dimensions of PTSD. Factor analysis and Cronbach's alpha suggest that this subscale is best conceptualized as a unidimensional index of PTSD symptomatology. Study 2 confirmed these results in a sample of 1,044 college men and women. Findings in the second sample also supported the subscale's validity, as it correlates well with the Posttraumatic Diagnostic Scale and with trauma frequency and can discriminate between individuals with and without PTSD diagnoses. Results suggest that the SCL-90-R PTSD subscale is a reliable, but unidimensional, measure for screening for distress associated with PTSD. Although there is some support for the usefulness of this scale, especially with women, it should only be considered a general indicator of distress with limited use for men.

[Classification of mental disorders of soldiers participating in peace missions and warfare actions]

Numerous media reports (press, radio, television) and several scientific publications on psychiatric disorders among Polish soldiers participating in peace missions in Iraq indicate that there is a serious threat caused by the disorders defined in the DSM-IV classification as: acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). The authors analyzed psychiatric documentation and conducted their own researches, which revealed that adjustment disorders, especially with anxiety, are the main psychiatric problem among Polish soldiers in Iraq, while incidence of ASD and PTSD is very low. The aim of this publication is to present and compare mental disorders which occur during peace missions and welfare actions according to the international ICD-10 and American DSM-IV classifications. The authors paid attention to the role and significance of hitherto diagnosed impulsive disorders, which occur among the soldiers in Iraq as the intermittent explosive disorder, according to DSM-IV. The general and essential conclusions of the presented publication is that the guidelines of diagnosing mental disorders that occur during peace missions and welfare actions should be developed and introduced quickly.

Structural validity of the posttraumatic stress disorder checklist among college students with a trauma history

The authors conducted confirmatory factor analyses to test three-factor and four-factor models of posttraumatic stress disorder (PTSD) using the PTSD Checklist with college students reporting a traumatic event history. The authors found support for the three-factor DSM-IV-based PTSD diagnostic model including reexperiencing, avoidance/numbing, and hyperarousal symptom factors, with slightly better support for a four-factor model separating the avoidance and numbing factors. Results further attest to the PTSD Checklist's construct validity, and to research finding that PTSD avoidance and numbing constructs are distinct.

[Complex posttraumatic stress disorder]

The characteristic symptoms resulting from exposure to an extreme trauma include three clusters of symptoms: persistent experience of the traumatic event, persistent avoidance of stimuli associated with the trauma and persistent symptoms of increased arousal. Beyond the accepted clusters of symptoms for posttraumatic stress disorder exists a formation of symptoms related to exposure to extreme or prolonged stress e.g. childhood abuse, physical violence, rape, and confinement within a concentration camp. With accumulated evidence of the existence of these symptoms began a trail to classify a more complex syndrome, which included, but was not confined to the symptoms of posttraumatic stress disorder. This review addresses several subjects for study in complex posttraumatic stress disorder, which is a complicated and controversial topic. Firstly, the concept of complex posttraumatic stress disorder is presented. Secondly, the professional literature relevant to this disturbance is reviewed and finally, the authors present the polemic being conducted between the researchers of posttraumatic disturbances regarding validity, reliability and the need for separate diagnosis for these symptoms.

A paradigm shift in the conceptualization of psychological trauma in the 20th century

The inclusion of posttraumatic stress disorder (PTSD) in DSM-III in 1980 represented a paradigm shift in the conceptualisation of post-trauma illness. Hitherto, a normal psychological reaction to a terrifying event was considered short-term and reversible. Long-term effects, characterized as "traumatic neurosis", were regarded as abnormal. Enduring symptoms were explained in terms of hereditary predisposition, early maladaptive experiences or a pre-existing psychiatric disorder. The event served merely as a trigger to something that existed or was waiting to emerge. Secondary gain, the benefits often but not solely financial that a person derived as a result of being ill, was considered the principal cause of any observed failure to recover. The recognition of PTSD reflected a diversion from the role of the group, in particular the "herd instinct", towards a greater appreciation of the individual's experience. From being the responsibility of the subject, traumatic illness became an external imposition and possibly a universal response to a terrifying and unexpected event. This shift from predisposition to the characteristics of the event itself reduced guilt and blame, while the undermining of secondary gain made it easier to award financial compensation.

[Differentiation possibilities in posttraumatic neuropsychiatric disorders in medico-legal certification]

This paper is a continuation of the previous work entitled "Difficulties in estimation of posttraumatic neuropsychiatric disorders for the purpose of criminal and civil law proceedings" presented during the 5th National Symposium "Days of Medical Certification", Poznan 2005. Referring to the then mentioned problem, the authors present in a greater detail the possibilities of objectivization of claims using simple psychiatric and psychological diagnostic tools

Posttraumatic stress disorder: diagnostic data analysis by data mining methodology

AIM

To use data mining methods in assessing diagnostic symptoms in posttraumatic stress disorder (PTSD). METHODS. The study included 102 inpatients: 51 with a diagnosis of PTSD and 51 with psychiatric diagnoses other than PTSD. Several models for predicting diagnosis were built using the random forest classifier, one of the intelligent data analysis methods. The first prediction model was based on a structured psychiatric interview, the second on psychiatric scales (Clinician-administered PTSD Scale--CAPS, Positive and Negative Syndrome Scale--PANSS, Hamilton Anxiety Scale--HAMA, and Hamilton Depression Scale--HAMD), and the third on combined data from both sources. Additional models placing more weight on one of the classes (PTSD or non-PTSD) were trained, and prototypes representing subgroups in the classes constructed.

RESULTS

The first model was the most relevant for distinguishing PTSD diagnosis from comorbid diagnoses such as neurotic, stress-related, and somatoform disorders. The second model pointed out the scores obtained on the CAPS scale and additional PANSS scales, together with comorbid diagnoses of neurotic, stress-related, and somatoform disorders as most relevant. In the third model, psychiatric scales and the same group of comorbid diagnoses were found to be most relevant. Specialized models placing more weight on either the PTSD or non-PTSD class were able to better predict their targeted diagnoses at some expense of overall accuracy. Class subgroup prototypes mainly differed in values achieved on psychiatric scales and frequency of comorbid diagnoses.

CONCLUSION

Our work demonstrated the applicability of data mining methods for the analysis of structured psychiatric data for PTSD. In all models, the group of comorbid diagnoses, including neurotic, stress-related, and somatoform disorders, surfaced as important. The important attributes of the data, based on the structured psychiatric interview, were the current symptoms and conditions such as presence and degree of disability, hospitalizations, and duration of military service during the war, while CAPS total scores, symptoms of increased arousal, and PANSS additional criteria scores were indicated as relevant from the psychiatric symptom scales.

Stress predicts brain changes in children: a pilot longitudinal study on youth stress, posttraumatic stress disorder, and the hippocampus

OBJECTIVE

Does stress damage the brain? Studies of adults with posttraumatic stress disorder have demonstrated smaller hippocampal volumes when compared with the volumes of adults with no posttraumatic stress disorder. Studies of children with posttraumatic stress disorder have not replicated the smaller hippocampal findings in adults, which suggests that smaller hippocampal volume may be caused by neurodevelopmental experiences with stress. Animal research has demonstrated that the glucocorticoids secreted during stress can be neurotoxic to the hippocampus, but this has not been empirically demonstrated in human samples. We hypothesized that cortisol volumes would predict hippocampal volume reduction in patients with posttraumatic symptoms.

PATIENTS AND METHODS

We report data from a pilot longitudinal study of children (n = 15) with history of maltreatment who underwent clinical evaluation for posttraumatic stress disorder, cortisol, and neuroimaging.

RESULTS

Posttraumatic stress disorder symptoms and cortisol at baseline predicted hippocampal reduction over an ensuing 12- to 18-month interval.

CONCLUSIONS

Results from this pilot study suggest that stress is associated with hippocampal reduction in children with posttraumatic stress disorder symptoms and provide preliminary human evidence that stress may indeed damage the hippocampus. Additional studies seem to be warranted.

[Quality of psychological strain in police work--development of a taxonomy of sources of stress]

OBJECTIVES

Police officers frequently face traumatic stressors of different origins and thus bear an increased risk of developing a post-traumatic stress disorder. The most mentally burdening situations range from shootings, death of fellow officers, dealing with dead bodies in general, the effects of shift work, time pressure or discontent with management due to mobbing. Part of the present study examines the quality of stress in police work with the goal of developing a taxonomy of the origins of stress.

METHODS

A stratified sample of 109 police officers participated in the study. They were interviewed about stressful situations in their work life. In the interviews participants generated incidents describing stressful or straining situations. These incidents were used to develop a taxonomy of stressful situations in everyday police work. A further 22 interviews with officers of the federal police were carried out to examine the transferability of the developed taxonomy to other occupational groups.

RESULTS

The taxonomy distinguishes between five sources of strain. Strain can arise from (1.) the task itself, (2.) the organization and structure of work, (3.) the temporal conditions and (4.) the social conditions. The fifth category describes the source of strain based on other conditions. The results also show that the taxonomy is transferable to other occupational groups.

CONCLUSIONS

This taxonomy leads to the systematisation of the differences among the stress phenomena which occur in police work. The results can help in the development of practical prevention, counselling and therapeutic programs.

Battered woman syndrome: empirical findings

The construct of Battered Woman Syndrome (BWS) has been conceptualized as a subcategory of posttraumatic stress disorder (PTSD). It is composed of the following symptoms: (a) re-experiencing the battering as if it were reoccurring even when it is not, (b) attempts to avoid the psychological impact of battering by avoiding activities, people, and emotions, (c) hyperarousal or hypervigilance, (d) disrupted interpersonal relationships, (e) body image distortion or other somatic concerns, and (f) sexuality and intimacy issues. This article presents empirical data derived from administering the Battered Woman Syndrome Questionnaire (BWSQ) to women of four countries--United States, Spain, Greece, and Russia. The data support a theory of BWS.

Post-traumatic stress disorder: medicine and politics

Regrettably, exposure to trauma is common worldwide, and can have serious adverse psychological results. The introduction of the notion of post-traumatic stress disorder has led to increasing medicalisation of the problem. This awareness has helped popular acceptance of the reality of post-traumatic psychiatric sequelae, which has boosted research into the pathogenesis of the disorder, leading to improved pharmacological and psychological management. The subjective experience of trauma and subsequent expression of symptoms vary considerably over space and time, and we emphasise that not all psychological distress or psychiatric disorders after trauma should be termed post-traumatic stress disorder. There are limits to the medicalisation of distress and there is value in focusing on adaptive coping during and after traumas. Striking a balance between a focus on heroism and resilience versus victimhood and pathological change is a crucial and constant issue after trauma for both clinicians and society. In this Review we discuss the advantages and disadvantages of medicalising trauma response, using examples from South Africa, the Armed Services, and post-disaster, to draw attention to our argument.