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

Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child

OBJECTIVE

To study posttraumatic stress disorder (PTSD) in parents after unexpected pediatric intensive care unit (PICU) treatment of their child and to identify risk factors for its development.

METHOD

Parents completed PTSD questionnaires 3 and 9 months (N = 190) after PICU treatment. Risk factors included pretrauma data, medical data, social demographics and posttraumatic stress responses at 3 months.

RESULTS

In total, 30.3% of parents met criteria for subclinical PTSD and 12.6% for clinical PTSD at 3 months. Clinical PTSD prevalence rates did not change over time. At 9 months, 10.5% of parents still met criteria for PTSD. Number of earlier stressful life events, earlier psychosocial care and posttraumatic stress responses at 3 months predicted persistent subclinical and clinical PTSD.

CONCLUSIONS

PICU admission is a stressful event associated with persistent parental PTSD. Assessment of risk factors can facilitate detection of persistent PTSD for early intervention.

Biologic correlates to the development of post-traumatic stress disorder in female victims of intimate partner violence: implications for practice

PURPOSE

The purpose of this article is to discuss the current literature about the risk of post-traumatic stress disorder (PTSD) in victims of intimate partner violence (IPV).

CONCLUSIONS

PTSD is a complex and serious syndrome with emotional symptoms, psychiatric symptoms, and physical consequences. PTSD is associated with impaired immune function, obesity, increased risk of diabetes, increased severity of premenstrual syndrome symptoms, depression, suicide, and increased likelihood of re-abuse. Female victims of IPV develop PTSD and related consequences at a rate of 74-92%, compared to 6-13% in non-abused women.

PRACTICE IMPLICATIONS

Advanced practice nurses (APNs) are likely to see one or both of these problems in their practices. The vague, nonspecific symptoms can present challenges to APNs. Biologic correlates are identified to help the APNs identify those most at risk of developing PTSD. Treatment options are discussed.

Identification and measurement of work-related psychological injury: piloting the psychological injury risk indicator among frontline police

OBJECTIVE

To develop a self-report measure of work-related psychological injury, the Psychological Injury Risk Indicator (PIRI), with a comparable level of accuracy and reliability to individual clinical assessment by a skilled clinical psychologist.

METHOD

Two pilot studies investigated the responses of a) 34 frontline police officers completing the PIRI measure who were also examined by a highly experienced clinical psychologist and b) 217 officers who completed the PIRI measure and also the General Health Questionnaire 12 measure.

RESULTS

The PIRI scale identified both the presence and the level of psychological injury in the clinical group with a remarkably high level of correspondence to concurrent clinical assessment (r = 0.80).

SIGNIFICANCE

The PIRI scale can be used both for the individual assessment of psychological injury and as a potential online screening tool. Its latter use is that it could enable the early identification of evolving psychological injury among workers, facilitating timely and career-preserving intervention.

Post-traumatic stress disorder: emerging concepts of pharmacotherapy

Post-traumatic stress disorder (PTSD) can result from a traumatic experience that elicits emotions of fear, helpless or horror. Most individuals remain asymptomatic or symptoms quickly resolve, but in a minority intrusive imagery and nightmares, emotional numbing and avoidance, and hyperarousal persist for decades. PTSD is associated with psychiatric and medical co-morbidities, increased risk for suicide, and with poor social and occupational functioning. Psychotherapy and pharmacotherapy are common treatments. Whereas, research supports the efficacy of the cognitive behavioral psychotherapies, there is insufficient evidence to unequivocally support the efficacy of any specific pharmacotherapy. Proven effective pharmacologic agents are sorely needed to treat core and targeted PTSD symptoms, and for prevention. This review describes current and emerging pharmacotherapies that advance these goals.

An open-label study of mirtazapine as treatment for combat-related PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among war veterans. Antidepressants are effective in reducing symptoms and associated disability for some patients.

OBJECTIVE

To assess the effectiveness of mirtazapine for combat-related PTSD among veterans treated in an Australian hospital.

METHODS

This open-label prospective study assessed the effectiveness of mirtazapine as empirical treatment for combat-related PTSD. The initial dose was 15 mg at night, titrated against response to 15-45 mg. PTSD symptoms were assessed using the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Clinician-Administered PTSD Scale (CAPS). Subjects also completed the Hospital Anxiety and Depression Scale (HADS). Body weight and biochemical assessments, including fasting blood glucose (FBG), total serum cholesterol, and serum triglycerides, were also measured. Baseline measurements were repeated after 12 weeks.

RESULTS

During the 18-month recruitment phase, 17 subjects were enrolled and 13 completed the protocol. The CAPS measurement decreased from a mean pretreatment score of 87.5 to 64.4 (p = 0.01). In 4 cases, the CAPS score decreased to below the diagnostic cut-point, consistent with a remission of PTSD. The Mississippi scale measurement decreased from a mean pretreatment score of 126.6 to 115.5 (p < 0.01). The mean HADS anxiety score decreased from 15.6 +/- 4.2 to 13.5 +/- 5.6 (p = 0.016), although the proportion of subjects with scores above the diagnostic cut-point remained high. The mean HADS depression score at baseline was not significantly different from the postintervention score. One subject had a postintervention FBG of 155 mg/dL (consistent with diabetes mellitus), which was increased from the baseline level of 83 mg/dL. All subjects experienced an increase in body weight. One subject had an increase in body weight of 8.75 kg (8.4%) from baseline.

CONCLUSIONS

Although small and with methodological limitations, this study suggests that mirtazapine is an effective treatment for combat-related PTSD. Additional research incorporating an appropriately powered, double-blind, placebo-controlled study design is required.

Measurement of problems in activities and participation in patients with anxiety, depression and schizophrenia using the ICF checklist

BACKGROUND

Although disability in persons with anxiety and depression disorders has been measured, the problem with some studies is that they use tools that measure the state of health, when the subjective nature of the measuring system does not permit the exact measurement of disability. The ICF Checklist provides a new paradigm for measuring disability that focuses more on the consequences than on the illness itself. The objective of this study is to compare the problems in Activities and Participation observed in patients with anxiety, depressive, and schizophrenic disorders, using the ICF Checklist.

METHODS

The ICF Checklist was administered to 72 patients with anxiety or depressive disorders and 28 patients with schizophrenia. They were diagnosed in accordance with the criteria of the ICD-10. Chi-square analysis was carried out to determine the differences between the groups studied with respect to the Activities and Participation scales of the ICF Checklist and the nominal data of the socio-demographic variables.

RESULTS

The group with anxiety-depression had a higher percentage of patients with problems preparing meals (30.6%) and achieving intimate relationships (59.7%) than did the patients with schizophrenia. The group with schizophrenia had a higher percentage of patients who had problems watching (39.3%), listening (42.9%), undertaking a single task (60.7%), communicating, fine hand use (57.1%), using transportation (64.3%), and caring for body parts (67.9%), among others.

CONCLUSIONS

The ICF Checklist permits comparison of the impact mental disorders have on patients. It provides a more appropriate way of evaluating these illnesses in relation to others, considering not only the question of mortality but also the years lived with disability due to illness.

Post-traumatic stress disorder in Canada

Post-traumatic stress disorder (PTSD) has become a global health issue, with prevalence rates ranging from 1.3% to 37.4%. As there is little current data on PTSD in Canada, an epidemiological study was conducted examining PTSD and related comorbid conditions. Modified versions of the Composite International Diagnostic Interview (CIDI) PTSD module, the depression, alcohol and substance abuse sections of the Mini International Neuropsychiatric Interview (MINI), as well as portions of the Childhood Trauma Questionnaire (CTQ) were combined, and administered via telephone interview in English or French. Random digit dialing was used to obtain a nationally representative sample of 2991, aged 18 years and above from across Canada. The prevalence rate of lifetime PTSD in Canada was estimated to be 9.2%, with a rate of current (1-month) PTSD of 2.4%. Traumatic exposure to at least one event sufficient to cause PTSD was reported by 76.1% of respondents. The most common forms of trauma resulting in PTSD included unexpected death of a loved one, sexual assault, and seeing someone badly injured or killed. In respondents meeting criteria for PTSD, the symptoms were chronic in nature, and associated with significant impairment and high rates of comorbidity. PTSD is a common psychiatric disorder in Canada. The results are surprising, given the comparably low rates of violent crime, a small military and few natural disasters. Potential implications of these findings are discussed.

Symptoms of posttraumatic stress disorder and mental health in women who escaped prostitution and helping activists in shelters

PURPOSE

This study compared the mental symptoms, especially symptoms of posttraumatic stress disorder (PTSD), of women who escaped prostitution, helping activists at shelters, and matched control subjects.

MATERIALS AND METHODS

We assessed 113 female ex-prostitutes who had been living at a shelter, 81 helping activists, and 65 control subjects using self-reporting questionnaires on demographic data, symptoms related to trauma and PTSD, stress-related reactions, and other mental health factors.

RESULTS

Female ex-prostitutes had significantly higher stress response, somatization, depression, fatigue, frustration, sleep, smoking and alcohol problems, and more frequent and serious PTSD symptoms than the other 2 groups. Helping activists also had significantly higher tension, sleep and smoking problems, and more frequent and serious PTSD symptoms than control subjects.

CONCLUSION

These findings show that engagement in prostitution may increase the risks of exposure to violence, which may psychologically traumatize not only the prostitutes themselves but also the people who help them, and that the effects of the trauma last for a long time. Future research is needed to develop a method to assess specific factors that may contribute to vicarious trauma of prostitution, and protect field workers of prostitute victims from vicarious trauma.

Post-traumatic stress disorder following disasters: a systematic review

BACKGROUND

Disasters are traumatic events that may result in a wide range of mental and physical health consequences. Post-traumatic stress disorder (PTSD) is probably the most commonly studied post-disaster psychiatric disorder. This review aimed to systematically assess the evidence about PTSD following exposure to disasters. MethodA systematic search was performed. Eligible studies for this review included reports based on the DSM criteria of PTSD symptoms. The time-frame for inclusion of reports in this review is from 1980 (when PTSD was first introduced in DSM-III) and February 2007 when the literature search for this examination was terminated.

RESULTS

We identified 284 reports of PTSD following disasters published in peer-reviewed journals since 1980. We categorized them according to the following classification: (1) human-made disasters (n=90), (2) technological disasters (n=65), and (3) natural disasters (n=116). Since some studies reported on findings from mixed samples (e.g. survivors of flooding and chemical contamination) we grouped these studies together (n=13).

CONCLUSIONS

The body of research conducted after disasters in the past three decades suggests that the burden of PTSD among persons exposed to disasters is substantial. Post-disaster PTSD is associated with a range of correlates including sociodemographic and background factors, event exposure characteristics, social support factors and personality traits. Relatively few studies have employed longitudinal assessments enabling documentation of the course of PTSD. Methodological limitations and future directions for research in this field are discussed.

Differences in the response to the combined DEX-CRH test between PTSD patients with and without co-morbid depressive disorder

BACKGROUND

Neuroendocrine studies have shown profound alterations in HPA-axis regulation in posttraumatic stress disorder (PTSD). Based on baseline assessments and the response to dexamethasone, a hypothalamic overdrive with enhanced glucocorticoid feedback inhibition has been suggested. The dexamethasone-corticotrophin releasing hormone (DEX-CRH) test has shown to be a more sensitive test to assess HPA-axis dysregulation in major depression and therefore may provide a useful test tool to probe HPA-axis regulation in PTSD.

METHODS

To evaluate the effect of PTSD on HPA-axis regulation, we compared the response to a DEX-CRH test between male veterans with PTSD (n=26) and male veterans, who had been exposed to similar traumatic events during their deployment, without PTSD (n=23). Patients and controls were matched on age, year and region of deployment. Additionally, we compared the response of PTSD patients with (n=13) and without co-morbid major depressive disorder (MDD) (n=13).

RESULTS

No significant differences were observed in ACTH and cortisol response to the DEX-CRH test between patients and controls. PTSD patients with co-morbid MDD showed a significantly lower ACTH response compared to patients without co-morbid MDD. The response to the DEX-CRH test did not correlate with PTSD or depressive symptoms.

CONCLUSION

The DEX-CRH test did not reveal HPA-axis abnormalities in PTSD patients as compared to trauma controls. PTSD patients with a co-morbid MDD showed an attenuated ACTH response compared to PTSD patients without co-morbid MDD, suggesting the presence of subgroups with different HPA-axis regulation within the PTSD group. Altered sensitivity of the CRH receptors at the pituitary or differences in AVP secretion might explain these differences in response.

Longitudinal determinants of posttraumatic stress in a population-based cohort study

BACKGROUND

Posttraumatic stress disorder is a prevalent and disabling psychologic pathology. Longitudinal research on the predictors of posttraumatic stress symptomatology is limited.

METHODS

We recruited 2752 participants to a prospective, population-based cohort study by conducting a telephone survey of adult residents of the New York City metropolitan area in 2002; participants completed 3 follow-up interviews over a 30-month period. Censoring weights were estimated to account for potential bias. We used generalized estimating equation logistic regression models with bootstrapped confidence intervals to assess the predictors of posttraumatic stress over time in multivariable models.

RESULTS

Predictors of posttraumatic stress over time included ongoing stressors (odds ratio [OR] = 1.91 per 1 unit increase in number of stressors, [95% confidence interval = 1.55-2.36]) and traumatic events (OR = 1.92 per 1 unit increase in number of traumatic events [CI = 1.71-2.22]), social support (compared with high levels, OR = 1.71 for medium [1.09-2.52]; OR = 1.57 for low [1.08-2.35]), low income (OR = 0.87 per $10,000 increase [0.81-0.92]), female sex (1.60 [1.11-2.23]), and Latino ethnicity (compared with white, OR = 1.74 [1.05-2.97]).

CONCLUSIONS

These findings suggest that ongoing stressors play a central role in explaining the trajectory of posttraumatic stress over time, and that factors beyond the experience of stressors and traumas may account for sex and ethnic differences in posttraumatic stress risk. Interventions that focus on reducing ongoing adversity may help mitigate the consequences of traumatic events.

Elevated plasma arginine vasopressin levels in veterans with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with altered hypothalamic-pituitary-adrenal (HPA) axis functioning. Arginine vasopressin (AVP), in conjunction with corticotrophin releasing hormone, has shown to be an important modulator of the HPA axis. In order to evaluate the effect of trauma and PTSD on central AVP secretion we assessed plasma AVP levels in equally trauma exposed veterans with and without PTSD and a non-traumatized healthy control group.

METHODS

Assessment of plasma AVP in 29 male veterans with PTSD, 29 traumatized veterans without PTSD, matched for age, gender, year and region of deployment (trauma controls), and 26 age matched healthy controls.

RESULTS

Plasma AVP levels were higher in PTSD patients compared to both healthy controls (p = 0.004) and trauma controls (p < 0.001). In PTSD patients without a comorbid MDD a significant correlation was observed between plasma AVP levels and symptoms of avoidance measured with the Clinician Administered PTSD Scale (CAPS).

CONCLUSION

Elevated plasma AVP levels are specifically related to PTSD and not to exposure to traumatic stress during deployment. Our results indicate that AVP may play a role as an anxiogenic factor, but they do not support a role for AVP in the altered response to dexamethasone in PTSD.

Glucocorticoids for the treatment of post-traumatic stress disorder and phobias: a novel therapeutic approach

Post-traumatic stress disorder (PTSD) and phobias belong to the most common anxiety disorders and to the most common psychiatric illnesses in general. In both disorders, aversive memories are thought to play an important role in the pathogenesis and symptomatology. Previously, we have reported that elevated glucocorticoid levels inhibit memory retrieval in animals and healthy humans. We therefore hypothesized that the administration of glucocorticoids might also inhibit the retrieval of aversive memory, thereby reducing symptoms in patients with PTSD and phobias. In recent clinical studies, we found first evidence to support this hypothesis. In patients with PTSD, low-dose cortisol treatment for one month reduced symptoms of traumatic memories without causing adverse side effects. Furthermore, we found evidence for a prolonged effect of the cortisol treatment. Persistent retrieval and reconsolidation of traumatic memories is a process that keeps these memories vivid and thereby the disorder alive. By inhibiting memory retrieval, cortisol may weaken the traumatic memory trace, and thus reduce symptoms even beyond the treatment period. In patients with social phobia, we found that a single oral administration of cortisone 1 h before a socio-evaluative stressor significantly reduced self-reported fear during the anticipation-, exposure-, and recovery phase of the stressor. In subjects with spider phobia, repeated oral administration of cortisol 1 h before exposure to a spider photograph induced a progressive reduction of stimulus-induced fear. This effect was maintained when subjects were exposed to the stimulus again two days after the last cortisol administration, indicating that cortisol facilitated the extinction of phobic fear. In conclusion, by a common mechanism of reducing the retrieval of aversive memories, glucocorticoids may be suited for the treatment of PTSD as well as phobias. More studies are needed to further evaluate the therapeutic efficacy of glucocorticoids in the treatment of anxiety disorders and to explore the potential of combining glucocorticoid treatment with psychotherapy.

Personality characteristics of adult survivors of childhood trauma

Lenore Terr (1991) proposed a framework for childhood trauma that distinguishes between single-incident trauma (Type I) and repeated or prolonged trauma (Type II). Terr's framework and data collected from the National Comorbidity Survey (NCS) are used to examine differences in personality between adult survivors of childhood Type I trauma, childhood Type II trauma, and a control group of adults not traumatized as children. Groups were compared on five personality scales. Results indicate that individuals in the trauma categories scored higher in neuroticism and openness to new experiences than individuals in the control group. The Type I group was lower than the control group on interpersonal dependency, whereas the Type II group scored higher than the control group on this measure.

Stress-related musculoskeletal pain

While stress is often considered by patients and clinicians alike as an important factor in the onset and maintenance of widespread musculoskeletal pain, the relationship is more complex than appears on initial consideration. The types of event that lead to stress need description, and the role of traumatic events are particularly important because of the shared association with post-traumatic stress disorder. The substantial overlap with psychiatric disorders and the role of stress in their aetiology must be assessed in patients. The lack of specificity of the symptoms of the different disorders used to describe widespread musculoskeletal pain may be explained by their shared aetiology, including neural sensitization and alterations of the hypothalamic-pituitary-adrenal (HPA) axis due to stress. Fear avoidance is a central stress-related perceptual characteristic and behavioural dimension in these disorders. Treatment depends on thorough assessment, including psychiatric diagnosis, avoiding simplistic attributions and implementing evidence-based treatments that are well documented.

Leukocyte glucocorticoid receptor expression and immunoregulation in veterans with and without post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is associated with a dysregulation of the hypothalamus-pituitary-adrenal axis (HPA axis). In addition, there is evidence for altered glucocorticoid receptor (GR) expression and function in peripheral blood mononuclear cells. The aim of the present study was to differentiate between the effect of trauma exposure and PTSD on leukocyte GR expression and glucocorticoid immune regulation. Leukocyte GR binding characteristics and glucocorticoid sensitivity of immune activity, determined as the effect of dexamethasone (DEX) on in vitro cytokine release and T-cell proliferation, were compared between veterans with PTSD, traumatized veterans without PTSD and healthy controls. Leukocyte GR density was significantly lower in veterans with and without PTSD compared to healthy controls. DEX-induced inhibition of T-cell proliferation was significantly lower in PTSD compared to trauma and healthy controls. DEX-induced increase in lipopolysaccharide-stimulated interleukin-10 was less pronounced in traumatized veterans with and without PTSD compared to healthy controls. No group differences were observed in the effect of DEX on other cytokines or in baseline immune activity, except for lower tumor necrosis factor-alpha production in PTSD patients compared to healthy controls. The results suggest that trauma exposure is sufficient to induce changes in GR binding characteristics, whereas resistance of T-cell proliferation to DEX only occurs in PTSD. DEX resistance of in vitro immune activity was not a general phenomenon, but was restricted to specific immune functions.

Is PTSD caused by traumatic stress?

Sequential subjects (N=103) presenting for pharmacologic treatment of major depression were examined prior to treatment for history of traumatic experiences. Subjects were also examined for symptoms of posttraumatic stress disorder (PTSD). Two blinded raters subsequently judged whether subjects' experiences met DSM-IV criteria for trauma (criterion A of PTSD). Among 54 subjects scored by both raters as having experienced trauma, 42 (78%) met all other DSM-IV criteria for PTSD. Among 36 subjects scored by both raters as not having experienced trauma, 28 displayed all other DSM-IV criteria for PTSD--also a rate of 78%. This equivalence suggests that in a treatment-seeking population, caution should be exercised in attributing the PTSD syndrome to trauma.

Not by genes alone: New hope for prevention

New understanding of the etiology of mental disorders calls for a revised look at psychiatric research priorities. Current research efforts are focused on the search for biogenetic causes of mental disorders. However, a small but growing body of research is revealing the inextricable relationship between genes and environment. The article questions the prevailing assumption that biogenetic factors are more fundamental than co-occurring psychosocial factors. The article synthesizes findings from clinical studies and gene-environment literature to illuminate the role of psychosocial adversity and other environmental stressors as primary etiological factors interacting with genetic vulnerabilities in the development of mental disorders. Applying this understanding of etiology combined with recent advances in prevention research methods offers new promise of positive dividends from investments in primary prevention.

Malingering of PTSD: forensic and diagnostic considerations, characteristics of malingerers and clinical presentations

OBJECTIVE

This paper aims to study the detection of individuals malingering posttraumatic stress disorder (PTSD) in criminal and civil situations.

METHOD

A brief history of PTSD and its rise to prominence in legal circles are discussed. The characteristics of individuals who malinger and particularly those who fake PTSD are discussed. Diagnostic dilemmas inherent to the condition, such as the definition of a traumatic exposure, what constitutes a PTSD flashback and the potential for normal symptom exaggeration, are explored.

RESULTS

The typical presentation of malingered symptoms is presented to help clinicians detect commonly seen malingering patterns. Suggestions for interview techniques, Minnesota Multiphasic Personality Inventory test values and sources of collateral information to help detect malingering are reviewed.

CONCLUSION

The paper concludes with a review of the typical presentations of malingered PTSD symptoms and a reminder that physicians need to distinguish legitimate symptoms from faked or embellished presentations.

Dresden PTSD treatment study: randomized controlled trial of motor vehicle accident survivors

BACKGROUND

We translated, modified, and extended a cognitive behavioral treatment (CBT) protocol by Blanchard and Hickling (2003) for the purpose of treating survivors of MVA with full or subsyndromal posttraumatic stress disorder (PTSD) whose native language is German. The treatment manual included some additional elements, e. g. cognitive procedures, imaginal reliving, and facilitating of posttraumatic growth. The current study was conducted in order to test the efficacy of the modified manual by administering randomized controlled trial in which a CBT was compared to a wait-list control condition.

METHODS

Forty-two motor vehicle accident survivors with chronic or severe subsyndromal posttraumatic stress disorder (PTSD) completed the treatment trial with two or three detailed assessments (pre, post, and 3-month follow-up).

RESULTS

CAPS-scores showed significantly greater improvement in the CBT condition as compared to the wait list condition (group x time interaction effect size d = 1.61). Intent-to-treat analysis supported the outcome (d = 1.34). Categorical diagnostic data indicated clinical recovery of 67% (post-treatment) and 76% (3 months FU) in the treatment group. Additionally, patients of the CBT condition showed significantly greater reductions in co-morbid major depression than the control condition. At follow-up the improvements were stable in the active treatment condition.

CONCLUSION

The degree of improvement in our treatment group was comparable to that in previously reported treatment trials of PTSD with cognitive behavioral therapy.

TRIAL REGISTRATION

ISRCTN66456536.

Intimate partner violence, PTSD, and adverse health outcomes

The high prevalence of adverse health outcomes related to intimate partner violence (IPV) is well documented. Yet we know little about the pathways that lead to adverse health outcomes. Research concerning the psychological, biological, neurological, behavioral, and physiological alterations following exposure to IPV--many of which are associated with posttraumatic stress disorder (PTSD)--represents a promising area of empirical discovery. New technologies and interdisciplinary collaborative efforts are required to integrate diverse methodologies and to apply new findings to improving the health and well being of those affected by IPV. This article focuses on victimization by IPV and addresses the most important research findings in the last 20 years (health and mental health burden of IPV), the most important research issue for the next decade (pathways between IPV and adverse health outcomes), and the most promising methodological innovation for the study of IPV (integrated, interdisciplinary, biobehavioral methodology).

Low salivary cortisol and elevated depressive affect among rural men in Botswana: reliability and validity of laboratory results

Most research on hypothalamic-pituitary-adrenal axis function under aversive conditions has focused on relatively increased acute episodic, or chronic secretions as an operationalization of "stress." Severe or recurrent stress, perhaps in interaction with individual characteristics, results in chronically decreased HPA function among some persons suffering from posttraumatic stress disorder. Little evidence exists to assess the population distribution of chronic low cortisol in different free-ranging human populations, as a manifestation of past trauma or stress. This study reports findings of chronically depressed ambulatory salivary cortisol among rural-dwelling Batswana men (n=30) compared with men living in Gaborone (n=34), the capital of Botswana, based on repeated ambulatory sampling. Out of 914 saliva samples analyzed by radioimmunoassay, 268 (29.3%) samples (41 urban, 227 rural) were below the minimum detectable dose (<MDD of 0.034 ug/dL) of the assay. Low values were distributed across comparable times of day as were =MDD samples. There was significant clustering of low cortisol within individuals; percentage of intra-individual repeats that were <MDD ranged from zero to 94.1% for rural participants (median=59.8%; mean=54.8%; SD=27.8%), and from zero to 40% for urban (median=0%; mean=8%; SD=11.9%). There was no association between number of repeats and proportion <MDD (P[F=-0.47]=0.639; beta(1)=-0.0045+/-0.0019). Examination of laboratory quality control suggests that this pattern is not a result of measurement error, or poor sample preservation, but instead reflects a difference from residing in a remote rural versus a central urban community.

Alcohol use in New York after the terrorist attacks: a study of the effects of psychological trauma on drinking behavior

Research has suggested that exposure to psychological trauma is associated with increased abuse of psychoactive substances, particularly alcohol. To assess this, we analyzed alcohol consumption, binge drinking, and alcohol dependence among a random sample of 1681 New York City adults 1 year and 2 years after the September 11 attacks. In multivariate models controlling for demographic factors, other stressor exposures, social psychological resources, and history of anti-social behavior, we found that greater exposure to the World Trade Center disaster (WTCD) was associated with greater alcohol consumption at 1 year and 2 years after this event. In addition, our analyses also indicated that exposure to the WTCD was associated with binge drinking at 1 year after but not 2 years after this event. Alcohol dependence, assessed as present in either year 1 or year 2, also was positively associated with greater WTCD exposures. Posttraumatic stress disorder was not associated with alcohol use, once WTCD exposure and other covariates were controlled. Our study suggests that exposure to psychological trauma may be associated with increases in problem drinking long after exposure and deserves further investigation.

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Post traumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for post traumatic stress disorder.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register (CCDANCTR-Studies) on 18 August 2005, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library issue 4, 2004), MEDLINE (January 1966 to December 2004), PsycINFO (1966 to 2004), and the National PTSD Center Pilots database. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for PTSD.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

35 short-term (14 weeks or less) RCTs were included in the analysis (4597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference -5.76, 95% confidence intervals (CI) -8.16 to -3.36, number of participants (N) = 2507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents to placebo (relative risk 1.49, 95% CI 1.28 to 1.73, number needed to treat = 4.85, 95% CI 3.85 to 6.25, N = 1272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs. Medication was superior to placebo in reducing the severity of PTSD symptom clusters, comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of 3 maintenance trials suggested that long term medication may be required in treating PTSD.

AUTHORS' CONCLUSIONS

Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of SSRIs as first line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization

OBJECTIVE

This study estimates the prevalence of posttraumatic stress disorder (PTSD) and describes the relationships among PTSD status and health indices in a civilian primary care patient sample.

METHODS

Participants (N = 232) completed a paper-and-pencil survey of life events, PTSD symptoms, physical symptoms and health functioning. Utilization was assessed from medical records.

RESULTS

Nine percent of the participants met the criteria for full PTSD (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) and another 25% were defined as partial PTSD. The full-PTSD group evidenced higher rates of medical utilization, more intense physical symptoms and poorer health functioning than the no-PTSD group. The partial-PTSD group more closely resembled the full-PTSD group.

CONCLUSIONS

This study, although limited by sample size and diagnosis by questionnaire vs. diagnostic interview, suggests research directions for enhancing our understanding of PTSD among civilian primary care patients and for developing appropriate interventions that can be conducted in the primary care setting.

The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model

OBJECTIVES

Persistent pain and psychological sequelae are common after motor vehicle collision (MVC), but their etiology remains poorly understood. Such common sequelae include whiplash-associated disorders (WAD), fibromyalgia, and posttraumatic stress disorder (PTSD). Increasing evidence suggests that these disorders share overlapping epidemiologic and clinical features. A model is proposed in which central neurobiological systems, including physiologic systems and neuroanatomical structures involved in the stress response, are an important substrate for the development of all 3 disorders and interact with psychosocial and other factors to influence chronic symptom development.

METHODS

Epidemiologic and clinical characteristics regarding the development of these disorders after MVC are reviewed. Evidence suggesting a role for stress response systems in the development of these disorders is presented.

RESULTS

Contemporary evidence supports a model of chronic symptom development that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-MVC behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after MVC. Such a model incorporates factors identified in prior biopsychosocial theories and places them in the landscape of our rapidly developing understanding of stress systems and CNS pain-modulating pathways.

CONCLUSION

New models are needed to stimulate deeper examination of the interacting influences of initial tissue damage, acute pain, psychosocial contingencies, and central stress pathways during chronic symptom development after MVC. Deeper understanding could contribute to improved treatment approaches to reduce the immense personal and societal burdens of common trauma-related disorders.

Mental disorders, disability and health service use amongst Vietnamese refugees and the host Australian population

OBJECTIVE

To compare the prevalence of common mental disorders, disability and health service utilization amongst Vietnamese refugees resettled in Australia for 11 years, with data obtained from a national survey of the host population.

METHOD

A stratified multistage probability household survey of 1611 Vietnamese undertaken in the state of New South Wales was compared with data from 7961 Australian-born respondents. Measures included the CIDI 2.1 and the MOS SF-12.

RESULTS

The 12-month prevalence of anxiety, depression and drug and alcohol dependence amongst Vietnamese was 6.1% compared with 16.7% amongst Australians. Vietnamese with a mental illness reported higher disability but exhibited similar levels of mental health consultation. The overall service burden of mental disorders was lower for the Vietnamese.

CONCLUSION

The findings suggest that refugee groups resettled for some time in Western countries may show sound mental health adaptation and do not necessarily impose a burden on general or mental health services.

Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum

Much of today's psychological trauma can be identified as resulting from sudden and seemingly random events, and particularly from events that involve the loss of human life. This article presents a perspective on how behavioral health providers may approach the design, development, and implementation of community-based psychological trauma interventions. These interventions allow those community members most affected by the trauma to play a central role in the resolution of, and community adaptation to, traumatic losses. After a brief discussion of "critical incident stress debriefing"--a common form of psychological "first aid" that is sometimes used following traumatic events that affect a community--the article turns to the description of a community-based trauma-response program that provides a continuum-of-care model for the care and management of individual and group reactions to shared, traumatic events. A recent evaluation of that program, which was developed by the Community Services Program of the Trauma Center in Boston, is presented as an important first step toward determining the types of community-based responses that show promise in our efforts to ameliorate the impact of traumatic events in communities nationwide and internationally.

Anxiety, depressive, and posttraumatic stress disorders among mothers of pediatric survivors of hematopoietic stem cell transplantation

OBJECTIVE

To examine the prevalence and predictors of anxiety, depression, and posttraumatic stress disorder among mothers of children who underwent hematopoietic stem cell transplantation (HSCT).

METHODS

A total of 111 mothers of children who survived HSCT completed self-report measures of psychological functioning at the time of HSCT and self-report measures and a structured psychiatric interview 18 months after HSCT. Demographic data and medical data were also collected.

RESULTS

Approximately 20% of mothers had clinically significant distress reactions. When subthreshold posttraumatic stress disorder was included, nearly one third of mothers met the criterion for persistent distress. Mothers with 1 of the 4 psychiatric diagnoses reported a significantly lower quality of life, suggesting that the diagnoses had an impact on their general quality of life. Mothers who had 1 of the 4 diagnoses at 18 months were younger and had higher anxiety and depressive symptoms at the time of HSCT.

CONCLUSIONS

A subset of mothers of children who survive HSCT may require psychological intervention. Mothers who are most at risk are younger and evidence anxiety and depressive symptoms at the time of transplantation.

Threat and trauma: an overview

Common responses after exposure to threat include reexperiencing the event, intrusive thoughts and images, hyperarousal, avoidance and numbing, a sense of a foreshortened future, and shattered assumptions about control and safety.

Treatment of Anxiety and Depression in Transplant Patients

Depressive and anxiety disorders appear during the transplant process due to psychological stressors, medications and physiological disturbances. Treatment is necessary to prevent impact on patient compliance, morbidity and mortality. Psychotropic medications provide an effective option, although most are only available as oral formulations. Because of this, they are more susceptible to alterations in pharmacokinetic behaviour arising from organ dysfunction in the pretransplant period. Kinetics are also an issue when considering potential drug-drug interactions before and after transplantation. Prior to transplant, organ dysfunction can change the pharmacokinetic behaviour of some psychotropic agents, requiring adjustment of dosage and schedules. Thoracic or abdominal organ failure may reduce drug absorption through disturbances in intestinal motility, perfusion and function. Cirrhotic patients experience increased drug bioavailability due to portosystemic shunting, and thus dosage is adjusted downward. In contrast, dosage needs to be raised when peripheral oedema expands the drug distribution volume for hydrophilic and protein-bound agents. Drug clearance for most psychotropic medications is dependent upon hepatic metabolism, which is often disrupted by endstage organ disease. Selection of drugs or their dosage may need to be adjusted to lower the risk of drug accumulation. Further adjustments in dosage may be called for when renal failure accompanies thoracic or abdominal organ failure, resulting in further impairment of clearance. Studies regarding the treatment of anxiety and depressive disorders in the medically ill are limited in number, but recommendations are possible by review of clinical and pharmacokinetic data. Selective serotonin reuptake inhibitors are well tolerated and efficacious for depression, panic disorder and post-traumatic stress disorder. Adjustments in dosage are required when renal or hepatic impairment is present. Among them, citalopram and escitalopram appear to have the least risk of drug-drug interactions. Paroxetine has demonstrated evidence supporting its use with generalised anxiety disorder. Venlafaxine is an alternative option, beneficial in depression, post-traumatic stress and generalised anxiety disorders. Nefazodone may also be considered, but there is some risk of hepatotoxicity and interactions with immunosuppressant drugs. Mirtazapine still needs to be studied further in anxiety disorders, but can be helpful for depression accompanied by anorexia and insomnia. Bupropion is effective in the treatment of depression, but data are sparse about its use in anxiety disorders. Psychostimulants are a unique approach if rapid onset of antidepressant action is desired. Acute or short-term anxiolysis is obtained with benzodiazepines, and selection of particular agents entails consideration of distribution rate, half-life and metabolic route.

Psychopathology and psychological problems in patients with burn scars: epidemiology and management

Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses. Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13-23% and 13-45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury. Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life.In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Public health context of women's mental health research

As more attention is directed to the mental health care of women, sex and gender differences in research design and in regulatory policies have interfaced with clinical care and public policy. An emphasis on women's mental health issues in the provision of treatment and care as well as the design of large-scale screening strategies to identify and treat women with mental disorders promises to be effective public health approaches to reducing the burden of mental illness in women. The past decade has seen increased emphasis on women's mental health and sex/gender differences in the federal sector and in the research community. Federal regulations (summarized in the NIH Outreach Notebook) call for the inclusion of women and minorities in NIH-funded clinical research. The regulations also place emphasis on gender analysis of the results of clinical trials, in particular phase III trials, the findings of which are likely to influence practice. There has been substantial progress toward the goal of including women in research, but more remains to be done. A 2000 GAO report titled "Women's Health: NIH Has Increased Its Efforts to Include Women in Research" commended NIH for tracking the number of women in clinical research but the report also noted that relatively few NIH-funded studies, including major clinical trials, had reported findings by gender of study participants. This was seen as an impediment to progress in developing gender-based effective treatments. In the past decade, the women's health field has moved beyond an exclusive emphasis on women's reproductive function to one that defines health as a scientific enterprise to identify clinically important sex and gender differences in prevalence, etiology, course, and treatment of illnesses affecting men and women in the population as well as conditions specific to women. Nonetheless, for mental disorders, women's reproductive function and its impact on mental health conditions is still understudied. Based on the epidemiology of mental disorders, the course of mental disorders in women in relation to reproductive transitions remains an important issue for the mental health field because the burden of mental disorders, such as depression and anxiety, fall disproportionately on women of childbearing and childrearing age. The public health emphasis on women's mental health does not lessen the basic scientific opportunities to be had by a focus on gender and sex differences. A 2001 report of the Institute of Medicine titled "Exploring the Biological Contributions to Health: Does Sex Matter?" underscores the benefit to health care of looking for sex differences at the biological level. Basic and clinical neuroscience research is rapidly accruing a knowledge base that will provide information at the level of genes and cells of the influences of biological sex on mental health outcomes in both women and men. A focus on women's mental health and gender/sex differences research promises to yield improvement in treatments and services and thereby to improve the public health as well as to increase fundamental knowledge about the etiology and neurophysiology of mental disorders.

To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors

Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as "insomnia related to another mental disorder," a.k.a. "psychiatric insomnia." Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.