Posttraumatic stress disorder in the National Comorbidity Survey

Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients

The aims of this study were: a) to assess the prevalence of posttraumatic stress disorder (PTSD) after an acute psychotic episode in schizophrenic and delusional patients, b) to explore which psychotic symptoms and aspects of treatment were associated with traumatization, and c) to compare the extent of the traumatic impact of psychosis and involuntary hospitalization. Forty-six schizophrenic and delusional patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Impact of Event Scale-Revised (IES-R), and the Clinician-Administered PTSD Scale (CAPS) at weeks 1 and 8 after acute psychiatric admission. Traumatic symptoms related to psychosis and coercive measures were scored separately. The prevalence of PTSD was found to be 11%. Sixty-nine percent of traumatic symptoms were related to psychosis and 24% to hospitalization. High PANSS score at week 8 was the strongest risk factor for the development of PTSD. Particularly positive and depressive/anxious symptomatology were associated with psychosis-related traumatic symptoms at both weeks 1 and 8. These data suggest that, in general, schizophrenic and delusional symptoms are more traumatic than the coercive measures used to control them.

The need for mental health services research focusing on poor young women

Despite the fact that the relationship between poverty and increased risk for a broad spectrum of mental disorders has been documented for several decades, very little is known about providing mental health treatments to poor individuals. In this paper, we emphasize the importance of developing, and empirically evaluating, sensitive and appropriate interventions for poor young women who suffer from common mental disorders. WHO ARE THE US POOR?: In the US, nearly 14% of individuals live in poverty, and another 20% in near poverty. The poor are disproportionally women and children such that 63% of female-headed households are poor. Young women and ethnic minorities are over-represented among the poor also, with 55% of those living below the poverty level being minorities. NEEDS AND BARRIERS TO CARE AMONG POOR, YOUNG WOMEN: The poor have more mental disorders than those with more resources. Further, women are twice as likely as men to have a mood or anxiety disorder, including major depression and post-traumatic stress disorder (PTSD), with younger women at higher risk than older women. Research alos indicates that poor women have high exposure to traumatic events and cumulative adversity that is directly related to their mental health. This history may serve, in part, as a barrier to seeking mental health care. Other barriers in this population include lack of insurance, lack of access to primary care where mental disorders might be detected, practical problems like lack of childcare or transportation, and the inflexibility of low-income service jobs. Religious beliefs and attitudes about mental health treatment may play a role as well. Recent policy changes in the US have contributed to the vulnerability of this group as eligibility for welfare programs has reduced, and time limits have decreasd. Services for immigrants are also severely limited, and managed care strategies for those in the public sector may be confusing. IMPORTANT, UNANSWERED QUESTION: More needs to be learned about the mental health status and needs of poor women, along with the impact of loss of public support on their physical and mental health. Access to mental health care within a managed care setting also needs to be addressed, and care taken to understand the particular needs of poor populations that will actually make these services accessible to them. Insufficient attention has thus far been paid to the cost implications of providing these services to the poor. While providing treatment is associated with significant costs, the costs of not providing care, especially the effects of depression on offspring, should not be overlooked. CHALLENGES TO EXAMINING MENTAL HEALTH IN POOR WOMEN: A number of suggestions were made for addressing practical and methodological challenges to providing mental health services. These include placing services for these individuals within their familiar medical settings, which requires close working relationships between psychiatric and medical personnel within these settings. Outreach is a necessary part of getting poor women into treatment, and should be a routine part of helping women become engaged with caregivers. Providing culturally sensitive treatments is an important focus too, through developing knowledge about the culturally based customs and expectations of target groups. Measurement issues need to be attended to, as most research instruments have been developed on middle class populations, and have not been examined for their psychometric properties and norms in less advantaged groups. Careful translation techniques are also required. Finally, working with institutions sponsoring research to educate them about special problems and challenges with these groups will help improve the quality and efficiency of the work accomplished.

Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans

We used path analysis to model the effects of combat exposure, posttraumatic stress disorder (PTSD) symptoms, and health behaviors on physical health. Participants were 921 male military veterans from the Normative Aging Study. Their mean age at time of study was 65. Measures of combat exposure, PTSD symptoms, smoking, and alcohol problems were used to predict subsequent self-reported physical health status. Both combat exposure and PTSD were correlated with poorer health. In path analysis, combat exposure had only an indirect effect on health status, through PTSD, whereas PTSD had a direct effect. Smoking had a small effect on health status but did not mediate the effects of PTSD, and alcohol was unrelated to health status. We conclude that PTSD is an important predictor of physical health and encourage further investigation of health behaviors and other possible mediators of this relationship.

Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation

BACKGROUND

Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant.

METHODS

A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant.

RESULTS

After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74).

CONCLUSIONS

The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.

PTSD in heart transplant recipients and their primary family caregivers

Posttraumatic stress disorder associated with transplantation (PTSD-T) is a complication for some heart transplant recipients. By using a structured, standardized interview and DSM-III-R criteria, the authors examined whether recipients (n = 158) and their family caregivers (n = 142) showed similar PTSD-T rates and clinical characteristics during the first year posttransplant. Among the recipients, 10.5% met full criteria for the disorder and an additional 5% were probable cases. Among the caregivers, 7.7% met full criteria and an additional 11.0% were probable cases. Severity and duration of disorder were similar across the groups. Being female, having a history of psychiatric illness, and having lower friend support were increased risks for PTSD-T.

A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder

BACKGROUND

The anticonvulsant, lamotrigine, may be useful for symptom management in PTSD.

METHODS

Subjects enrolled in a 12-week double-blind evaluation of lamotrigine and placebo. Patients were randomized 2:1 to either lamotrigine or placebo. Lamotrigine was initiated at 25 mg/day and slowly titrated every 1 to 2 weeks over 8 weeks to a maximum dosage of 500 mg/day if tolerated.

RESULTS

Fifteen subjects entered treatment, fourteen of whom returned for subsequent visits. Of 10 patients who received lamotrigine, 5 (50%) responded according to the DGRP, compared to 1 of 4 (25%) who received placebo. Lamotrigine patients showed improvement on reexperiencing and avoidance/numbing symptoms compared to placebo patients. Treatments were generally well tolerated.

CONCLUSIONS

Lamotrigine may be effective as a primary psychopharmacologic treatment in both combat and civilian PTSD and could also be considered as an adjunct to antidepressant therapy used in the treatment of PTSD. These promising results warrant further large sample double-blind, placebo-controlled trials.

Intimate violence and post-traumatic stress disorder among individuals with cocaine dependence

Intimate physical assault and post-traumatic stress disorder (PTSD) were assessed in a sample of 91 adults seeking treatment for cocaine dependence. Physical assault included self-report of aggravated assault with a weapon, aggravated assault without a weapon, and simple assault. PTSD was assessed with a structured interview. Overall, 85.7% of the participants reported having been physically assaulted at least once during their lifetime. Slightly less than half of these individuals (46.2%) reported physical assault by an intimate partner. Close to half also met criteria for PTSD at some point in their lives. Women were more likely than men to be physically assaulted by an intimate partner and to report PTSD. Men who experienced physical assault by an intimate were more likely to report PTSD than men assaulted by others. Male victims of intimate violence had higher scores on certain subscales measuring addiction severity than male victims assaulted by others. Findings suggest careful assessment of intimate violence is essential given its high prevalence among cocaine-dependent women and men and its association with PTSD.

Children's responses to a nuclear waste disaster: PTSD symptoms and outcome prediction

OBJECTIVE

To examine the psychological impact of living near a nuclear waste disaster that involved ongoing threat of radioactive contamination.

METHOD

Participants were an exposed sample (residence within a 5-mile radius of the nuclear plant) of 120 children (7-15 years old) and their parents and a nonexposed comparison sample of 60 children and their parents. Parent and self-ratings of the children's psychological functioning and posttraumatic stress disorder (PTSD) symptoms were obtained, along with cognitive variables.

RESULTS

Minimal differences between the 2 samples were found. In the exposed sample, stress responses for the child self-reports showed several age group by gender interactions. Girls' PTSD symptoms tended to increase with age while boys' symptoms decreased, with intrusion showing the strongest effects. While child and parent PTSD symptom ratings were correlated, children reported approximately twice as many symptoms. Cognitive understanding increased with age and was greater in boys. Exposure and parent functioning significantly predicted outcome.

CONCLUSIONS

Age and gender effects after disaster might best be explored as an interaction. While disaster effects were mild, the psychological health of the parents may be an important determinant of psychological health in children in this type of disaster.

Exposure to violence and posttraumatic stress symptomatology among abortion clinic workers

The intent of this study was to examine the relationship between exposure to abortion clinic violence, either as a victim or witness, and the reporting of posttraumatic stress disorder (PTSD) symptoms among clinic employees. Semi-structured interviews with 71 clinic workers from eight abortion clinics in a Southeastern state were used for analyses. Findings showed that as victims, clinic workers experienced moderate forms of violence and witnessed greater variety and numbers of violent acts. Twenty-one percent of the sampled workers reported symptoms similar to the syndrome described in the DSM-IIIR/DSM-IV classification for PTSD. A multivariate analysis showed that even when controlling for significant life circumstances and stressors outside the clinic setting, witnessing violence was a significant predictor of PTSD symptomatology.

Posttraumatic stress disorder in hospitalized adolescents: psychiatric comorbidity and clinical correlates

OBJECTIVE

To describe the diagnostic comorbidity and clinical correlates of posttraumatic stress disorder (PTSD) in adolescent psychiatric inpatients.

METHOD

Seventy-four adolescent inpatients were given a structured diagnostic interview, the revised version of the Diagnostic Interview for Children and Adolescents, and a battery of standard self-report measures to assess general trauma exposure, posttraumatic stress symptoms, suicidal behavior, dissociation, and depression.

RESULTS

Ninety-three percent of subjects reported exposure to at least one traumatic event such as being a witness/victim of community violence, witnessing family violence, or being the victim of physical/sexual abuse. Thirty-two percent of subjects met diagnostic criteria for current PTSD, with sexual abuse cited as the most common traumatic stressor in 69% of PTSD cases. Girls were significantly more likely to develop PTSD than boys, although the total number of types of trauma did not differ by gender. Compared with psychiatric controls, male youngsters with PTSD were significantly more likely to have comorbid diagnoses of eating disorders, other anxiety disorders, and somatization disorder. Furthermore, male and female youngsters with PTSD were significantly more likely to have attempted suicide and report greater depressive and dissociative symptoms.

CONCLUSION

In clinical populations of hospitalized adolescents exposed to multiple forms of trauma, PTSD is a common, but highly comorbid disorder. Specific multimodal assessments and treatments targeted to both PTSD and its comorbidity profile are warranted.

PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children: a longitudinal prospective analysis

This study examined the prevalence of posttraumatic stress disorder (PTSD) among parents bereaved by the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of Medical Examiner records and followed for 2 years. Four important findings emerged: Both parents' gender and children's causes of death significantly affected the prevalence of PTSD symptoms. Twice as many mothers and fathers whose children were murdered met PTSD caseness (full diagnostic) criteria compared with accident and suicide bereavement. Symptoms in the reexperiencing domain were the most commonly reported. PTSD symptoms persisted over time, with 21% of the mothers and 14% of the fathers who provided longitudinal data still meeting caseness criteria 2 years after the deaths. Parents who met caseness criteria for PTSD, compared with those who did not, were significantly different on multiple study variables. Both theoretical and clinical implications for the findings are discussed.

Smoking and anxiety in combat veterans with chronic posttraumatic stress disorder: a review

There is growing evidence that smoking, and in particular heavy smoking, is prevalent in Vietnam combat veterans with posttraumatic stress disorder. However, the pathways responsible for development and perpetuation of smoking in this clinical population have not been identified. Relevant smoking, substance abuse, and anxiety disorder research is reviewed. Although an association between smoking and PTSD has not been directly tested, there is evidence that such research is warranted. Suggestions for future research are offered.

Purification and MALDI-MS characterization of stressin, a stress-associated glycoprotein

Glycoconjugates have a whole spectrum of biological roles, from those that appear trivial to those that are crucial. Results accumulated in the past years indicate they might also play an important role in the response to stress, a complex physiological response of the human organism to various threats. We have recently identified stressin, a human serum glycoprotein, which was found to be increased under stress conditions. Here we report the purification of stressin from sera of professional soldiers and partial characterization of its protein and carbohydrate parts using lectin blotting and matrix assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS). Stressin was purified using a combination of ammonium sulfate precipitation, ion exchange chromatography, preparative gel electrophoresis and reverse-phase HPLC. It was found to be a highly glycosylated protein. Only 21.9 kDa (out of 36.7 kDa) was the protein part, whereas the remaining 40% of the mass originated from N-linked oligosaccharides. The carbohydrate part contained 12 sialic acids moieties, nearly 90% of which were lost due to post-source decay in the field-free tube. Tryptic fragments were produced from glycosylated and deglycosylated stressin, separated by reverse-phase HPLC and their exact molecular masses were determined using MALDI-MS. Comparison with tryptic maps of other proteins in computer databases indicated that stressin does not correspond to any already described protein.

[How to prevent post-traumatic stress disorder before traumatization occurs?]

OBJECTIVE

To provide an update on methods of preventing the onset of posttraumatic stress disorder (PTSD) before trauma occurs.

METHOD

Survey and analysis of the literature (mainly articles) found in the Medline, Psychinfo, and Pilot databases.

RESULTS

Most research focuses on identifying risk factors and reinforcing individual resistance as the prime means of preventing PTSD. The severity of the trauma is by far the most serious risk factor. To reinforce resistance and prevent the onset of PTSD, the army has favoured psychoeducational approaches. However, the literature survey has found no pretrauma prevention program for other high-risk occupations.

CONCLUSION

The usefulness of identified risk factors for the primary prevention of PTSD is limited, since with the exception of the trauma itself, they play a minor role on the onset of severe-trauma PTSD. Psychoeducational approaches aimed at reinforcing the resistance of individuals at risk are promising, but their potential has to be further explored in individuals in high-risk trades. Finally, it has been suggested that other avenues of research in the primary prevention (pretrauma) of PTSD be explored. These include the identification of possible protection factors, the influence of genetic make-up and of biological variables, the cumulative effects of exposure to stressors, and the presence of chronic stressors.

Predictors of chronic post-traumatic stress disorder. A prospective study

BACKGROUND

Most individuals who, shortly after trauma, express symptoms of post-traumatic stress disorder (PTSD) recover within one year of their traumatic experiences. In contrast, those who remain ill for one year rarely recover completely. The early identification of the latter is, therefore, very important.

AIMS

To prospectively evaluate predictors of PTSD at four months and one year.

METHOD

We followed 236 trauma survivors recruited from admissions to a general hospital's emergency room for four months, at which point 41 (17.4%) met diagnostic criteria for PTSD. Twenty-three of these individuals, and 39 individuals without PTSD at four months, were assessed again at one year.

RESULTS

Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peri-traumatic dissociation were better at predicting four-month PTSD than one-year PTSD.

CONCLUSIONS

The occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

Quality of life and posttraumatic stress disorder: a pilot study assessing changes in SF-36 scores before and after treatment in a placebo-controlled trial of fluoxetine

In this small pilot study, we evaluated quality of life for 16 posttraumatic stress disorder (PTSD) patients by administering the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at baseline and endpoint during a 12-week double-blind trial of fluoxetine and placebo. At baseline, our subjects reported greater impairment relative to subjects with major depression or obsessive-compulsive disorder on several SF-36 domains. Significant effects of fluoxetine relative to placebo were observed for vitality, social functioning, and mental health. Overall, PTSD was associated with greatly reduced quality of life, but considerable improvement was achieved through treatment.

The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework

Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

Regional cerebral blood flow during script-driven imagery in childhood sexual abuse-related PTSD: A PET investigation

OBJECTIVE

The purpose of this study was to determine whether anterior limbic and paralimbic regions of the brain are differentially activated during the recollection and imagery of traumatic events in trauma-exposed individuals with and without posttraumatic stress disorder (PTSD).

METHOD

Positron emission tomography (PET) was used to measure normalized regional cerebral blood flow (CBF) in 16 women with histories of childhood sexual abuse: eight with current PTSD and eight without current PTSD. In separate script-driven imagery conditions, participants recalled and imagined traumatic and neutral autobiographical events. Psychophysiologic responses and subjective ratings of emotional state were measured for each condition.

RESULTS

In the traumatic condition versus the neutral control conditions, both groups exhibited regional CBF increases in orbitofrontal cortex and anterior temporal poles; however, these increases were greater in the PTSD group than in the comparison group. The comparison group exhibited regional CBF increases in insular cortex and anterior cingulate gyrus; increases in anterior cingulate gyrus were greater in the comparison group than in the PTSD group. Regional CBF decreases in bilateral anterior frontal regions were greater in the PTSD group than in the comparison group, and only the PTSD group exhibited regional CBF decreases in left inferior frontal gyrus.

CONCLUSIONS

The recollection and imagery of traumatic events versus neutral events was accompanied by regional CBF increases in anterior paralimbic regions of the brain in trauma-exposed individuals with and without PTSD. However, the PTSD group had greater increases in orbitofrontal cortex and anterior temporal pole, whereas the comparison group had greater increases in anterior cingulate gyrus.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey

INTRODUCTION

In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community.

METHODS

From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys.

RESULTS

Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations.

CONCLUSIONS

This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Acute and chronic posttraumatic stress disorder in motor vehicle accident victims

OBJECTIVE

This study reports the rates of acute and chronic posttraumatic stress disorder (PTSD) in a suburban community study group of 122 victims of serious motor vehicle accidents and a comparison group of 42 (who had been involved in minor, non-motor-vehicle accidents) followed over 12 months.

METHOD

Motor vehicle accident victims were systematically recruited and examined with comparison subjects at 1, 3, 6, 9, and 12 months after the accident. The authors used the Structured Clinical Interview for DSM-III-R to assess DSM-III-R axis I disorders including PTSD.

RESULTS

One month after the accident, 34.4% of the motor vehicle accident victims met criteria for PTSD (versus 2.4% of the comparison subjects). Similarly, at 3 and 6 months, rates of PTSD were higher (25.2% and 18.2%) in the motor vehicle accident victims than in the comparison group. Female victims were 4.64 times more likely than male victims to have PTSD at 1 month. Victims with a history of PTSD were 8.02 times more likely at 1 month and 6.81 times more likely at 3 months to have PTSD than those without a history of PTSD. Having an axis II disorder increased the risk for PTSD at 6 months. After adjustment for a history of PTSD and potentially confounding variables, women were 4.39 times more likely than men to develop PTSD at 1 month but did not have a higher risk for chronic PTSD; at 6 months, those with an axis II disorder were at greater risk of PTSD.

CONCLUSIONS

Rates of PTSD are high in victims of serious motor vehicle accidents and remain high 9 months later. Female victims have an increased risk of acute but not chronic PTSD. Individuals with a history of PTSD are at risk of acute and chronic PTSD. An axis II disorder increases the risk for chronic but not acute PTSD.

Psychopathology: description and classification

DSM-IV's strong empirical base has yielded an instrument with good to excellent reliability and improved validity. Diagnostic reliability depends on both the clarity and validity of diagnostic criteria and the changeability of disorders over time: The reliability of schizophrenic spectrum disorders, personality disorders, and some childhood and adolescent disorders remains problematic. Findings on diagnostic validity appear paradoxical: Attempts to validate schizophrenic spectrum disorders with neurobiological and genetic-familial validators have been only modestly successful, whereas the tripartite personality trait model has differentiated a range of depressive and anxiety disorders. Research on comorbidity has identified several highly comorbid disorders (substance-related disorders, personality disorders, depression, and anxiety) as well as some adverse consequences of comorbidity. The advantages of dimensional approaches to diagnosis have largely been demonstrated conceptually; ultimate conclusions about the strengths and weaknesses of dimensional and syndromal methods await substantial additional empirical research.

No association between D2 dopamine receptor (DRD2) "A" system alleles, or DRD2 haplotypes, and posttraumatic stress disorder

BACKGROUND

Association studies between marker alleles at the D2 dopamine receptor gene (DRD2) and various psychiatric illnesses have produced conflicting results. Reports of allelic associations were originally made with alcoholism, but were then extended to other psychiatric disorders, including posttraumatic stress disorder (PTSD).

METHODS

We studied allele frequency of the DRD2 TaqI "A," "B," and "D" system markers in 52 European-American subjects with diagnoses of PTSD (based on structured interviews).

RESULTS

Frequency of the A1 allele in this sample was .15, not significantly different from the .19 allele frequency seen in 87 control subjects. We were thus unable to replicate the previous reports of allelic association between the DRD2 TaqI "A1" allele and PTSD. There were also no significant differences in allele frequency for the "B" or "D" systems. We then computed three marker (TaqI "A," "B," and "D" system) haplotypes for the sample; DRD2 haplotype frequencies also did not differ between control subjects and subjects with PTSD.

CONCLUSIONS

We conclude that DRD2 alleles are not associated with PTSD in this sample, and that genetic variation at the DRD2 locus is not likely to be an important contributor to risk for this disorder.

Using qualitative methods to elicit recall of a critical time period

The period during and after puberty seems to be important for breast cancer initiation. Because experiences during that time are likely to be influenced by a woman's cultural background, we conducted a pilot study among Hispanic and Caucasian women to elicit their memories of early life events. These data were used to design culture-specific questionnaire modules for the retrospective assessment of peripubertal breast cancer risk factors, using specific strategies to trigger accurate recall. Study subjects were volunteer breast cancer survivors or relatives of survivors. In carrying out this work, we took methods from the social sciences and applied them to a research question in chronic disease epidemiology. We found both qualitative and quantitative differences in recall of peripubertal exposures and experiences between Hispanic and Caucasian subjects. Our preliminary data indicate that in contrast to Caucasian women, Hispanic women consider the church rather than school a touchstone for recalling past events. Under the domain "body development," Hispanic women are more likely to mention menstruation than Caucasian women but less likely to recall changes in body hair and breast development. Caucasian women cited team sports as an important physical activity during the peripubertal period, whereas Hispanic women listed more sedentary games and housework as the main activities. Results of our pilot study support the view that to enhance the validity of retrospective data on peripubertal breast cancer risk factors, it is important to take account of cultural differences. Our experience using qualitative methods to elicit data of this kind in the context of a larger epidemiologic research effort suggests that such innovative approaches are valuable.

Acute stress response and posttraumatic stress disorder in traffic accident victims: a one-year prospective, follow-up study

OBJECTIVE

This study was designed to assess the natural course of posttraumatic symptoms formation, as well as the degree to which acute stress reactions predict later posttraumatic stress disorder (PTSD) in injured traffic accident victims.

METHOD

A prospective, 1-year follow-up study was carried out on 74 injured traffic accident victims and a comparison group of 19 patients who were hospitalized for elective orthopedic surgery. Participants were interviewed within the first week following the accident, and follow-up interviews were performed 1, 3, 6, and 12 months after the accident. At 12 months, a structured clinical interview was administered to determine a formal DSM-III-R diagnosis of PTSD.

RESULTS

Twenty-four (32%) of the 74 traffic accident victims, but none of the 19 comparison subjects, met DSM-III-R criteria for PTSD at 1 year. Traffic accident victims who developed PTSD had higher levels of premorbid and comorbid psychopathology. Levels of posttraumatic symptoms were significantly higher from the outset in the subjects who developed PTSD and worsened progressively over the first 3 months, in contrast to subjects without PTSD, who manifested gradual amelioration of symptoms during this time. Existence of posttraumatic symptoms immediately after the accident was a better predictor of later PTSD than was accident or injury severity.

CONCLUSIONS

In this study, a significant portion of injured traffic accident victims manifested PTSD 1 year after the event. The development of PTSD at 1 year can be predicted as early as 1 week after the accident on the basis of the existence and severity of early PTSD-related symptoms. However, the first 3 months following the accident appear to be the critical period for the development of PTSD.

Individual differences in posttraumatic distress: problems with the DSM-IV model

OBJECTIVE

To evaluate the evidence concerning the role of threatening life events in accounting for clinically significant posttraumatic stress responses.

METHOD

Research was examined to review the epidemiology, evidence of dose-response relations, and individual difference factors in accounting for variations in conditions, including posttraumatic stress disorder, after exposure to threatening events.

RESULTS

The evidence is significantly discrepant from the clinical Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) model. Greater distress arises from individual differences than from event characteristics. Important individual differences that interact with threat exposures include trait negative affectivity (neuroticism); beliefs about emotions, the self, the world, and the sources and consequences of danger; and prevent acts, disorders, and intelligence. Reasons for the discrepancies between the evidence and the current model of posttraumatic distress are proposed.

CONCLUSION

In accounting for responses to threatening life events, the relatively minor contribution of event qualities compared with individual differences has significant treatment implications. Treatment approaches assuming that toxic event exposure creates a posttraumatic disorder fail to consider individual differences that could improve treatment efficacy.

Häufigkeit der Posttraumatischen Belastungsstörung bei Jugendlichen: Ergebnisse der Bremer Jugendstudie

Zusammenfassung: In diesem Artikel werden Häufigkeit, Komorbidität und psychosoziale Beeinträchtigung bei der Posttraumatischen Belastungsstörung an 1035 Jugendlichen im Alter von zwölf bis 17 Jahren dargestellt. Die Posttraumatische Belastungsstörung sowie andere psychische Störungen wurden nach DSM-IV-Kriterien anhand des computergestützten Interviews der Münchener Version des Composite International Diagnostic Interview kodiert. Insgesamt hatten 17 Jugendliche (1,6%) irgendwann in ihrem Leben die DSM-IV-Kriterien der Posttraumatischen Belastungsstörung erfüllt. Etwas mehr Mädchen als Jungen erfüllten die diagnostischen Kriterien dieser Störung, deren Häufigkeit mit dem Alter zunahm. Die Lebenszeit-Häufigkeit traumatischer Ereignisse lag weitaus höher. 233 (22,5%) aller Jugendlichen berichteten von mindestens einem traumatischen Ereignis in ihrem Leben. Am häufigsten wurden körperliche Angriffe, Verletzungen und schwerwiegende Unfälle von den Jugendlichen erlebt. Traumatische Ereignisse waren bei Jungen signifikant häufiger als bei Mädchen. Das Auftreten eines traumatischen Ereignisses war meist verbunden mit Hypervigilanz sowie wiederholter und eindringlicher psychischer Belastung bei Konfrontation mit Hinweisreizen, die einen Aspekt des Ereignisses symbolisieren oder ihm ähneln. Die Posttraumatische Belastungsstörung trat in hohem Maße komorbid mit Depressiven und Somatoformen Störungen sowie mit Störungen durch Substanzkonsum auf. Über 90% der Jugendlichen waren in ihrem Alltagsleben stark beeinträchtigt. Trotz des hohen Grades psychosozialer Beeinträchtigung nahm nur ein kleiner Teil der Fälle professionelle Hilfe in Anspruch.

A model to explain the relationship between sexual abuse and HIV risk among women

This paper presents a model developed to advance the understanding of the relationship between sexual abuse and HIV risk among women. It is proposed that the relationship is mediated by many of the long-term sequelae of sexual abuse. The process of mediation is believed to occur through various causal pathways propelled by specific underlying mechanisms that increase the likelihood of HIV risk. The following causal pathways are proposed: (1) initiation of and/or increasing reliance on drug use as a method of coping with the sexual abuse experience, (2) problems with sexual adjustment related to sex risk taking, and (3) psychopathology (e.g. depression) which increases the likelihood of an individual participating in HIV risk behaviours. These hypothesized pathways are based on the characteristics and behaviours of individuals with histories of sexual abuse and do not take into account the influence of the individual's social environment. Increasingly, evidence suggests that understanding the social context of HIV risk is crucial to the development of preventive interventions. Therefore, a final pathway is explored which suggests that specific social network characteristics (e.g. network membership type, social support, and social isolation) influence HIV risk exposure opportunities among women with sexual abuse histories.

Biological factors associated with susceptibility to posttraumatic stress disorder

Because only a proportion of persons exposed to traumatic events develop posttraumatic stress disorder (PTSD), it has become important to elucidate the factors that increase the risk for the development of PTSD following trauma exposure as well as the factors that might serve to protect individuals from developing this condition. Putative risk factors for PTSD may describe the index traumatic event or characteristics of persons who experience those events. Recent data have implicated biological and familial risk factors for PTSD. For example, our recent studies have demonstrated an increased prevalence of PTSD in the adult children of Holocaust survivors, even though these children, as a group, do not report a greater exposure to life-threatening (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] Criterion A) events. These studies are reviewed. It is difficult to know to what extent the increased vulnerability to PTSD in family members of trauma survivors is related to biological or genetic phenomena, as opposed to experiential ones, because of the large degree of shared environment in families. In particular, at-risk family members, such as children, may be more vulnerable to PTSD as a result of witnessing the extreme suffering of a parent with chronic PTSD rather than because of inherited genes. But even if the diathesis for PTSD were somehow "biologically transmitted" to children of trauma survivors, the diathesis is still a consequence of the traumatic stress in the parent. Thus, even the most biological of explanations for vulnerability must at some point deal with the fact that a traumatic event has occurred.

Posttraumatic stress disorder and service utilization among urban mental health center clients

Although the urban poor are at high risk for exposure to trauma, community mental health clinics rarely diagnose clients with PTSD. Failure to diagnose PTSD may undermine the effectiveness of services provided. Our objectives were to (1) assess prevalence of traumatic experiences and PTSD, and (2) examine differences in service utilization between those who had PTSD and those who did not. Interview data were gathered from 181 urban psychiatric outpatients. A substantial number of clients had experienced at least one lifetime trauma (94%), and of those, 42% had PTSD during the past year. Analyses comparing service use between PTSD and nonPTSD clients supported our expectation that clients with PTSD would use more mental health services, and would be less satisfied with services than their nonPTSD counterparts.

Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel

This study examines the longitudinal course and predictors of stress-specific and general symptomatic distress in emergency services personnel. A three-group quasi-experimental design was used to determine the responses of 322 rescue workers to the Loma Prieta earthquake Interstate 880 Freeway collapse and to unrelated control critical incidents. Self-report questionnaires, including measures of incident exposure, peritraumatic dissociation and emotional distress, and current symptoms, were administered 1.9 years (initial) and 3.5 years (follow-up) after the freeway collapse. Despite modest symptom improvement at follow-up, rescue workers were at risk for chronic symptomatic distress after critical incident exposure. Peritraumatic dissociation accounted for significant increments in current posttraumatic stress disorder symptoms, over and above exposure, adjustment, years of experience, locus of control, social support, and general dissociative tendencies. The results suggest that rescue workers, particularly those with more catastrophic exposure and those prone to dissociate at the time of the critical incident, are at risk for chronic symptomatic distress.

Chronicity in posttraumatic stress disorder (PTSD) and predictors of course of comorbid PTSD in patients with anxiety disorders

The purpose of this study was to examine the course of comorbid posttraumatic stress disorder (PTSD) in 54 patients with another anxiety disorder. Using a prospective longitudinal design, the present study found that during the first 5 years of follow-up the probability of full remission from a chronic episode of PTSD was .18. Findings from this and other research confirm clinical impressions that a substantial number of people never fully remit from their PTSD even after many years. Variables associated with a longer time to remit from an episode of chronic PTSD were a history of alcohol abuse and a history of childhood trauma.

The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder

The growing body of research into treatment efficacy with Posttraumatic Stress Disorder (PTSD) has, by-and-large, been limited to evaluating treatment components or comparing a specific treatment against wait-list controls. This has led to two forms of treatment, Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive-Behavior Therapy (CBT), vying for supremacy without a controlled study actually comparing them. The present research compared EMDR and a CBT variant (Trauma Treatment Protocol; TTP) in the treatment of PTSD, via a controlled clinical study using therapists trained in both procedures. It was found that TTP was both statistically and clinically more effective in reducing pathology related to PTSD and that this superiority was maintained and, in fact, became more evident by 3-month follow-up. These results are discussed in terms of past research. Directions for future research are suggested.

Screening for posttraumatic stress disorder symptoms among Bosnian refugees

To assess the level of posttraumatic stress disorder (PTSD) symptoms among Bosnian war refugees, a consecutive cohort of 206 Bosnian refugees, arriving in Sweden in 1993, was screened for PTSD using a modified version of the self-report instrument PTSS-10. A comparison group of 387 visitors to seven Swedish health centers was recruited. Prevalence of possible PTSD, using two estimates, was 18 to 33% among the Bosnian refugees, and .3 to 1% in the comparison group. The PTSS-10 showed high internal consistency reliability (Cronbach's alpha = .92) and stability (test-retest reliability r = .89). Thus, Bosnian war refugees showed high levels of PTSD symptoms compared to a nonrefugee comparison group.

The influence of traumatic brain injury on acute stress disorder and post-traumatic stress disorder following motor vehicle accidents

This study compared the acute stress disorder and post-traumatic stress disorder (PTSD) symptom profiles in motor vehicle accident survivors who sustained a mild traumatic brain injury (MTBI) or no TBI. Consecutive adult patients who sustained a MTBI (n = 79) and no TBI (n = 92) were assessed for acute stress disorder within 1 month of their trauma and reassessed for PTSD (MTBI: n = 63; non-TBI; n = 72) 6-months post-trauma. Comparable rates of acute stress disorder and PTSD were reported in MTBI and non-TBI patients. Intrusive memories and fear and helplessness in response to the trauma were reported less frequently by MTBI than non-TBI patients at the acute phase. Six-months post-trauma fewer MTBI patients than non-TBI reported fear and helplessness in response to the trauma. These findings suggest that, whereas impaired consciousness at the time of a trauma may reduce the frequency of traumatic memories in the initial month post-trauma, MTBI does not result in a different profile of longer-term PTSD.

Modeling physical health and functional health status: the role of combat exposure, posttraumatic stress disorder, and personal resource attributes

This study examined associations of combat exposure and posttraumatic stress disorder (PTSD) with physical health conditions and also incorporated hardiness and social support as mediators and functional health status as an outcome. Data were derived from 1,632 male and female Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. Path analysis revealed that hardiness and social support operated primarily as intermediary variables between combat exposure and PTSD, and PTSD emerged as the pivotal variable explaining physical health conditions and functional health status. Gender-based differences in means and patterns of associations among variables were found. The results stress the importance of assessing trauma in clinical settings as a meaningful determinant of health outcomes.

Antecedents and complications of trauma in boys with ADHD: findings from a longitudinal study

OBJECTIVE

To examine the relationship between trauma and attention-deficit hyperactivity disorder (ADHD), evaluating whether ADHD increases the risk for trauma, the risk for posttraumatic stress disorder (PTSD), or the risk for trauma-associated psychopathology.

METHOD

Data from a longitudinal sample of 260 children and adolescents with and without ADHD were examined. All were evaluated comprehensively with assessments in multiple domains of functioning including systematic assessments of trauma and PTSD. Comparisons were made between traumatized and nontraumatized youths with and without ADHD.

RESULTS

No meaningful differences were detected in comparisons between ADHD and control children, either in the rate of trauma exposure or in the development of PTSD. Although trauma was associated with the development of major depression, this effect was independent of ADHD status. In contrast, bipolar disorder at baseline assessment was a significant risk factor for subsequent trauma exposure.

CONCLUSIONS

ADHD was not found to be a risk factor for either trauma exposure or PTSD, but childhood mania was. If confirmed, this finding stresses the potential severe clinical sequelae of childhood mania in children.

Psychological impact and prevalence of traumatic events in a student sample in Israel: the effect of multiple traumatic events and physical injury

The prevalence of exposure and the psychological impact of traumatic events were studied in 983 Israeli university students. The psychological effects of exposure to single versus multiple traumatic events, and the effects of trauma-related physical injury were also examined. It was found that 67% of the respondents reported having been exposed to at least one traumatic event. Of those exposed, 6% were diagnosed as having posttraumatic stress disorder (PTSD). Men were more at risk for exposure, but women were more at risk for PTSD. Women and the physically injured showed more psychological distress following exposure. Being exposed to one type of traumatic event was associated with increased psychological distress, but being exposed to multiple types of traumatic events was associated with lowering of distress. The results are discussed in comparison with similar studies from the United States.

Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event

Posttraumatic stress disorder (PTSD) is a psychiatric condition that is directly precipitated by an event that threatens a person's life or physical integrity and that invokes a response of fear, helplessness, or horror. In recent years it has become clear that only a proportion of those exposed to fear-producing events develop or sustain PTSD. Thus, it seems that an important challenge is to elucidate aberrations in the normal fear response that might precipitate trauma-related psychiatric disorder. This paper summarizes the findings from recent studies that examined the acute and longer term biological response to traumatic stress in people appearing to the emergency room immediately following trauma exposure. In the aggregate, these studies have demonstrated increased heart rate and lower cortisol levels at the time of the traumatic event in those who have PTSD at a follow-up time compared to those who do not. In contrast, certain features associated with PTSD, such as intrusive symptoms and exaggerated startle responses, are only manifest weeks after the trauma. The findings suggest that the development of PTSD may be facilitated by an atypical biological response in the immediate aftermath of a traumatic event, which in turn leads to a maladaptive psychological state.

Lifetime exposure to traumatic events among a sample of city bus drivers

Lifetime exposure to traumatic events was assessed retrospectively among a representative sample of city bus drivers (228 men and 54 women) from Montréal, Canada. Among them, 68.1% reported at least one exposure to a traumatic event of any type. Among the 68% exposed. 70.4% reported multiple traumatic exposures (M = 2.6, SD = 1.67), with ratings ranging from 0 to 12. This report underlines the fact that the prevalence of traumatic events is not yet well known. Epidemiological research should devote more effort to assess fully the lifetime prevalence of traumatic events and not only cases of PTSD.

Functional associations among trauma, PTSD, and substance-related disorders

This review article presents several potential functional pathways which may explain the frequent co-occurrence of PTSD and substance abuse disorders in traumatized individuals. Emerging empirical studies which have examined these potential pathways are reviewed, including studies on relative order of onset, PTSD patients' perceptions of various drug effects, comparisons of PTSD patients with and without comorbid substance use disorders, and correlational studies examining the relations between severity of specific PTSD symptom clusters and substance disorder symptoms. Research on the acute and chronic effects of alcohol and other drugs on cognitive and physiological variables relevant to PTSD intrusion and arousal symptoms is reviewed to highlight ways in which these two sets of PTSD symptoms might be functionally interrelated with substance abuse. Finally, based on these findings, recommendations are made for the treatment of individuals with comorbid PTSD-substance use disorders.

Posttraumatic stress disorder in response to HIV infection

This study investigated the psychological impact of HIV infection through assessment of posttraumatic stress disorder in response to HIV infection. Sixty-one HIV-positive homosexual/bisexual men were assessed for posttraumatic stress disorder in response to HIV infection (PTSD-HIV) using a modified PTSD module of the DIS-III-R. Thirty percent met criteria for a syndrome of posttraumatic stress disorder in response to HIV diagnosis (PTSD-HIV). In over one-third of the PTSD cases, the disorder had an onset greater than 6 months after initial HIV infection diagnosis. PTSD-HIV was associated with other psychiatric diagnoses, particularly the development of first episodes of major depression after HIV infection diagnosis. PTSD-HIV was significantly associated with a pre-HIV history of PTSD from other causes, and other pre-HIV psychiatric disorders and neuroticism scores, indicating a similarity with findings in studies of PTSD from other causes. The findings from this preliminary study suggest that a PTSD response to HIV diagnosis has clinical validity and requires further investigation in this population and other medically ill groups. The results support the inclusion of the diagnosis of life-threatening illness as a traumatic incident that may lead to a posttraumatic stress disorder, which is consistent with the DSM-IV criteria.

Epidemiological evidence about the relationship between PTSD and alcohol abuse: the nature of the association

This article uses the Bradford Hill criteria for assessing causal associations to examine the nature of the relationship between PTSD and alcohol abuse. A series of studies are presented which examine this relationship. A cross-sectional study of 2,501 subjects in a community sample examined the relationship between at-risk drinking and 11 types of traumatic events. The traumatic events associated with at-risk drinking were involvement in life threatening accidents, witnessing severe injury, rape, being the victim of serious physical assault using the CIDI. In a longitudinal study of 469 firefighters exposed to a natural disaster, PTSD was associated with both an increase and decrease in alcohol consumption and PTSD rather than exposure accounted for the changes in drinking behaviour. In three other populations, psychiatric inpatients, motor accident victims and female prisoners, the association between PTSD and alcohol abuse emphasised the clinical and public health importance of this relationship. The available evidence does nevertheless support the causal nature of this relationship. Other risk factors are necessary to predict alcohol abuse following exposure to traumatic events, although exposure to traumatic events can be caused by alcohol abuse.

Investigations of causal pathways between PTSD and drug use disorders

Although numerous studies have demonstrated an association between PTSD and substance use disorders, little is known about the causal nature of this relationship. In this article, we put forth and test major causal hypotheses. Specific hypotheses to be tested include self-medication of PTSD symptoms, substance users' high risk of exposure to traumatic events, and drug users' increased susceptibility to PTSD following a traumatic exposure. We also examine the possibility of an indirect pathway linking drug use disorders and PTSD via a shared vulnerability. Evidence for these causal hypotheses is evaluated using Hill's criteria for causal inference: strength, consistency, specificity, temporality, gradient, plausibility, coherence, experimental evidence, and analogy. We present data analytic strategies that exploit information about the temporal order of PTSD and drug use disorders to shed light on their causal relationship. Finally, we present findings on the PTSD/drug use disorder association from an epidemiologic study of young adults.

Prevalence of traumatic events and peritraumatic predictors of posttraumatic stress symptoms in a nonclinical sample of college students

This study investigated lifetime prevalence of traumatic events and posttraumatic stress disorder (PTSD) symptoms among 937 college students. Participants rated their lifetime experiences of traumatic events and, in response to their "most stressful" event, completed measures of objective stressor dimensions, PTSD, and peritraumatic reactions. Approximately 67% of respondents reported at least one traumatic event. An estimated 4% of the full sample (12% of traumatized individuals) met PTSD criteria within the past week. After controlling for vulnerability factors and objective characteristics, peritraumatic reactions remained strongly predictive of PTSD symptoms. Results are discussed with respect to immediate reactions to traumatic events as potential precursors of PTSD symptomatology.

Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women

This paper provides information on the relation between victimization status, crime factors, posttraumatic stress disorder (PTSD), and several other psychological disorders among a community sample of women. Results indicated that victims of crime were more likely than nonvictims to suffer from PTSD, major depressive episode, agoraphobia, obsessive-compulsive disorder, social phobia, and simple phobia. Furthermore, life threat was associated with increased risk of major depression, agoraphobia, obsessive-compulsive disorder, and social phobia. Completed rape was strongly related to almost every disorder assessed, while robbery and burglary were not related to any disorder. When demographics, victimization status, and crime factors were entered hierarchically into multivariate logistic regressions with PTSD in the final step, associations between victimization status, other crime characteristics (e.g., life threat, injury), and non-PTSD Axis I disorders were greatly reduced. This suggests that PTSD may be an important mediating factor in the victimization-psychopathology relation for many disorders.

Physical symptom trajectories following trauma exposure: longitudinal findings from the normative aging study

This study modeled physical symptom trajectories from ages 30 to 75 in 1079 older male military veterans who were assessed every 3 to 5 years since the 1960s. Combat exposure and noncombat trauma were used to define four groups: no trauma (N = 249), noncombat trauma only (N = 333), combat only (N = 152), and both combat and noncombat trauma (N = 345). Number of symptoms on the Cornell Medical Index physical symptom scale increased 29% per decade. Men who had experienced either combat or noncombat trauma did not differ from nonexposed men, but those who had experienced both combat and noncombat trauma had 16% more symptoms across all ages. There were no differences in age-related trajectories as a function of trauma history. In cross-sectional analysis, men with combat and noncombat trauma had more posttraumatic stress disorder symptoms, but not more depression symptoms, than men with either no trauma or noncombat trauma only. Discussion focuses on the importance of considering physical as well as psychological outcomes of exposure to traumatic events.

Anxiety and cardiovascular reactivity: the basal forebrain cholinergic link

The relations between anxiety states and autonomic functions are considered from the vantage of a model of the neural systems underlying anxiety and autonomic control. An important component of this model is the involvement of the basal forebrain cortical cholinergic system that is seen to play a crucial role in the cognitive aspects of anxiety, and the links between anxiety and autonomic regulation. An additional aspect of the model is the detailing of the routes by which autonomic reactivity and associated visceral afference can modulate more rostral components of the system. The proposed model offers a more comprehensive framework for research on the neurobiology of anxiety and autonomic control.

Follow-up of sexual assault victims

OBJECTIVES

Our goal was to describe medical findings and health-related concerns of sexual assault victims who returned for follow-up and to assess demographic and assault characteristics of victims who used follow-up services compared to those who did not.

STUDY DESIGN

This study is a retrospective cohort analysis involving records from two sources: the acute sexual assault evidentiary examination and the SAFE (Sexual Assault Follow-up Evaluation) Clinic visit. Data were extracted from the records of 389 adolescent and adult victims who reported an acute sexual assault and underwent a complete evidentiary examination between January 1, 1995, and June 30, 1997. Descriptive statistics were generated on demographic and historical information, assault characteristics, and medical and laboratory findings. For the subgroup that presented for follow-up, additional descriptive statistics were generated to describe their interim history, concerns, medical outcomes, treatments, and psychosocial functioning. Chi2 analyses were used to identify differences in the group that returned for follow-up compared with the group that did not. Statistical significance was defined as P < .05.

RESULTS

There were no differences in age, race, or perpetrator factors between patients who used follow-up services and patients who did not return to the SAFE Clinic. Similarly, there were no other assault characteristics, relationships, or physical examination findings that were associated with follow-up patterns. A total of 31% (n = 122) of all sexual assault victims returned for a follow-up visit. Physical complaints were reported by 42.6%, but 98.0% had normal findings at a general examination, and 94.8% had a normal result of gynecologic examination. Pregnancy and sexually transmitted diseases, including human immunodeficiency virus, were identified through the follow-up clinic. Since the assault, 49.2% had been sexually active, 10% with multiple partners and 73.3% without consistent condom use. Disturbances in sleep, sexual function, and appetite were commonly reported among victims at follow-up. Numerous assault-related fears were reported.

CONCLUSIONS

Among recent rape victims, follow-up rates are low, and there are no factors that correlate with the use of follow-up services. Those who do come in for follow-up have physical complaints and health-related concerns that are related to their recent assault, but most have normal physical findings. Efforts to reach sexual assault victims will require aggressive and innovative strategies to remain in contact with women and girls after rape.