Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims

Description of an early intervention to prevent substance abuse and psychopathology in recent rape victims

Approximately 683,000 adult women are raped each year. Only one in seven of these victims report the assault to police and receive forensic exams and other professional services. For many rape victims, this may be the only professional contact with service providers; however these services are typically limited to evidence collection and prophylactic STD treatment. Yet this exam also presents a unique opportunity for a preventive intervention to help prepare women to cope with potential stress related to rape-exam procedures and to address potential post rape psycho-pathology. This article reviews psychological interventions for trauma victims used in the acute post rape time frame and provides data from an ongoing clinical trial that evaluates delivery of a preventive intervention for victims presenting for forensic rape exams.

Behavioral interventions for recent trauma: empirically informed practice guidelines

Despite the successes in the treatment of chronic trauma-related distress, little attention has been devoted to developing behavioral interventions to be delivered soon after traumatic exposure in an effort to promote positive posttraumatic adjustment and to minimize the likelihood of enduring psychopathology. As a result, other forms of early intervention have filled this void and have been widely disseminated and applied, despite the lack of compelling evidence attesting to their efficacy. This article reviews the literature bearing on early interventions for trauma, including the encouraging outcomes of recently developed behavioral treatments. Empirically informed practice guidelines for intervening with recently traumatized individuals are presented. Future treatment development efforts will need to address an issue that has been largely neglected in traditional treatment models for traumatized populations-that of traumatic bereavement. Behavioral interventions may be particularly well-equipped to address this source of distress.

Psychosocial approaches of acute stress reactions

What are the conceptual and empirical bases for current interventions for acute stress reactions following trauma exposure? This review compares the two major alternatives to managing acute stress reactions, outlines their conceptual bases and critiques the evidence for their efficacy in preventing subsequent stress disorders. The review integrates current evidence for cognitive behavior therapy with recent neuroscience findings that fear reduction learning can be enhanced by modulating glutamatergic systems. D-cycloserine provides exciting opportunities to enhance the effects of cognitive-behavioral therapy, and points to closer understanding of the biological mechanisms that underpin clinical gains achieved by psychological therapies.

Lessons learned from the last twenty years of sexual violence research

The present article attempts to answer important questions about the most important thing learned from the past 20 years of research on sexual violence, the most important thing to be learned about sexual violence over the next 10 years, and the most promising methodological innovation in the study of sexual violence from the last 20 years. It is hoped that discussion of such important questions might further stimulate researchers and mental health professionals to continue making progress in our understanding of, as well as the struggle against, sexual violence.

Eine Meta-Analyse unter Einsatz des Random Effects-Modells zur Effektivität kurzfristiger psychologischer Interventionen nach akuter Traumatisierung

Zusammenfassung. Theoretischer Hintergrund: In der Sekundärprävention der Posttraumatischen Belastungsstörung (PTB) werden verstärkt kurzfristige Interventionen eingesetzt. Fragestellung: Es wurde die Wirksamkeit dieser Verfahren untersucht und zusätzlich mögliche Einflussfaktoren betrachtet. Methode: Die Integration der bisherigen Ergebnisse erfolgte mittels einer Meta-Analyse unter Nutzung eines Random Effects-Modells. Die Vorteile des statistischen Modells werden beschrieben. 21 Studien konnten integriert werden. Ergebnisse: Weder für die PTB-Symptomatik, noch für die Gesamtsymptomatik zeigte sich eine bedeutsame Effektstärke. Der mittlere Effekt lag nahe Null. Mittels explorativer Analysen wurde der Einfluss von Eigenschaften der Stichprobe untersucht. Das Geschlechterverhältnis zeigte einen signifikanten Zusammenhang, nicht aber der Professionalitätsstatus der Betroffenen. Schlussfolgerung: Die betrachteten Verfahren scheinen nicht als Präventionsmaßnahme für die PTB geeignet zu sein.

[Efficiency of psychological debriefing in preventing post-traumatic stress disorders]

BACKGROUND

Traumatic events are frequently followed by an acute stress reaction that may develop into a post-traumatic stress disorder. An intervention called psychological debriefing has been proposed to prevent these disorders. Although this method is widely used at present, its preventive effect is controversial. This article consist in a review of the studies which evaluated psychological debriefing efficiency in the prevention of post-traumatic stress disorder and associated disorders in adults.

METHOD

We carried out a bibliographical search on MEDLINE (1966-2001), PASCAL (1987-2001), EMBASE (1988-2001), FRANCIS (1984-2001) and SCIENCEDIRECT (1967-2001). The key words were posttraumatic stress disorder, debriefing, treatment, psychological follow up, and prevention. We selected the studies with the following criteria: adults, one psychological debriefing session in the Month following the event, inclusion of a control group, more than 20 persons per group and evaluation of psychological disorders with standardized instruments more than one Month after the trauma.

RESULTS

Twenty nine studies were identified and 8 selected. Four studies did not show any intervention effect, 3 suggested a negative intervention effect, and 1 suggested a positive effect on anxiety, depressive symptoms and alcohol dependence.

CONCLUSION

Psychological debriefing implies re-exposure through memory processes to the trauma, which can interfere with the natural course of adjustment and recovery. Several Authors have suggested that psychological debriefing may delay the diagnosis and thus the early treatment of post-traumatic stress disorder. Psychological debriefing may not be appropriate to all victims of every type of incident or trauma. We discuss the intervention and its design. This review did not show evidence for psychological debriefing efficiency, as a unique session, in the prevention of posttraumatic reactions. The design and the objectives may be re-examined. Further evaluations following rigorous methods are warranted.

All symptoms are not created equal: the prominent role of hyperarousal in the natural course of posttraumatic psychological distress

This 3-wave longitudinal study examined the natural course of posttraumatic stress disorder symptoms using data collected from young adult survivors of community violence. Three key findings emerged. 1. Mean levels of distress for each symptom cluster decreased over time, with reexperiencing decreasing most rapidly. 2. Cross-lagged panel analysis revealed that hyperarousal strongly influences, but is not generally influenced by, other symptoms clusters. 3. Trajectory analysis demonstrated that respondents for whom hyperarousal was the most pronounced baseline symptom showed lower overall symptom improvement relative to trauma exposed counterparts for whom hyperarousal was a less prominent early symptom. Implications for theory, research, and clinical practice are discussed.

Revisiting Recent Research on Social Learning Theory as an Etiological Proposition for Sexually Abusive Male Adolescents

This article examines social learning theory as a construct that is applicable to adolescent sexual abusers based upon recent published research. Bandura's (1986) work is used to outline the theory and then research on victimization, aggression, criminality, pornography and personality is reviewed to assess the theory as a reasonable fit for adolescent sexually abusive behavior. Research implications are offered that argue for rigorous research methods in the field to allow for further test of this theory.

Brain environment interactions: stress, posttraumatic stress disorder, and the need for a postmortem brain collection

Stress, especially the extreme stress of traumatic events, can alter both neurobiology and behavior. Such extreme environmental situations provide a useful model for understanding environmental influences on human biology and behavior. This paper will review some of the evidence of brain alterations that occur with exposure to environmental stress. This will include recent studies using neuroimaging and will address the need for histological confirmation of imaging study results. We will review the current scientific approaches to understanding brain environment interactions, and then make the case for the collection and study of postmortem brain tissue for the advancement of our understanding of the effects of environment on the brain. Creating a brain tissue collection specifically for the investigation of the effects of extreme environmental stressors fills a gap in the current research; it will provide another of the important pieces to the puzzle that constitutes the scientific investigation of negative effects of environmental exposures. Such a resource will facilitate new discoveries related to the psychiatric illnesses of acute stress disorder and posttraumatic stress disorder, and can enable scientists to correlate structural and functional imaging findings with tissue abnormalities, which is essential to validate the results of recent imaging studies.

An acute post-rape intervention to prevent substance use and abuse

The trauma of rape is routinely associated with extreme acute distress. Such peri-event anxiety increases risk of developing psychopathology and substance use or abuse post-rape, with the degree of initial distress positively predicting future problems. Unfortunately, the nature of post-rape forensic evidence collection procedures may exacerbate initial distress, thereby potentiating post-rape negative emotional sequelae. Consequently, substance use may increase in an effort to ameliorate this distress. To address this, a two-part video intervention was developed for use in acute post-rape time frames to (a) minimize anxiety during forensic rape examinations, thereby reducing risk of future emotional problems, and (b) prevent increased post-rape substance use and abuse. Pilot study data with 124 rape victims indicated that the low-cost, easily administered intervention was effective in reducing risk of marijuana abuse at 6 weeks. Nonstatistically significant trends also were evident for reduced marijuana use. Trends were also noted in favor of the intervention in the subgroup of women who were actively using substances pre-rape (among pre-rape alcohol users, 28% viewers vs. 43% nonviewers met criteria for post-rape alcohol abuse; among pre-rape marijuana users, the rates of post-marijuana use were 17% vs. 43%).

Predictors of efficacy in depression prevention programmes. Meta-analysis

BACKGROUND

Worldwide, 340 million people are affected by depression, with high comorbid, social and economic costs.

AIMS

To identify potential predictors of effect in prevention programmes.

METHOD

A meta-analysis was made of 69 programmes to reduce depression or depressive symptoms.

RESULTS

The weighted mean effect size of 0.22 was effective for different age groups and different levels of risk, and in reducing risk factors and depressive or psychiatric symptoms. Programmes with larger effect sizes were multi-component, included competence techniques, had more than eight sessions, had sessions 60-90 min long, had a high quality of research design and were delivered by a health care provider in targeted programmes. Older people benefited from social support, whereas behavioural methods were detrimental.

CONCLUSIONS

An 11% improvement in depressive symptoms can be achieved through prevention programmes. Single trial evaluations should ensure high quality of the research design and detailed reporting of results and potential predictors.

Early Psychosocial and Pharmacological Interventions After Traumatic Events

1. There is no evidence to suggest that routine provision of single-session psychological interventions after traumatic events prevents the development of psychological sequelae. Some such evidence exists regarding multiple-session, cognitive-behavioral interventions. 2. There is no evidence to suggest that routine use of pharmacological agents prevents development of psychological sequelae in traumatized individuals. 3. Given the current evidence base, development of stepped-care programs focusing on education, screening, and treatment is warranted. 4. Currently, the main role of mental health professionals early on is to ensure emotionally supportive systems of care are in place, which will help identify individuals who appear most distressed so evidence-based interventions can be offered.

A systematic review of single-session psychological interventions ('debriefing') following trauma

BACKGROUND

Single-session psychological interventions such as psychological debriefing have become widely used following traumatic events. The evidence for their effectiveness has been widely debated. This review aimed to consider the evidence for the effectiveness of one-off early interventions within 1 month of a traumatic event.

METHODS

A systematic review using the standard Cochrane Collaboration methodology. Literature searches of various databases were performed to identify randomised controlled trials. The methodological quality of the studies identified was determined using standard measures, and the results were pooled to consider the overall evidence for effectiveness.

RESULTS

Eleven randomised controlled trials were found, all of individual or couple interventions. Three studies associated the intervention with a positive outcome, 6 demonstrated no difference in outcome between intervention and non-intervention groups and 2 showed some negative outcomes in the intervention group (these studies had the longest follow-up periods). The methodological quality of the studies varied widely, but was generally poor. This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that it should not be advocated for routine use. There remains an urgent need for randomised controlled trials of group debriefing and other early interventions.

Cognitive behaviour therapy for posttraumatic stress disorder

Following considerable empirical scrutiny, cognitive behaviour therapy (CBT) has proven to be a safe and effective treatment for posttraumatic stress disorder (PTSD). This article overviews the general principles of treatment and describes the components that comprise CBT for PTSD. We then move on to review the efficacy of CBT for the treatment of PTSD caused by various traumas, including assault, road traffic accident (RTA), combat, and terrorism. Recent advances in early intervention and in the treatment of disorders that are comorbid with PTSD are reviewed. Finally, future directions are discussed. In particular, it is proposed that randomised controlled trials (RCT) of CBT for PTSD must be conducted with enhanced methodological rigour and public health relevance.

Early predictors of posttraumatic stress disorder

The benefits of providing early intervention for people recently exposed to trauma have highlighted the need to develop means to identify people who will develop chronic posttraumatic stress disorder (PTSD). This review provides an overview of prospective studies that have indexed the acute reactions to trauma that are predictive of chronic posttraumatic stress disorder. Ten studies of the predictive power of the acute stress disorder diagnosis indicate that this diagnosis does not have adequate predictive power. There is no convergence across studies on any constellation of acute symptoms that predict posttraumatic stress disorder. A review of biological and cognitive mechanisms occurring in the acute posttraumatic phase suggests that these factors may provide more accurate means of predicting chronic posttraumatic stress disorder. Recommendations for future research to facilitate identification of key markers of acutely traumatized people who will develop posttraumatic stress disorder are discussed.

Early psychological interventions for adult survivors of trauma: a review

Psychological interventions after traumatic events have only recently been evaluated in randomized, controlled trials. Recent systematic reviews concluded that single sessions of individual psychological debriefing are not effective in reducing distress or subsequent posttraumatic stress disorder (PTSD) symptoms. The present article reviews trials of early cognitive behavior therapy (CBT) after trauma. Cognitive behavioral therapy was more effective than supportive counseling in preventing chronicity of PTSD symptoms; however, in most available studies it remained unclear whether supportive counseling facilitated or retarded recovery, compared with no intervention. A brief CBT program given in the first month of trauma was not superior to repeated assessment; however, a course of CBT of up to 16 sessions given at 1-4 months after trauma was superior to self-help, repeated assessment, and no intervention. Possible reasons for the difference in efficacy between CBT and debriefing or self-help are discussed. These include the way of working through traumatic memories and the impact of the interventions on patients' interpretations of their PTSD symptoms. Possible ways of identifying people who are in need of specialist psychological intervention after trauma and who are unlikely to recover on their own are discussed. Some ideas for alternative ways of offering help to trauma survivors are presented, and methodologic suggestions for future research are given.

Posttraumatic stress symptoms in mothers of premature infants

OBJECTIVE

To examine mothers' responses to having a premature infant in the neonatal intensive-care unit and to determine the degree to which they appear similar to a posttraumatic stress response.

DESIGN

Mothers were enrolled in this descriptive, correlational study shortly before the infant was discharged from the hospital. Data were collected at enrollment and when the infant was 6 months old, corrected for prematurity.

PARTICIPANTS

A convenience sample of 30 mothers of high-risk premature infants.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

A semistructured interview of the mothers was conducted at 6 months corrected age. Interview responses were analyzed to identify three symptoms related to posttraumatic stress disorder: re-experiencing, avoidance, and increased arousal. Other measures focused on maternal psychological well-being--neonatal intensive-care unit stress, depressive symptoms, and worry about the infant--and demographic characteristics. Infant illness severity included birth weight, length of mechanical ventilation, multiple birth, and the severity of neurological insults.

RESULTS

All mothers interviewed had at least one posttraumatic symptom, 12 had two, and 16 had three symptoms. Twenty-six mothers reported increased arousal; re-experiencing and avoidance were reported by 24 mothers each. The number, but not the type, of posttraumatic stress symptoms was related to maternal psychological well-being. Maternal demographic characteristics, except marital status, and infant illness severity, were unrelated to posttraumatic stress symptoms.

CONCLUSIONS

These mothers appeared to be experiencing emotional responses similar to posttraumatic stress reactions at 6 months after their child's expected birth date. Since maternal emotional responses may affect the parenting of premature infants, additional nursing research is needed provide a basis for interventions with these highly vulnerable mothers and infants.

Misconceptions, discrimination, and disabling language: synthesis and review

Misconceptions about various disabling conditions abound in the general population and are related to the presence of socially disabling stereotyping as a cultural phenomenon. Significant levels of misconception have been demonstrated among the population regarding head injuries, epilepsy, and electroconvulsive shock treatment. Public ignorance in these domains is thought to breed a climate ripe for discrimination, and numerous studies have shown that such discrimination does occur in the workplace and, perhaps more important, in the world of everyday discourse. Discrimination patterns are not uniform, however, and all disabling conditions are not alike in their susceptibility to discrimination. This article presents a review of the relationships among misconceptions, employment discrimination, and language discrimination patterns, as these factors function as obstacles to community reentry for many persons with disabilities. Strategies for overcoming the effects of social stereotyping and discrimination are offered, with the goal of educating the professional and rehabilitation communities about unwitting discrimination perpetrated by individuals belonging to these communities.

The efficacy of a mental health program in Bosnia-Herzegovina: impact on coping and general health

The efficacy of a community-based psychosocial program in Bosnia-Herzegovina during the war and immediate postwar years (1994-1999) was described in this article. Ten centers provided various kinds of psychological help in the besieged city of Sarajevo and the towns of Zenica, Travnik, and Vitez. Since 1994, an intensive monitoring system has documented data on clients, interventions, and outcomes. This study focused on the systematic evaluation of counseling interventions aimed to alleviate the distress in wartime. The sample consisted of 3,283 and 1,785 inhabitants of Sarajevo, Zenica, Travnik, and Vitez who filled out the GHQ-28 and IES respectively. Pre- and post-assessments were compared throughout consecutive years (1994-1999) and across age groups and both sexes. Outcomes of these scales reflected very high scores, especially among people between 30 and 40 years of age. Furthermore, intake scores increased in time rather than decreased. Differences between pre- and postmeasurements are highly significant--throughout the years. Analyses revealed substantial proportions of clinically recovered or generally improved individual functioning, although some clients revealed no improvement.

Personality, coping, chronic stress, social support and PTSD symptoms among adult burn survivors: a path analysis

This paper presents a longitudinal study of the relationship between personality, coping, chronic stress, social support and posttraumatic stress disorder (PTSD). A hypothesized model of the relationship between the predictor variables and PTSD symptoms was proposed. Path analyses was completed to test the model. One hundred fifty-eight adult burn survivors completed questionnaires measuring each of the variables in the hospital. Of those 124 and 94 completed the PTSD measure at 1 month and 6 months postdischarge, respectively. The hypothesized model fit the data at each time point with slight variations. The model accounted for 46 and 29% of the variance of PTSD symptoms at hospitalization and 1 month. Neuroticism was the most important personality dimension in predicting PTSD. Avoidant Coping and Social Support mediated a high percentage of the relationship between Neuroticism and PTSD. The best predictor of PTSD symptoms at 1 and 6 months was PTSD symptoms at hospitalization.

The Trauma Recovery and Empowerment Model (TREM): conceptual and practical issues in a group intervention for women

This article describes the Trauma Recovery and Empowerment Model (TREM), a manualized group intervention designed for women trauma survivors with severe mental disorders, and discusses key issues in its conceptualization and implementation. TREM recognizes the complexity of long-term adaptation to trauma and addresses a range of difficulties common among survivors of sexual and physical abuse. Focusing primarily on the development of specific recovery skills and current functioning, TREM utilizes techniques shown to be effective in trauma recovery services. The group's content and structure are also informed by the role of gender in the ways women experience and cope with trauma.

Victimization and Substance Abuse among Women: Contributing Factors, Interventions, and Implications

Although the literature indicates that there is an association of victimization with substance abuse, there has been limited research focused on understanding and synthesizing the factors that have been identified as contributing to victimization and substance abuse and on interventions designed to address these contributing factors. The purposes of this article are to (a) review the literature on factors related to victimization and substance abuse, (b) review interventions and outcomes, and (c) discuss clinical implications for interventions and research. Results suggest that there is a high rate of co-occurrence of victimization and substance abuse among women, that the factors contributing to victimization and substance abuse are complex, and that there is a lack of treatment models addressing victimization and substance abuse.

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.

Early interventions following psychological trauma

What is the best way to provide early interventions for psychiatric disorders after trauma? The terrorist attacks of September 11, 2001, have raised urgent concerns about the evidence for early treatments after trauma that can prevent psychiatric disorders. This review outlines the expected course of posttraumatic stress reactions and discusses the current means of identifying people who are at risk of developing disorders. A critique of psychological debriefing and an analysis of evidence for cognitive-behavioral therapy as an early intervention is provided. The major challenges for early intervention are discussed, including increasing treatment effectiveness, delivering therapy when it is required by thousands of people, and developing early interventions for a wide array of psychiatric disorders in addition to posttraumatic stress disorder that can develop following trauma.

Treatment of PTSD: stress inoculation training with prolonged exposure compared to EMDR

The effectiveness of Stress Inoculation Training with Prolonged Exposure (SITPE) was compared to Eye Movement Desensitization and Reprocessing (EMDR). Twenty-four participants who had a diagnosis of Post Traumatic Stress Disorder (PTSD) were randomly assigned to one of the treatment conditions. Participants were also their own wait-list control. Outcome measures included self-report and observer-rated measures of PTSD, and self-report measures of depression. On global PTSD measures, there were no significant differences between the treatments at the end of therapy. However on the subscale measures of the degree of intrusion symptoms, EMDR did significantly better than SITPE. At follow-up EMDR was found to lead to greater gains on all measures.

Managing acute stress response to major trauma

In this article, the authors review the current empiric literature on early interventions. Findings on the effects, course, help-seeking, and recovery from disasters are first reviewed, with recommendations given that are pertinent to intervention following mass casualties. In reviewing the most commonly used interventions, it is clear that evidence from well-controlled studies showing that early intervention can help prevent longer-term problems is limited. The authors discuss the approaches that have received the most attention or empiric support as early interventions following trauma, which include psychologic debriefing, cognitive-behavioral interventions, eye movement desensitization and processing (EMDR) and other neoteric approaches, and psychopharmacology. At this time, the most promising results for prevention of psychopathology have been achieved with brief four- or five-session cognitive-behavioral therapy. In contrast, randomized clinical trials on psychologic debriefing currently suggest that this approach is either ineffective at preventing psychopathology, or contributive to post-traumatic stress disorder symptoms. Research support is currently lacking for EMDR and pharmacotherapy as early interventions. A major challenge to the field is to integrate the practical experience and knowledge of professional responders with well-controlled, timely intervention research, and to effectively disseminate these findings to practitioners in the field.

Research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature

Tragic events such as those of September 11, 2001, underscore the increasingly prominent role that psychiatrists play in aiding survivors, emergency workers, and broader communities to cope with disaster. The present review was undertaken to identify whether there exists a scientific basis for the practice of psychiatry in the aftermath of disasters. Most of the extensive literature over the past 30 years suggests that disasters have psychopathological consequences as well as medical and social ones. Pre-existing mood and anxiety disorders, although surprisingly not psychotic illness, appear to be risk factors for further psychopathology after a disaster. Thus, both acute psychopharmacological and psychotherapeutic interventions at disaster sites may prevent long-term sequelae, although their efficacy remains uncertain. Future controlled treatment trials are needed to determine the optimal treatment strategy.

Implications of biological findings for psychological treatments of post-traumatic stress disorder

The goal of this article is to initiate dialogue among those conducting research on the biological aspects of post-traumatic stress disorder (PTSD) and clinicians and researchers concerned with developing effective psychological treatments for PTSD. Important biological findings in PTSD are reviewed, paying special attention to the clinical implications of these findings. A discussion of the psychological treatments effective for PTSD follows, focusing on how these empirically supported treatments may address some of the issues raised by the biological findings. Finally, suggestions are made for future directions for psychological treatment development for this disabling condition, examining how these innovative treatment approaches may be relevant to the reviewed biological findings.

Psychobiology of the acute stress response and its relationship to the psychobiology of post-traumatic stress disorder

The literature to date that examines the biology of the acute stress reactions suggests that relatively lower baseline cortisol is associated with the development of PTSD. This is particularly informative because of the ongoing controversy surrounding baseline cortisol in PTSD. Studies have found low baseline cortisol, normal range, and elevated baseline cortisol in chronic PTSD, and it has been unclear whether this reflects methodologic differences across studies or true heterogeneity within the disorder. Thus, the few studies to date support the finding of low-normal baseline cortisol in chronic PTSD and suggest that it is a pre-existing functional trait. Whether it plays an etiologic role or is an epiphenomenon of some other process is unclear. What does seem clear, however, is that this characteristic is relatively nonspecific to PTSD, given the fact that low cortisol has been observed in multiple subject populations, including normal individuals under chronic stress as well as chronic medical conditions (for review see [23]). For example, it is possible that reduced baseline cortisol reflects the net result of input to the hypothalamus from cortical and subcortical regions of the brain linked to increased vigilance, sensitization to trauma because of prior traumatic experiences, or genetic factors. For example, primate studies have demonstrated persistent alterations in HPA axis functioning in animals reared by mothers living in moderately stressful conditions [24]. The development of PTSD is associated with sensitization of the startle response. Because the neurobiology of startle is well characterized, this finding implicates a role for specific neurocircuitry in PTSD [25]. Non-habituation of the startle response in PTSD appears related to sensitization specifically to contextual cues (i.e., the environment) that signal the presence of potential threat of danger-related fears [26]. This may be the neurobiological correlate to the over-generalization seen in PTSD that distinguishes the disorder from a simple trauma-induced phobia. The bed nucleus of the stria terminalis (BNST) is specifically implicated from preclinical research in the mediation of context-dependent cues [1]. Treatments that result in down-regulation of the BNST are therefore of particular interest in therapeutic models of prevention after trauma. The fact that a number of vulnerability factors associated with increased risk for developing PTSD are also likely to be biologically based (e.g., a genetic component, prior psychiatric history, prior family of history of psychiatric disorder), provides further evidence in support of a role for psychobiological factors in producing PTSD. Nevertheless, the considerable overlap on these measures between those who will develop PTSD, and those who eventually recover spontaneously, belies any attempt to identify any single or pathognomonic biological marker for risk. For now, the standard of care in predicting level of symptomatology and prognosis in the acute setting continues to be based on careful, informed, serial assessments of symptoms and functioning. Because the capacity to learn from and adapt to adverse conditions are essential to the survival of any species, understanding the neurobiological pathways that mediate learning from traumatic experiences in an adaptive way is as important as understanding the etiology of PTSD and other trauma-related maladaptive consequences. Biological models that trace the causal cascade of post-traumatic events in the brain and neuroendocrine systems may offer a multiplicity of possibilities for intervention. It is well established that conditioned responses are robust and persistent. Moreover, the primary mechanism of habituation is overlearning rather than extinction. Interventions that promote overlearning may therefore prove to be the most powerful and efficient preventative treatments. The therapeutics literature supports this hypothesis, in that brief psychosocial interventions based on sophisticated cognitive-behavioral models have proven effective in reducing suffering, symptom severity, and chronicity in individuals presenting with acute PTSD symptoms [27-29]. No acutely administered pharmacologic treatment to date has been shown effective in accelerating the process of recovery or in preventing the development of chronic PTSD. However, pharmacologic interventions that would prevent sensitization of circuits related to context-dependent threat perception, dysregulation of affect, and/or dysregulation of normal circadian rhythms are of theoretical interest and deserve further study.

Emergency mental health management in bioterrorism events

The United States has not suffered significant psychosocial or medical consequences from the use of biological weapons within its territories. This has contributed to a "natural" state of denial at the community level. This denial could amplify the sense of crisis, anxiety, fear, chaos, and disorder that would accompany such a bioterrorist event. A key part of primary prevention involves counteracting this possibility before an incident occurs. Doing so will require realistic information regarding the bioterrorism threat followed by the development of a planned response and regular practice of that response. Unlike in natural disasters or other situations resulting in mass casualties, emergency department physicians or nurses and primary care physicians (working in concert with epidemiologic agencies), rather than police, firemen, or ambulance personnel, will be most likely to first identify the unfolding disaster associated with a biological attack. Like community leaders, this group of medical responders must be aware of its own susceptibility to mental health sequelae and performance decrement as the increasing demands of disaster response outpace the availability of necessary resources. A bioterrorist attack will necessitate treatment of casualties who experience neuropsychiatric symptoms and syndromes. Although symptoms may result from exposure to infection with specific biological agents, similar symptoms may result from the mere perception of exposure or arousal precipitated by fear of infection, disease, suffering, and death. Conservative use of psychotropic medications may reduce symptoms in exposed and uninfected individuals, as may cognitive-behavioral interventions. Clear, consistent, accessible, reliable, and redundant information (received from trusted sources) will diminish public uncertainty about the cause of symptoms that might otherwise prompt persons to seek unnecessary treatment. Training and preparation for contingencies experienced in an attack have the potential to enhance delivery of care. Initiating supportive social, psychotherapeutic, and psychopharmacologic treatments judiciously for symptoms and syndromes known to accompany the traumatic stress response can aid the efficient treatment of some patients and reduce long-term morbidity in affected individuals. Preventive strategies and planning must take into account the idea that specific groups within the population are at higher risk for psychiatric morbidity. First responders comprise one group at psychologic risk in this situation, and healthcare providers comprise another. These and other high-risk groups will benefit from the same supportive interventions developed for the community as a whole.

Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb

Studies in academic research centres with selected patients have shown that several cognitive behaviour therapies are effective in the treatment of PTSD following traumas affecting individuals or small groups. Little information is available on the extent to which these positive findings will generalize to more routine clinical settings with less selected patients or to a trauma that affects a whole community. The present study addresses these generalization issues. A consecutive series of 91 patients with PTSD resulting from a car bomb which exploded in the centre of Omagh, Northern Ireland in August 1998 were treated with cognitive therapy, along lines advocated by Ehlers and Clark (2000). There were no major exclusion criteria and 53% of patients had an additional axis I disorder (comorbidity). Therapists were NHS staff with heavy caseloads and modest prior training in CBT for PTSD. A brief training in specialist procedures for PTSD was provided. Patients received an average of eight treatment sessions. Significant and substantial improvements in PTSD were observed. Degree of improvement was comparable to that in previously reported research trials. Comorbidity was not associated with poorer outcome, perhaps because comorbid patients were given more sessions of treatment (average 10 vs 5 sessions). Patients who were physically injured improved less than those who were not physically injured. Overall, the results indicate that the positive findings obtained in research settings generalize well to a frontline, non-selective service.

Acute stress reactions in adults

This article summarizes the literature on acute reactions to traumatic stress in adults. It describes their morphology, natural course, long-term outcome, and underlying biological factors, and outlines directions for management and research. It assumes two categories of responses: those that mediate survival and those related to learning and adaptation. The complementary roles of fear conditioning, processing novelty, and adjusting to change are discussed.

60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research

On the basis of the literature reviewed in Part I of this two-part series (Norris, Friedman, Watson, Byrne, Diaz, and Kaniasty, this volume), the authors recommend early intervention following disasters, especially when the disaster is associated with extreme and widespread damage to property, ongoing financial problems for the stricken community, violence that resulted from human intent, and a high prevalence of trauma in the form of injuries, threat to life, and loss of life. Meeting the mental health needs of children, women, and survivors in developing countries is particularly critical. The family context is central to understanding and meeting those needs. Because of the complexity of disasters and responses to them, inter-agency cooperation and coordination are extremely important elements of the mental health response. Altogether, the research demands that we think ecologically and design and test societal- and community-level interventions for the population at large and conserve scarce clinical resources for those most in need.

Entwicklung eines Screeninginstrumentes zur Identifizierung von Risikopatienten für die Entwicklung einer Posttraumatischen Belastungsstörung (PTB) nach einem Verkehrsunfall

Zusammenfassung. Theoretischer Hintergrund: Verkehrsunfälle stellen häufige Ereignisse dar, die von Personen als Trauma erlebt werden können. Oft weisen die Verletzten eine Reihe psychischer Symptome auf, die meist jedoch vorübergehend sind. Eine Minderheit entwikkelt jedoch psychische Störungen, vor allem eine Posttraumatische Belastungsstörung (PTB). Fragestellung: Entwicklung eines Screeningfragebogens zur Identifizierung von Patienten mit dem Risiko der Entwicklung einer PTB oder dem subsyndromalen Bild einer PTB. Methode: Einer Stichprobe von 182 Unfallpatienten wurde kurz nach dem Unfall verschiedene Selbstbeurteilungsverfahren vorgelegt. Nach 6 Monaten wurde untersucht, welche Patienten innerhalb dieser Zeit eine PTB resp. ein subsyndromales Bild einer PTB entwickelten hatten. Diejenigen Items, die am besten zur Trennung dieser Patienten von den anderen Patienten beitrugen, wurden zu einem Screeningfragebogen zusammengestellt. Ergebnisse: Es konnte ein aus 10 Items bestehender Screeningfragebogen entwickelt werden. Erste psychometrische Analysen im Hinblick auf Sensitivität und Spezifität sowie Reliabilität und Validität können als günstig angesehen werden. Schlußfolgerung: Mit dem Screeningfragebogen liegt ein zeitökonomisch einsetzbares Verfahren zur Identifizierung von Risikopatienten für die Entwicklung einer PTB oder einem subsyndromalen Bild einer PTB vor.

Effectiveness of psychological debriefing

OBJECTIVE

To identify literature concerning the effectiveness of psychological debriefing (PD) and analyse results according to different criteria of success and different uses of the intervention format.

METHOD

Literature search was made in databases PubMed, PsycInfo and Psychlit. Twenty-five studies were selected for a thorough description. Forty-two studies provided additional information.

RESULTS

Results indicate that, in general, debriefing does not prevent psychiatric disorders or mitigate the effects of traumatic stress, even though people generally find the intervention helpful in the process of recovering from traumatic stress. The intervention holds potential as a screening procedure, and there may be economic arguments for continued use. When used with adherence to traditional descriptions of treatment group, events, group format, leadership and time spent, a preventive effect emerges. No tendency according to timing was found.

CONCLUSION

Current uses of PD are problematic. The concept needs to be redefined, and the scope of application must be revised. The objectives for use need to be clarified.

Preparing for bioterrorism: category A agents

September 11, 2001, brought the possibility of biologic acts of terrorism against the United States into the national consciousness. As the American people brace themselves for this new threat to the national well-being, clinicians must understand how to prevent, recognize, and treat the biologic agents that could be used in terrorist attacks. This article discusses the most likely biologic agents, including diagnostic laboratory procedures, treatment options, psychological effects, special populations, and reporting requirements.

Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.