Trauma exposure and posttraumatic stress disorder: a study of youths in urban America

Neighborhood social cohesion and posttraumatic stress disorder in a community-based sample: findings from the Detroit Neighborhood Health Study

PURPOSE

Posttraumatic stress disorder (PTSD) is common and debilitating. Although research has identified individual-level risk factors for PTSD, the role of macro-social factors in PTSD etiology remains unknown. This study tests whether perceived neighborhood social cohesion (NSC), measured at the both the individual and neighborhood levels, plays a role in determining past-year risk of PTSD among those exposed to trauma.

METHODS

Data (n = 1,221) were obtained from an ongoing prospective epidemiologic study in the city of Detroit. Assessment of traumatic event exposure and PTSD was consistent with DSM-IV criteria. Generalized estimating equations (GEE) and logistic regression models were used to estimate the association of neighborhood-level perceived NSC with the risk of PTSD, adjusting for individual-level perceptions of NSC and other covariates.

RESULTS

The odds of past-year PTSD were significantly higher among those residing in a neighborhood with low social cohesion compared to high (OR = 2.44, 95 % CI: 1.58, 3.78), independent of individual sociodemographic characteristics, number of traumas, and individual-level perceptions of NSC. The odds of past-year PTSD were not significantly associated with individual-level perceptions of NSC.

CONCLUSIONS

These results demonstrate that social context shapes risk of PTSD and suggest that changing the social context may shift vulnerability to this disorder.

Youth violence across multiple dimensions: a study of violence, absenteeism, and suspensions among middle school children

OBJECTIVE

To determine how multidimensional measures of violence correlate with school absenteeism and suspensions among middle school youth.

STUDY DESIGN

A cross-sectional survey was conducted in 2004 with 28 882 sixth graders from an urban school district. Data were collected on role (witness, victim, perpetrator) and mode (verbal, physical, weapons) of past-year violence exposures, and absences and suspensions over 1 academic year. Associations between violence and absenteeism and suspension were estimated using generalized linear models.

RESULTS

ORs for suspension increased from witnessing to victimization to perpetration and then victimization-perpetration. Among those exposed to weapons, victims (OR(boys) = 1.45; OR(girls) = 1.38) had similar or slightly higher ORs for absenteeism than perpetrators (OR(boys) = 1.39; OR(girls) = 1.17). Boy victims and witnesses of physical violence had similar absenteeism patterns as those unexposed to physical violence. Of all exposed girls, victim-perpetrators had the highest ORs for absenteeism (OR = 1.76).

CONCLUSION

Exposure to violence correlated with absenteeism and suspension. The strength of these relationships depended on mode and role in exposure. Our cross-sectional data limits our ability to establish causality. Findings have implications for prevention.

Factors related to posttraumatic stress disorder in adolescence

Studies of posttraumatic stress disorder (PTSD) in adolescence published from 2000 to 2011 indicate that adolescents are at greater risk of experiencing trauma than either adults or children, and that the prevalence of PTSD among adolescents is 3-57%. Age, gender, type of trauma, and repeated trauma are discussed as factors related to the increased rates of adolescent PTSD. PTSD in adolescence is also associated with suicide, substance abuse, poor social support, academic problems, and poor physical health. PTSD may disrupt biological maturational processes and contribute to the long-term emotion and behavior regulation problems that are often evident in adolescents with the disorder. Recommendations are presented for practice and research regarding the promotion of targeted prevention and intervention services to maximize adolescents' strengths and minimize vulnerabilities. Public policy implications are discussed.

Gambling and adverse life events among urban adolescents

This study explored the cross sectional association between adverse life events and gambling in a sample of 515 urban adolescents (average age 17, 55% male, 88% African American). Approximately half of the sample had gambled in the past year (51%); 78% of the gamblers gambled monthly and 39% had a gambling-related problem. On the other hand, 88% of the sample had experienced at least one life event in the past year, and those experiencing events tended to live in more disadvantaged neighborhoods. The mere acknowledgement of experiencing a stressful life event in the past year (yes/no) was not associated with an increase in odds of being a gambler, with gambling more frequently, or with having a gambling problem. However, when the context of the event was considered, an association was found between directly experiencing threatening and deviant/violent types of events and frequent gambling (OR > 2). Additionally, the probability of being a gambler increased as the number of events experienced increased (aOR = 1.07, 95% CI = 1.01, 1.13, P = 0.013), but problems among gamblers were not associated with the number of events experienced (aOR = 1.01, 95% CI = 0.92, 1.11, P = 0.876). During adolescence, life events appear to be connected more with the frequency of gambling rather than with problems related to gambling.

Experiential avoidance and the relationship between child maltreatment and PTSD symptoms: preliminary evidence

OBJECTIVE

Not every adolescent exposed to child maltreatment develops symptoms of post-traumatic stress disorder (PTSD), emphasizing the need to identify variables that explain how some maltreated children come to develop these symptoms. This study tested whether a set of variables, respiratory sinus arrhythmia (RSA) and cortisol reactivity as well as experiential avoidance, explained the relationship between child maltreatment and PTSD symptoms.

METHODS

Adolescent females (N=110; n=51 maltreated) 14-19 years of age completed interviews, questionnaires, and a stressor paradigm. A multiple mediator model was used to assess the effect for the set of variables while identifying specific indirect effects for each variable.

RESULTS

Results indicated that the set of variables mediated the relationship between child maltreatment and PTSD symptoms. However, only experiential avoidance contributed significantly to this effect when simultaneously estimating all other variables. The indirect effect for experiential avoidance was also significantly stronger than the effects of RSA and cortisol reactivity.

CONCLUSIONS

Data support the examination of experiential avoidance in understanding how adolescents who have been maltreated develop PTSD symptoms with implications for prevention and intervention.

Multiple traumas, postelection violence, and posttraumatic stress among impoverished Kenyan youth

Research on posttraumatic stress disorder (PTSD) among youth has focused on specific subgroups from developed countries. Most of the world's youth and war-like violence, however, is concentrated in developing countries, yet there is limited mental health data within affected countries. This study focused on a random community-based sample of 552 impoverished youth ages 6-18 within an informal settlement in Nairobi, Kenya, which experienced war-like violence for a month following the contested presidential election of 2007. Six months after the violence ended, 99 (18%) had PTSD according to the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004), and an additional 18 (3%) were found to have partial PTSD due to high overall scores. Kenyan psychologists conducted diagnostic interviews and found the positive predictive value of the assessment tool to be 72% in this sample; the confirmed prevalence was 12%. Similar to other studies worldwide, Criterion C (avoidance) was the limiting factor for diagnosing PTSD according to the DSM-IV-TR, and parent-child agreement was at best fair. The number of traumatic experiences was strongly associated with PTSD outcomes. Differences due to age or sex were not found. The findings indicate the need for universal mental health services for trauma-exposed youth and their families in the impoverished informal settlements of Nairobi, Kenya.

Traumatic event re-exposure in injecting drug users

Drug users have very high rates of lifetime exposure to traumatic events, leading to significant psychiatric complications. In spite of the high rate of lifetime exposure, very little is known about the rate of ongoing re-exposure to new traumatic events in drug users. We investigated the rate of traumatic event re-exposure in male and female injecting drug users using syringe exchange services in Baltimore (N = 197). Participants were assessed monthly for traumatic event re-exposure for 16 months. Averaged over the entire follow-up period, 27% of participants were re-exposed to a traumatic event each month and 72% were re-exposed over the 16-month study period. Women were over twice as likely to report any traumatic event re-exposure as men (adjusted odds ratio [AOR] = 2.48; 95% CI = 1.54-3.99), with the specific events of life-threatening illness, death of a loved one, and injury or illness of a loved one being more common in women than men. Traumatic event re-exposure occurs far more often than previously reported, with women injecting drug users at the highest risk. Reassessment of traumatic events may help to identify people most in need and encourage entry into treatment.

The impact of parental trauma exposure on community violence exposed adolescents

Previous research has documented an association between adolescent community violence (CV) exposure and poor psychological functioning. The purpose of this study was to delineate the relations of adolescent CV, parent trauma exposure (PTE), and adolescent internalizing and externalizing symptomatology while controlling for adolescent-reported home violence and parental self-reported posttraumatic stress disorder (PTSD). Participants consisted of 101 pairs of junior high school and high school students and their parents or caretakers. Adolescents completed measures to assess their history of violence exposure in the community and home setting and current internalizing symptoms. Parents or caretakers completed a demographic questionnaire, a measure assessing their trauma exposure and related symptomatology, and a measure of child externalizing symptoms. Hierarchical regression analyses were conducted; results indicated that after controlling for demographic variables, home violence exposure, and parental PTSD symptoms, PTE emerged as a moderator variable in the relationship between CV and adolescent-rated internalizing symptoms but not in the association between adolescent CV and externalizing symptoms.

How does the social environment 'get into the mind'? Epigenetics at the intersection of social and psychiatric epidemiology

The social environment plays a considerable role in determining major psychiatric disorders. Emerging evidence suggests that features of the social environment modify gene expression independently of the primary DNA sequence through epigenetic processes. Accordingly, dysfunction of epigenetic mechanisms offers a plausible mechanism by which an adverse social environment gets "into the mind" and results in poor mental health. The purpose of this review is to provide an overview of the studies suggesting that epigenetic changes introduced by the social environment then manifest as psychological consequences. Our goal is to build a platform to discuss the ways in which future epidemiologic studies may benefit from including epigenetic measures. We focus on schizophrenia, major depressive disorder, post-traumatic stress disorder, anorexia nervosa, and substance dependence as examples that highlight the ways in which social environmental exposures, mediated through epigenetic processes, affect mental health.

Cortisol suppression by dexamethasone reduces exaggerated fear responses in posttraumatic stress disorder

PTSD symptoms are associated with heightened fear responses in laboratory fear conditioning paradigms. This study examined the effects of dexamethasone administration on hypothalamic-pituitary-adrenal (HPA) function and fear-potentiated startle (FPS) in trauma-exposed individuals with and without PTSD. We used an established fear discrimination procedure, in which one visual stimulus (CS+, danger cue) was paired with aversive airblasts to the throat (unconditioned stimulus, US), and another stimulus (CS-, safety cue) was presented without airblasts. In addition to FPS, the dexamethasone suppression test (DST) was performed. The study sample (N=100) was recruited from a highly traumatized civilian population in Atlanta, GA. Half of the subjects (n=54, 16 PTSD, 38 controls) underwent conditioning at baseline and the other half (n=46, 17 PTSD, 29 controls) after DST, in a cross-sectional design. We found a significant interaction effect of diagnostic group and dexamethasone treatment. Under baseline conditions, subjects with PTSD showed more than twice as much fear-potentiated startle to the danger cue compared to traumatized controls, F(1,53)=8.08, p=0.006. However, there was no group difference in subjects tested after dexamethasone suppression. Furthermore, there was a significant treatment effect in PTSD subjects but not in controls, with dexamethasone reducing fear-potentiated startle to the CS+, F(1,32)=4.00, p=0.05. There was also a positive correlation between PTSD subjects' FPS and cortisol levels, r=0.46, p=0.01. These results suggest that transient suppression of HPA function via dexamethasone suppression may reduce exaggerated fear in patients with PTSD.

Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey

BACKGROUND

Prevalence rates of women in community samples who screened positive for meeting the DSM-IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two-stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP).

METHODS

In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS-SR. A total of 18 percent of women scored above the cutoff score on the PSS-SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health-promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well-being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ-2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey.

CONCLUSION

In this two-stage national survey the high percentage of mothers who screened positive for meeting all the DSM-IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic.

Posttraumatic stress disorder and alcohol dependence in young women

OBJECTIVE

The aim of the current study is to characterize the relationship between posttraumatic stress disorder (PTSD) and alcohol dependence (AD) in women, distinguishing PTSD-specific influences on AD from the contribution of co-occurring psychiatric conditions and from the influences of trauma more generally.

METHOD

Trauma histories and DSM-IV lifetime diagnoses, including PTSD and AD, were obtained via telephone interview from 3,768 female twins. Based on PTSD status and trauma history, participants were categorized as no trauma (43.7%), trauma without PTSD (52.6%), or trauma with PTSD (3.7%). Cox proportional hazards regression analyses were conducted using trauma/PTSD status to predict AD, first adjusting only for ethnicity and parental problem drinking, then including conduct disorder, major depressive disorder, regular smoking, and cannabis abuse.

RESULTS

Before accounting for psychiatric covariates, elevated rates of AD were evident in both trauma-exposed groups, but those with PTSD were at significantly greater risk for AD than those without PTSD. This distinction was no longer statistically significant when psychiatric covariates were included in the model, but both trauma-exposed groups continued to show elevated odds of developing AD compared with the no trauma group.

CONCLUSIONS

The elevated rates of AD in women who have experienced trauma are not accounted for in full by psychiatric conditions that commonly co-occur with AD and trauma exposure. The greater likelihood of developing AD in the subset of trauma-exposed individuals who develop PTSD may reflect higher levels of distress and/ or higher rates of psychopathology associated with traumas that lead to PTSD rather than PTSD-specific influences.

Psychometric properties of the Dutch Inventories of Prolonged Grief for Children and Adolescents

A significant minority of bereaved adults develops prolonged grief disorder (PGD), a syndrome encompassing debilitating symptoms of grief distinct from depression and anxiety. Few studies have examined the phenomenology and correlates of PGD among children and adolescents. In part, this is due to the lack of a psychometrically sound questionnaire to assess PGD symptoms in these groups. Based on an adult measure of PGD, we developed two questionnaires of PGD symptoms for children and adolescents named the Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A), respectively. Psychometric properties of these measures were examined in three samples, including mostly parentally bereaved children (aged 8-12 years, total sample n = 169) and adolescents (aged 13-18 years, total sample n = 153). First, findings showed that items of the IPG-C and IPG-A represented one underlying dimension. Second, the internal consistency and temporal stability of both questionnaires were adequate. Third, findings supported the concurrent validity (e.g., significant correlations with measures of depression and post-traumatic stress-disorder [PTSD]), convergent and divergent validity (stronger correlations with similar questionnaires of 'traumatic grief' than with two dissimilar questionnaires of 'ongoing presence' and 'positive memories') and incremental validity (significant correlations with an index of functional impairment, even when controlling for concomitant depression and PTSD) of the IPG-C and IPG-A. This report provides further evidence of the clinical significance of PGD symptoms among children and adolescents and promising psychometric properties of questionnaires that can be used to assess these symptoms.

KEY PRACTITIONER MESSAGE

The Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A) were developed to be able to assess symptoms of Prolonged Grief Disorder (PGD) among children and adolescents. In different samples, the internal consistency, temporal stability, and concurrent and construct validity of these questionnaires were found to be adequate. The IPG-C and the IPG-A can be used in research examining causes and consequences of PGD, and the effectiveness of bereavement interventions for children and adolescents. This study provides further evidence of the existence and clinical significance of PGD symptoms among children and adolescents and supports the inclusion of a new category for bereavement-related disorders in DSM-5.

Symptoms of posttraumatic stress disorder among urban residents

Previous studies indicate a high risk of Posttraumatic Stress Disorder (PTSD) among women and low-income, urban-residing African-Americans. This study examined PTSD symptoms among urban-residing, socioeconomically diverse, working-age African-Americans and whites. The participants completed the PTSD Checklist-Civilian Version. Of the 2104 participants, 268 (12.7%) were screened positive for PTSD symptoms. Women (13.8%) were more likely than men (11.3%), white participants (13.8%) were more likely than African-Americans (11.9%), and younger participants (16.1%) were more likely than older participants (10.2%) to screen positive for PTSD symptoms. A significant interaction (p = 0.05) revealed that white women living below the 125% poverty level were most likely to report PTSD symptoms. These findings highlight the importance of PTSD screening in low-income urban neighborhoods.

The urban environment and mental disorders: Epigenetic links

For the first time in human history, more than half of the world's population lives in urban areas and this is projected to increase to two-thirds by 2030. This increased urbanity of the world's population has substantial public health implications. Nearly a century of research has shown higher risk of mental disorder among persons living in urban versus rural areas. Epidemiologic research has documented that associations between particular features of the urban environment, such as concentrated disadvantage, residential segregation and social norms, contribute to the risk of mental illness. We propose that changes in DNA methylation may be one potential mechanism through which features of the urban environment contribute to psychopathology. Recent advances in animal models and human correlation studies suggest DNA methylation as a promising mechanism that can explain how the environment "gets under the skin." Aberrant DNA methylation signatures characterize mental disorders in community settings. Emerging evidence of associations between exposure to features of the environment and methylation patterns may lead toward the identification of mechanisms that explain the link between urban environments and mental disorders. Importantly, evidence that epigenetic changes are reversible offers new opportunities for ameliorating the impact of adverse urban environments on human health.

Impaired safety signal learning may be a biomarker of PTSD

A dysregulated fear response is one of the hallmark clinical presentations of patients suffering from posttraumatic stress disorder (PTSD). These patients show over-generalization of fear and in tandem an inability to inhibit fear responses in the presence of safety. Here, we summarize our recent findings using a conditional discrimination paradigm, which assesses safety signal processing (AX+/BX-) in combat and civilian PTSD populations. Overall, PTSD subjects demonstrate a lack of safety signal learning and an inability to modulate the fear responses with safety cues. We then review studies of the neurobiology of fear expression and inhibition in humans and non-humans, in order to provide a background for preliminary studies using reverse translation procedures in which the same AX+/BX- paradigm was used in rhesus macaques. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States

BACKGROUND

To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population.

METHOD

Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed.

RESULTS

The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%).

CONCLUSIONS

When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States

BACKGROUND

To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population.

METHOD

Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed.

RESULTS

The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%).

CONCLUSIONS

When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

Posttraumatic stress disorder is a risk factor for metabolic syndrome in an impoverished urban population

OBJECTIVE

Metabolic syndrome is associated with elevated risk for cardiovascular disease and diabetes and has increased prevalence in low-income African Americans, which constitutes a significant health disparity. The mechanisms responsible for this disparity remain unclear; the current study investigated the relationship between posttraumatic stress disorder (PTSD) and metabolic syndrome.

METHOD

We assessed childhood and adult trauma history, major depressive disorder, PTSD and the components of metabolic syndrome in an urban population. We recruited 245 low-socioeconomic-status, primarily African American subjects from general medical clinics in an inner-city hospital.

RESULTS

Trauma exposure was extremely prevalent, with 90.6% of subjects reporting at least one significant trauma and 18.8% of subjects meeting criteria for current PTSD. Metabolic syndrome was also prevalent in this population (33.2%), with significantly higher rates among patients with current PTSD (47.8%, P<.05). After controlling for demographics, smoking history, antipsychotic use, depression and exercise, current PTSD remained the only significant predictor of metabolic syndrome (P=.006).

CONCLUSIONS

PTSD is associated with increased rates of metabolic syndrome within a traumatized, impoverished urban population. Further studies should investigate if PTSD treatment may reduce the rates of metabolic syndrome, improve overall health outcomes and decrease health care disparities in minority populations.

Exposure to trauma: a comparison of cocaine-dependent cases and a community-matched sample

BACKGROUND

The purpose of this study was to examine rates of traumatic events and PTSD in cocaine-dependent cases and a community comparison sample.

METHODS

Participants were interviewed as part of the Family Study of Cocaine Dependence. A cross-sectional case-cohort design assessed a total of 918 participants: 459 cocaine-dependent cases recruited from chemical dependency treatment and 459 community-based participants. Community-based comparison participants were matched to cocaine-dependent cases on year of birth (within 1 year), ethnicity, gender, and neighborhood (zip code). Participants completed a personal interview modeled after the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA).

RESULTS

Compared to community-based individuals, cocaine-dependent cases recruited from treatment experienced higher rates of assaultive events including rape or sexual assault in women (58% vs. 33%) and threatened with a weapon in men (75% vs. 52%). Cocaine-dependent cases endured significantly more types of trauma than the community-based participants (4.64 vs. 3.08) and PTSD (22.4% and 12.2%). The number of traumatic exposures, witnessing trauma to others, experiencing violent trauma, and being female were predictive of conditional risk of PTSD, even after controlling for cocaine dependence and other demographic factors.

CONCLUSIONS

Cocaine dependence is strongly associated with an increased risk of exposure to traumatic events and PTSD, and experiencing multiple, violent traumas increases the risk of PTSD, regardless of cocaine dependence. The high prevalence of trauma seen in our community-based participants emphasizes the role of violence in the neighborhood and the connection between drug dependence, trauma exposure, and PTSD.

Tailoring therapeutic strategies for treating posttraumatic stress disorder symptom clusters

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, posttraumatic stress disorder (PTSD) is characterized by three major symptom clusters following an event that elicited fear, helplessness, or horror. This review will examine each symptom cluster of PTSD separately, giving case study examples of patients who exhibit a preponderance of a given symptom domain. We use a translational approach in describing the underlying neurobiology that is relevant to particular symptoms and treatment options, thus showing how clinical practice can benefit from current research. By focusing on symptom clusters, we provide a more specific view of individual patient's clinical presentations, in order to better address treatment needs. Finally, the review will also address potential genetic approaches to treatment as another form of individualized treatment.

Epigenetic and immune function profiles associated with posttraumatic stress disorder

The biologic underpinnings of posttraumatic stress disorder (PTSD) have not been fully elucidated. Previous work suggests that alterations in the immune system are characteristic of the disorder. Identifying the biologic mechanisms by which such alterations occur could provide fundamental insights into the etiology and treatment of PTSD. Here we identify specific epigenetic profiles underlying immune system changes associated with PTSD. Using blood samples (n = 100) obtained from an ongoing, prospective epidemiologic study in Detroit, the Detroit Neighborhood Health Study, we applied methylation microarrays to assay CpG sites from more than 14,000 genes among 23 PTSD-affected and 77 PTSD-unaffected individuals. We show that immune system functions are significantly overrepresented among the annotations associated with genes uniquely unmethylated among those with PTSD. We further demonstrate that genes whose methylation levels are significantly and negatively correlated with traumatic burden show a similar strong signal of immune function among the PTSD affected. The observed epigenetic variability in immune function by PTSD is corroborated using an independent biologic marker of immune response to infection, CMV-a typically latent herpesvirus whose activity was significantly higher among those with PTSD. This report of peripheral epigenomic and CMV profiles associated with mental illness suggests a biologic model of PTSD etiology in which an externally experienced traumatic event induces downstream alterations in immune function by reducing methylation levels of immune-related genes.

Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder

OBJECTIVES

We assessed sexual orientation disparities in exposure to violence and other potentially traumatic events and onset of posttraumatic stress disorder (PTSD) in a representative US sample.

METHODS

We used data from 34 653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions.

RESULTS

Lesbians and gay men, bisexuals, and heterosexuals who reported any same-sex sexual partners over their lifetime had greater risk of childhood maltreatment, interpersonal violence, trauma to a close friend or relative, and unexpected death of someone close than did heterosexuals with no same-sex attractions or partners. Risk of onset of PTSD was higher among lesbians and gays (adjusted odds ratio [AOR] = 2.03; 95% confidence interval [CI] = 1.34, 3.06), bisexuals (AOR = 2.13; 95% CI = 1.38, 3.29), and heterosexuals with any same-sex partners (AOR = 2.06; 95% CI = 1.54, 2.74) than it was among the heterosexual reference group. This higher risk was largely accounted for by sexual orientation minorities' greater exposure to violence, exposure to more potentially traumatic events, and earlier age of trauma exposure.

CONCLUSIONS

Profound sexual orientation disparities exist in risk of PTSD and in violence exposure, beginning in childhood. Our findings suggest there is an urgent need for public health interventions aimed at preventing violence against individuals with minority sexual orientations and providing follow-up care to cope with the sequelae of violent victimization.

A diagnostic interview for acute stress disorder for children and adolescents

The goal of this study was to develop a semistructured clinical interview for assessing acute stress disorder (ASD) in youth and test its psychometric properties. Youth (N = 168) with an acute burn or injury were administered the acute stress disorder module of the Diagnostic Interview for Children and Adolescents (DICA-ASD). The DICA-ASD demonstrated strong psychometric properties, including high internal consistency (alpha = .97) and perfect diagnostic interrater agreement (kappa = 1.00). Participants diagnosed with ASD scored significantly higher than those not diagnosed on validated traumatic stress symptomatology measures but not on other symptomatology measures, providing evidence of convergent and discriminant validity. Preliminary evidence supports the reliability and validity of the first semistructured clinical interview for diagnosing ASD in youth.

Childhood maltreatment, intervening variables, and adult psychological difficulties in women: an overview

This article reviews the complex relationship between child maltreatment and later psychosocial difficulties among adult women. Specifically addressed are (a) the various forms of childhood maltreatment, (b) the range of potential long-term psychological outcomes, and (c) important contextual variables that mediate or add to these maltreatment-symptom relationships. Among the latter are characteristics of the abuse and/or neglect; effects of impaired parental functioning; premaltreatment and postmaltreatment psychobiology; qualities of the parent-child attachment; abuse and/or neglect-related affect dysregulation that may lead to further symptomatology; the extent to which the child responds with significant emotional or behavioral avoidance; and whether later traumas are also present. Also relevant are sociocultural contributors to both child maltreatment and maltreatment effects, especially poverty and marginalization. Clinical and research implications are considered.

Epidemiology of child traumatic stress

In this article, we present an update on epidemiologic research that addresses the scope and impact of children's exposure to traumatic events in daily living, as well as under special circumstances, such as natural disasters. Toward this end, we provide an overview of the findings of key selected studies that estimate the prevalence of children's exposure to trauma and associated developmental, functional, mental, and physical health problems. Over the past few years, epidemiologic research on child traumatic stress has demonstrated that children's exposure to traumatic events is more common than once thought and that children exposed to multiple traumatic events are at a substantially greater risk for a wide range of adverse mental and physical health problems than children who have not suffered cumulative traumatic experiences. These findings have important implications for the provision of mental health and medical services to children and adolescents who have experienced child traumatic stress.

The epidemiology of trauma, PTSD, and other posttrauma disorders

Epidemiologic studies have reported that the majority of community residents in the United States have experienced posttraumatic stress disorder (PTSD)-level traumatic events, as defined in the DSM-IV. Only a small subset of trauma victims develops PTSD (<10%). Increased incidence of other disorders following trauma exposure occurs primarily among trauma victims with PTSD. Female victims of traumatic events are at higher risk for PTSD than male victims are. Direct evidence on the causes of the sex difference in the conditional risk of PTSD is unavailable. The available evidence suggests that the sex difference is not due to (a) the higher occurrence of sexual assault among females, (b) prior traumatic experiences, (c) preexisting depression or anxiety disorder, or (d) sex-related bias in reporting. Observed sex differences in anxiety, neuroticism, and depression, inducing effects of stressful experiences, might provide a theoretical context for further inquiry into the greater vulnerability of females to PTSD.

Pre-pubertal stress exposure affects adult behavioral response in association with changes in circulating corticosterone and brain-derived neurotrophic factor

Early-life stress produces a cascade of neurobiological events that cause enduring changes in neural plasticity and synaptic efficacy that appear to play pivotal roles in the pathophysiology of post-traumatic stress disorder (PTSD). Brain-derived neurotrophic factor (BDNF) has been implicated in the neurobiological mechanisms of these changes, in interaction with components of the stress response, such as corticosterone. This study examined the consequences of juvenile stress for behavior during adulthood in association with circulating corticosterone levels and BDNF expression. The experiments examined single exposure to predator scent stress (soiled cat litter for 10 min) as compared to repeated exposure, early in life and later on. Behavioral responses were assessed in the elevated plus maze and the acoustic startle response paradigms at 28, 60 and 90 days of age. Plasma corticosterone was measured and brain areas analyzed for BDNF levels. The results show that juvenile stress exposure increased anxiety-like behavior and startle amplitude and decreased plasma corticosterone. This response was seen immediately after exposure and also long term. Adult stress exposure increased anxiety-like behavior, startle amplitude and plasma corticosterone. Exposure to both early and later life trauma elicited reduced levels of corticosterone following the initial exposure, which were not raised by re-exposure, and elicited significant downregulation of BDNF mRNA and protein levels in the hippocampus CA1 subregion. The consequences of adult stress exposure were more severe in rats were exposed to the same stressor as juveniles, indicated increased vulnerability. The results suggest that juvenile stress has resounding effects in adulthood reflected in behavioral responses. The concomitant changes in BDNF and corticosterone levels may mediate the changes in neural plasticity and synaptic functioning underlying clinical manifestations of PTSD.

Early childhood behavior trajectories and the likelihood of experiencing a traumatic event and PTSD by young adulthood

This study modeled children's trajectories of teacher rated aggressive-disruptive behavior problems assessed at six time points between the ages of 6 and 11 and explored the likelihood of being exposed to DSM-IV qualifying traumatic events and posttraumatic stress disorder (PTSD) in 837 urban first graders (71% African American) followed-up for 15 years. Childhood trajectories of chronic high or increasing aggressive-disruptive behavior distinguished males more likely to be exposed to an assaultive violence event as compared to males with a constant course of low behavior problems (OR(chronic high) = 2.8, 95% CI = 1.3, 6.1 and OR(increasing) = 4.5, 95% CI = 2.3, 9.1, respectively). Among females, exposure to traumatic events and vulnerability to PTSD did not vary by behavioral trajectory. The findings illustrate that repeated assessments of disruptive classroom behavior during early school years identifies more fully males at increased risk for PTSD-level traumatic events, than a single measure at school entry does.

Modification of the association between serotonin transporter genotype and risk of posttraumatic stress disorder in adults by county-level social environment

Although both genetic factors and features of the social environment are important predictors of posttraumatic stress disorder (PTSD), there are few data examining gene-social environment interactions in studies of PTSD. The authors examined whether features of the social environment (county-level crime rate and unemployment) modified the association between the serotonin protein gene (SLC6A4) promoter variant (5-HTTLPR) and risk of current PTSD in a sample of 590 participants from the 2004 Florida Hurricane Study. Interviews conducted in 2005 were used to obtain individual-level risk factor measures and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PTSD diagnoses. DNA was extracted from salivary samples. County-level crime and unemployment rates were assessed from Federal Bureau of Investigation and US Census data, respectively. There was a significant interaction between 5-HTTLPR genotype and both crime rate (odds ratio = 2.68, 95% confidence interval: 1.09, 6.57) and unemployment rate (odds ratio = 3.67, 95% confidence interval: 1.42, 9.50) in logistic regression models predicting PTSD risk, after adjustment for individual-level determinants of PTSD. Stratified analyses indicated that the "s" allele of the 5-HTTLPR polymorphism was associated with decreased risk of PTSD in low-risk environments (low crime/unemployment rates) but increased risk of PTSD in high-risk environments. These results suggest that social environment modifies the effect of 5-HTTLPR genotype on PTSD risk.

An evidence-based review of the clinical use of sertraline in mood and anxiety disorders

Sertraline is a selective serotonin reuptake inhibitor that has been used and studied extensively throughout the world and found to be safe and well tolerated in numerous patient populations, including those with either psychiatric and/or medical comorbidities. Randomized clinical trials have shown that it is an effective treatment for depressive and anxiety disorders and its efficacy is unaffected by psychiatric comorbidity. In non-comorbid patients, sertraline is effective for the acute treatment of major depressive disorders and prevention of relapse or recurrence. It is effective for acute treatment and longer-term management of social anxiety disorder, posttraumatic stress disorder,panic disorder, and generalized anxiety disorder. In adults and in pediatric patients, it is an effective short-term and long-term treatment for obsessive compulsive disorder.Sertraline has a good tolerability profile and has low fatal toxicity. In summary, sertraline is as effective as other antidepressants over a wide range of indications but may offer tolerability benefits as well as efficacy in patients with psychiatric and/or medical comorbidities and certain subtypes of depression.

Accumulation of trauma over time and risk for depression in a twin sample

BACKGROUND

Few genetically informative studies have examined the effects of different types of trauma on risk for depression over time. The aim of the present study was to examine the relative contributions over time of assaultive trauma, non-assaultive trauma, and familial effects to risk for depression.

METHOD

Histories of depression and trauma were obtained during structured diagnostic interviews with 5266 (mean age 29.9 years, s.d.=2.4) members of a volunteer Australian twin panel from the general population. Age at first onset of a DSM-IV major depressive episode was the dependent variable. Associations of depression with traumatic events were examined while accounting for the temporal sequence of trauma and depression and familial effects.

RESULTS

Assaultive traumatic events that occurred during childhood had the strongest association with immediate and long-term risk for depression, and outweighed familial effects on childhood-onset depression for most twins. Although men and women endorsed equal rates of assaultive trauma, women reported a greater accumulation of assaultive events at earlier ages than men, whereas men reported a greater accumulation of non-assaultive events at all ages.

CONCLUSIONS

Early exposure to assaultive trauma can influence risk for depression into adulthood. Concordance for early trauma is a significant contributor to the familiality of early-onset depression.

Posttraumatic stress disorder and suicide attempts in a community sample of urban american young adults

CONTEXT

Previous research has shown that exposure to traumatic events, especially sexual trauma during childhood, is associated with an increased risk of attempted suicide. However, no information is available as to whether the increased risk of attempted suicide is related primarily to posttraumatic stress disorder (PTSD) following traumatic experiences or applies also to persons who experienced trauma but did not develop PTSD.

OBJECTIVE

We examine the association between exposure to traumatic events with and without resulting PTSD and the risk of a subsequent suicide attempt in a community sample of urban young adults.

DESIGN

A cohort study followed young adults who had participated in a randomized trial of all first-grade students entering 19 public schools.

SETTING

Baltimore, Maryland, an urban setting.

PARTICIPANTS

A total of 1698 young adults (mean age, 21; 47% male; 71% African American) who represented 75% of the original cohort of 2311 persons.

MAIN OUTCOME MEASURE

Relative risk of a subsequent suicide attempt associated with PTSD and with exposure to assaultive and non-assaultive traumas (no PTSD), as estimated using discrete time survival analysis.

RESULTS

Posttraumatic stress disorder was associated with increased risk of a subsequent suicide attempt. The PTSD-suicide attempt association was robust, even after adjustment for a prior major depressive episode, alcohol abuse or dependence, and drug abuse or dependence (adjusted relative risk, 2.7; 95% confidence interval, 1.3-5.5; P < .01). In contrast, exposure to traumatic events without PTSD was not associated with an increased risk of attempted suicide.

CONCLUSIONS

Posttraumatic stress disorder is an independent predictor of attempted suicide. Exposure to traumatic events without PTSD is not associated with a later suicide attempt.

Trauma exposure and stress-related disorders in inner city primary care patients

OBJECTIVE

This study was undertaken to increase understanding of environmental risk factors for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) within an urban, impoverished, population.

METHOD

This study examined the demographic characteristics, patterns of trauma exposure, prevalence of PTSD and MDD, and predictors of posttraumatic stress and depressive symptomatology using a verbally presented survey and structured clinical interviews administered to low-income, primarily African-American (>93%) women and men seeking care in the primary care and obstetrics-gynecology clinics of an urban public hospital.

RESULTS

Of the sample, 87.8% (n=1256) reported some form of significant trauma in their lifetime. Accidents were the most common form of trauma exposure followed by interpersonal violence and sexual assault. Childhood level of trauma and adult level of trauma separately, and in combination, predicted level of adult PTSD and depressive symptomatology. The lifetime prevalence of PTSD was 46.2% and the lifetime prevalence of MDD was 36.7%.

CONCLUSIONS

These data document high levels of childhood and adult trauma exposure, principally interpersonal violence, in a large sample of an inner-city primary care population. Within this group of subjects, PTSD and depression are highly prevalent conditions.

The potential for PTSD, substance use, and HIV risk behavior among adolescents exposed to Hurricane Katrina

Adverse psychosocial outcomes can be anticipated among youth exposed to Hurricane Katrina. Adolescents are particularly vulnerable to the consequences of this natural disaster and may suffer lasting consequences in the form of psychological morbidity and the development of negative health behaviors due to their exposure. We review existing literature on the effects of exposure to natural disasters and similar traumas on youth and, where data on youth are unavailable, on adults. The effect of natural disasters is discussed in terms of risk for three negative health outcomes that are of particular concern due to their potential to cause long-term morbidity: post-traumatic stress disorder, substance use disorder, and HIV-risk behavior. Where available, data from studies of the effects of Hurricane Katrina are included.

Physician-reported practice of managing childhood posttraumatic stress in pediatric primary care

OBJECTIVE

This study investigated pediatrician-reported practices in identifying, assessing, and treating traumatic exposure and posttraumatic stress disorder (PTSD) in children.

METHOD

Focus groups guided the development of a survey that was mailed to primary care pediatricians in Massachusetts in 2005. Descriptive statistics and multivariate analyses were used to describe clinical practices and perceived barriers to care.

RESULTS

A 60% (N=597) survey response-rate was obtained. On average, pediatricians reported that less than 8% of patients had psychological problems that may be related to traumatic exposure. Only 18% of pediatricians agreed that they had adequate knowledge of childhood PTSD. About 15% of pediatricians reported frequently learning about traumatic event(s) from direct inquiry in the past year. Only 10% of pediatricians reported frequent assessment and treatment of posttraumatic stress symptoms. Most pediatricians (72%) agreed that greater collaborations with mental health providers would improve pediatric assessment of PTSD. Finally, having received PTSD-specific training and believing that pediatricians should identify and manage PTSD were each significantly associated with learning about a traumatic event from direct inquiry.

CONCLUSION(S)

Providing PTSD-specific training and changing pediatricians' attitudes about childhood PTSD may be useful first steps in improving care for children.

Traumatic events and suicide-related outcomes among Mexico City adolescents

BACKGROUND

We report the prevalence and associations between traumatic events and suicidal ideation, suicide plans and suicide attempts among Mexican adolescents.

METHODS

The data are from a representative multistage probability household survey of 3,005 adolescents aged 12 to 17 years residing in the Mexico City Metropolitan Area that was carried out in 2005. We used discrete time survival analyses to model the net impact of retrospectively reported prior occurrence of traumatic events on ideation, plans and attempts, taking into account the onset of psychiatric disorders.

RESULTS

Prevalence of suicidality was high among respondents with traumatic events, ranging from a 43% prevalence of suicidal ideation among those with a history of 'Being raped' to a 25% prevalence of suicide attempts among those that reported 'Purposely injured, tortured or killed someone.' In cross-sectional estimates, any traumatic event was associated with an increase of 3.2 times the odds of suicide ideation, 5.1 times the odds of a plan and 6.6 times the odds of an attempt. Number of events was also associated with increasing suicidality such that those with three or more events were 13.7 times more likely to report a suicide attempt than those with none. Multivariate discrete time survival models that took into account a large number of demographic, suicide-related and psychiatric disorder variables reduced in strength but did not alter these basic relationships.

CONCLUSIONS

We conclude that traumatic events such as rape and sexual assault have a profound impact upon suicidality and that this relationship is not entirely explained by the onset of psychiatric disorders. Comprehensive interventions for adolescent victims of traumatic events, especially those with a history of cumulative events, should include, but not be restricted to, treatment of any associated psychiatric disorder.

The latent structure of post-traumatic stress disorder: tests of invariance by gender and trauma type

BACKGROUND

Measurement invariance of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) post-traumatic stress disorder (PTSD) criterion symptoms was tested by gender and trauma type, assaultive and non-assaultive.

METHOD

Analysis was conducted using latent class analysis (LCA), based on findings that the three-class LCA model from Breslau et al. (Archives of General Psychiatry 2005, 62, 1343-1351) fits the data across the four groups best. The classes represent three levels of PTSD-related disturbance: no disturbance, intermediate disturbance and pervasive disturbance, with the last one approximating the DSM-IV PTSD diagnosis.

RESULTS

Analysis of measurement invariance showed that, with respect to gender, there was no evidence of differential symptom reporting within the same disturbance class. DSM-IV symptom indicators represent the latent structure of PTSD equally in males and females. We found that more female than male victims of assaultive violence experienced pervasive disturbance. In the absence of measurement variability associated with gender, the finding is likely to reflect a gender difference in susceptibility. The analysis of measurement invariance detected evidence of variability associated with trauma type. Victims of assaultive violence in the pervasive disturbance class report more severe distress (especially emotional numbing) than do victims of non-assaultive violence in the same class.

CONCLUSIONS

The finding of measurement bias associated with type of trauma raises questions about the applicability of a single definition for PTSD associated with assaultive violence and PTSD associated with traumatic events of lesser magnitude.

Asthma severity and PTSD symptoms among inner city children: a pilot study

Although the association between posttraumatic stress symptoms and asthma severity among children has been hypothesized, it has yet to be explored rigorously. This study sought to describe the posttraumatic stress symptoms of children with asthma and explore the relationship between asthma severity and posttraumatic stress symptoms in an inner city sample with high rates of traumatic exposures. Children aged 7 to 17 years, with a clinician-defined asthma diagnosis, were recruited from an inner city outpatient asthma clinic. Caregivers completed measures assessing the child's asthma and posttraumatic stress symptoms and health care utilization. Children also completed measures of asthma, posttraumatic stress symptoms, and asthma-related quality of life. In all, 24 children-caregiver dyads were enrolled. The sample was 79% male and 83% African American, and the mean age was 11 years. Overall the sample had severe asthma, with 33% having been hospitalized over the past year. In addition, 25% of the sample met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for the diagnosis of posttraumatic stress disorder, and 74% of the sample experienced a traumatic event. Posttraumatic stress disorder symptoms were found to be significantly related to asthma severity, quality of life, and health care utilization. Assessing for and treating posttraumatic stress symptoms among children with severe asthma may help to improve their asthma course and quality of life. Further research should explore this relationship and related treatment implications.

Childhood traumatic grief: a multi-site empirical examination of the construct and its correlates

This study evaluated the construct of childhood traumatic grief (CTG) and its correlates through a multi-site assessment of 132 bereaved children and adolescents. Youth completed a new measure of the characteristics, attributions, and reactions to exposure to death (CARED), as well as measures of CTG, posttraumatic stress disorder (PTSD), depression, and anger. CTG was distinct from but highly correlated with PTSD, depression, and, to a lesser degree, anger. In contrast to a recent study of complicated grief, CTG severity was significantly associated with the degree to which the death was viewed as traumatic. CTG was also associated with caregivers' emotional reaction at the time of the death and caregivers' current sadness. Clinical implications and recommendations for future research are discussed.

The clinical significance criterion in DSM-IV post-traumatic stress disorder

BACKGROUND

The DSM-IV definition of post-traumatic stress disorder (PTSD) requires that the syndrome cause clinically significant distress or impairment. The impact of the clinical significance criterion on the lifetime prevalence of PTSD among civilian victims of traumatic events has not been evaluated.

METHOD

Data from two community-based samples were examined, the 1996 Detroit Area Survey of Trauma (n=2181) and the Mid-Atlantic Urban Youth Study (n=1698). The World Health Organization Composite International Diagnostic Interview (WHO CIDI) was used to ascertain DSM-IV PTSD.

RESULTS

The inclusion of the clinical significance criterion in DSM-IV reduces the conditional probability of PTSD given exposure to trauma by approximately 30%. Cases with clinically significant syndrome showed more pervasive and persistent disturbance and an excess in impaired activity days.

CONCLUSIONS

The consistency of the findings between the two studies strengthens the evidence on the impact of the clinical significance criterion in the diagnosis of PTSD, and the construct validity of its measurement. There is a need for greater research effort on the definition and measurement of the clinical significance criterion.

Long-lasting behavioral effects of juvenile trauma in an animal model of PTSD associated with a failure of the autonomic nervous system to recover

BACKGROUND

Early life exposure to potentially traumatic experiences (PTEs) significantly increases the risk of responding more severely to stressful events experienced in adulthood. The aim of this study was to assess the autonomic nervous system (ANS) response to exposure to two PTEs in youth and again in adulthood, in terms of heart rate and heart rate variability in animals that responded to the PTE dramatically as compared to those that displayed virtually no behavioral response and to control animals.

METHODS

The prevalence of individuals displaying extreme anxiety-like behavioral responses to the PTE (predator urine or elevated platform) was assessed in the elevated plus-maze and startle response paradigms. Behavioral paradigms were complemented by assessment of the involvement of the ANS in relation to changes in behavior.

RESULTS

Juvenile trauma increases the vulnerability for developing long-term behavioral disruptions, taken to represent post-traumatic stress symptoms, after a second exposure to the same stressor in adulthood. PTSD-like behaviors and persisting physiological abnormalities resulted from disturbed recovery from the initial stress response.

CONCLUSIONS

Exposure to a PTE during youth can have significant and long-lasting effects in adulthood and predispose the individual to PTSD upon subsequent re-exposure. Monitoring of ANS parameters confirms that development of extreme long-term (PTSD-like) behavioral changes is associated with a failure of recovery from the initial ANS responses to stress exposure.

Phenomenology and correlates of complicated grief in children and adolescents

OBJECTIVE

To describe the phenomenology of complicated grief (CG) in parentally bereaved children and adolescents and to examine its correlates.

METHOD

This is a preliminary report from an ongoing 5-year, population-based, longitudinal study of the impact of parental loss on family members. Analyses of cross-sectional data at intake are presented. The sample consists of 129 children and adolescents of parents who died by suicide, accident, or sudden natural death. Their average age is 13.3 +/- 3.1 years (range 7-18 years). A modified version of the Inventory of Complicated Grief-Revised (ICG-R) was administered and its factor structure, internal consistency, and convergent and discriminant validity were examined.

RESULTS

CG was significantly related to functional impairment even after controlling for current depression, anxiety, and posttraumatic stress disorder. CG was also associated with other measures of psychopathology, including suicidal ideation.

CONCLUSIONS

In this preliminary analysis, CG appears to be a clinically significant syndrome in children and adolescents. Longitudinal data will help to clarify the prognostic significance of CG as well as to examine the interrelationship of CG and other psychopathology over time.

New York City young adults' psychological reactions to 9/11: findings from the Reach for Health longitudinal study

This research examines psychological distress among 955 economically disadvantaged New York City residents surveyed during high school and again after the September 11th terrorist attacks (9/11), when they were young adults. As part of the longitudinal Reach for Health study, young adult surveys were conducted from 6-19 months post-9/11 (average 8 months), providing opportunity to assess types of exposures and psychological distress, including symptoms of post-traumatic stress disorder (PTSD), depression, hopelessness, and anger. Regressions of psychological distress on 9/11 exposure were performed, controlling for high school distress, prior exposure to violence victimization, and socio-demographic characteristics. Exposure to 9/11 was positively associated with anger, hopelessness, and PTSD symptoms and a measure of global distress. The relationship was greater among women for PTSD symptoms. Although those who reported high school distress also reported more distress in young adulthood, prior psychological distress did not moderate the relationship between exposure and psychological outcomes. Greater exposure is related to distress among those who, during high school, reported lower distress, as well as among those who reported prior greater distress.

Longitudinal studies of PTSD: overview of findings and methods

Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.

Psychiatric and physical health ramifications of traumatic events in women

All individuals are at some risk of experiencing a traumatic event and developing posttraumatic stress disorder (PTSD); however some individuals are at higher risk due to individual and environmental factors. This critical literature review focuses on women, as they are twice as likely as men to develop PTSD in their lifetimes. Should a woman develop PTSD, she is then at risk of developing psychiatric and physical health comorbidities that can further impact her quality of life. The strengths and limitations of current studies regarding this topic are discussed as are directions for future research and issues for nurses treating traumatized individuals.