Do cognitive models help in predicting the severity of posttraumatic stress disorder, phobia, and depression after motor vehicle accidents? A prospective longitudinal study

Examining relationships between anxiety and dangerous driving

Driving anxiety that has developed following crashes has been studied relatively frequently, but anxiety per se and its effects on driving has not as yet garnered much attention in the literature. The current study included 1121 participants and found higher levels of general anxiety were related to a wide variety of dangerous driving behaviors. While there were clear and expected sex differences on many dangerous driving variables, there were still more such differences with regard to anxiety levels and independent of sex, higher levels of anxiety were associated with greater levels of dangerous driving. Of particular import, it was found that the high anxiety group had caused significantly more crashes and engaged in more DUI episodes than the low and/or medium anxiety groups. Taken as a whole, the results suggest there is a tremendous need for more research in the area of anxiety and dangerous driving and that interventions for highly anxious drivers may well be warranted.

Heart rate responses to standardized trauma-related pictures in acute posttraumatic stress disorder

Physiological responses to trauma reminders are one of the core symptoms of posttraumatic stress disorder (PTSD). Nevertheless, screening measures for PTSD largely rely on symptom self-reports. It has been suggested that psychophysiological assessments may be useful in identifying trauma survivors with PTSD (Orr and Roth, 2000). This study investigated whether heart rate (HR) responses to standardized trauma-related pictures distinguish between trauma survivors with and without acute PTSD. Survivors of motor vehicle accidents or physical assaults (N=162) watched standardized trauma-related, generally threatening and neutral pictures at 1 month post-trauma while their ECG was recorded. At 1 and 6 months, structured clinical interviews assessed PTSD diagnoses. Participants completed self-report measures of PTSD severity and depression, peritraumatic responses, coping behaviors and appraisals. Trauma survivors with acute PTSD showed greater HR responses to trauma-related pictures than those without PTSD, as indicated by a less pronounced mean deceleration, greater peak responses, and a greater proportion showing HR acceleration of greater than 1 beat per minute. There were no group differences in HR responses to generally threatening or neutral pictures. HR responses to trauma-related pictures contributed to the prediction of PTSD diagnosis over and above what could be predicted from self-reports of PTSD and depression. HR responses to trauma-related pictures were related to fear and data-driven processing during the trauma, safety behaviors, suppression of trauma memories, and overgeneralized appraisals of danger. The results suggest that HR responses to standardized trauma-related pictures may help identify a subgroup of patients with acute PTSD who show generalized fear responses to trauma reminders. The early generalization of triggers of reexperiencing symptoms observed in this study is consistent with associative learning and cognitive models of PTSD.

Avoidance behaviour of patients with posttraumatic stress disorder. Initial development of a questionnaire, psychometric properties and treatment sensitivity

In this study, the development of the Posttraumatic Avoidance Behaviour Questionnaire (PABQ) is described and validated in 437 participants; PTSD patients (N = 75), clinical controls (patients with panic disorder with agoraphobia; PDA) (N = 50), and non-clinical traumatized controls (N = 312). Item reduction and exploratory factor analyses yielded 25 items reflecting seven factors. Internal consistency, test-retest reliability, convergent and discriminative validity of the PABQ proved adequate. In a second study, the PABQ showed to be sensitive to change due to exposure treatment outcome (N = 26).

The effects of "psychological inoculation" versus ventilation on the mental resilience of Israeli citizens under continuous war stress

Anxiety and hopelessness are common reactions of citizens exposed to continuous war threats. Common interventions focus on support, calming, and emotional ventilation, with few attempts to reduce people's cognitive barriers concerning active coping, which could increase their resilience. This study tested the effects of psychological inoculation (PI), which specifically aims to challenge such barriers, on the mental resilience of Israeli citizens living in Sderot. Participants were randomly assigned to either 2 PI sessions or 2 ventilation sessions, provided over the phone. Anxiety, helplessness, pessimism, and functioning were briefly assessed at baseline and 1 week after interventions. No time, group, or group x time interactions were observed. However, a time x group x sex interaction emerged for helplessness: Men benefited from the PI whereas women benefited from ventilation, in reducing helplessness. Under chronic war stress, it seems difficult to improve people's resilience, although PI may be partly beneficial for men. Further research is needed to test the effects of PI on mental resilience.

Early heart rate responses to standardized trauma-related pictures predict posttraumatic stress disorder: a prospective study

OBJECTIVE

To investigate whether chronic posttraumatic stress disorder can be predicted by heart rate responses (HRR) and skin conductance responses (SCR) to standardized trauma-related pictures at 1 month after trauma has ocurred. Trauma survivors with PTSD report heightened physiological responses to a wide range of stimuli. It has been suggested that associative learning and stimulus generalization play a key role in the development of these symptoms. Some studies have found that trauma survivors with PTSD show greater physiological responses to individualized trauma reminders in the initial weeks after trauma than those without PTSD.

METHODS

Survivors of motor vehicle accidents or physical assaults (n = 166) watched standardized trauma-related, generally threatening, and neutral pictures at 1 month post trauma, as their HRR and SCR were recorded. PTSD symptoms were assessed with structured clinical interviews at 1 month and 6 months; self-reports of fear responses and dissociation during trauma were obtained soon after the trauma.

RESULTS

At 1 month, trauma survivors with PTSD showed greater HRR to trauma-related pictures than those without PTSD, but not to general threat or neutral pictures. HRR to trauma-related pictures predicted PTSD severity at 1 month and 6 months, and were related to fear and dissociation during trauma. SCR were not related to PTSD.

CONCLUSION

HRR to standardized trauma reminders at 1 month after the trauma differentiate between trauma survivors with and without PTSD, and predict chronic PTSD. RESULTS are consistent with a role of associative learning in PTSD and suggest that early stimulus generalization may be an indicator of risk for chronic PTSD.

The psychological consequences of occupational blood and body fluid exposure injuries

PURPOSE

This article describes the psychological impact of occupational blood and body fluid (BBF) exposure injuries and provides suggestions for improving clinical practice.

METHOD

A literature review was conducted to search for articles relating to the psychological consequences and management of these work injuries.

RESULTS

Acute psychological symptoms including posttraumatic stress, anxiety and depression are frequently experienced postexposure, which appear to be the major contributing factors of time loss from work. Furthermore, a subgroup is at risk for chronic symptoms and disability that persists beyond notification that no disease transmission occurred. Distressed workers often go unrecognised and untreated, and their assistance needs are largely unknown. Accordingly, this article draws upon the posttraumatic stress literature to offer suggestions for advancing the postexposure management of these injuries.

CONCLUSIONS

This clinical commentary underscores the serious yet understudied secondary psychological effects of occupational BBF exposure injuries. Postexposure management programmes need to place greater emphasis on psychosocial and educational initiatives to improve the identification and treatment of symptomatic workers.

The effects of rumination on mood and intrusive memories after exposure to traumatic material: An experimental study

Correlational studies have shown that trauma-related rumination predicts chronic post-traumatic stress disorder (PTSD). This study aimed to experimentally test the hypothesis that rumination is causally involved in the development and maintenance of PTSD symptoms. A video depicting the aftermath of serious road traffic accidents was used as an analogue stressor. After having watched the video, N=101 healthy participants were randomly assigned to a guided thinking task designed to induce (a) rumination, (b) memory integration and (c) distraction. In line with the hypotheses, rumination led to less recovery from sad mood triggered by the video than the other two conditions. In addition, self-reported state levels of rumination during the guided thinking task predicted subsequent intrusive memories in the session. However, no significant main effect of the experimental manipulation on intrusive memories of the video was found. Results of exploratory analyses suggested possible sex differences in the way the processing manipulations were effective. Taken together, the results partially support the hypothesis that rumination is involved in the maintenance of negative mood and post-traumatic stress symptoms.

Clinically significant avoidance of public transport following the London bombings: travel phobia or subthreshold posttraumatic stress disorder?

Following the London bombings of 7 July 2005 a "screen and treat" program was set up with the aim of providing rapid treatment for psychological responses in individuals directly affected. The present study found that 45% of the 596 respondents to the screening program reported phobic fear of public transport in a screening questionnaire. The screening program identified 255 bombing survivors who needed treatment for a psychological disorder. Of these, 20 (8%) suffered from clinically significant travel phobia. However, many of these individuals also reported symptoms of posttraumatic stress disorder [PTSD]. Comparisons between the travel phobia group and a sex-matched group of bombing survivors with PTSD showed that the travel phobic group reported fewer re-experiencing and arousal symptoms on the Trauma Screening Questionnaire (Brewin et al., 2002). The only PTSD symptoms that differentiated the groups were anger problems and feeling upset by reminders of the bombings. There was no difference between the groups in the reported severity of trauma or in presence of daily transport difficulties. Implications of these results for future trauma response are discussed.

Dysfunctional cognitive appraisal and psychophysiological reactivity in acute stress disorder

The present study investigated the extent of dysfunctional appraisal as measured with the Posttraumatic Cognitions Inventory (PTCI) and physiological responses to trauma-related material in patients with acute stress disorder (ASD; N=44) in comparison to participants without trauma exposure (N=27). Heart-rate (HR), skin conductance responses (SCR), and viewing time were recorded in response to - for trauma victims - idiosyncratically trauma-relevant and control pictures. ASD patients evidenced greater dysfunctional appraisal than control participants with regard to the PTCI scales Self and World and also an accelerative HR reaction and greater SCRs to trauma-relevant pictures. Among patients, PTCI was highly correlated with ASD severity while PTCI World was positively correlated with resting HR and depression. Amplitude of the HR reaction to trauma-related pictures was negatively correlated with viewing time. Results suggest that dysfunctional appraisal and autonomic reactivity are only loosely related in ASD.

Mild traumatic brain injury and posttraumatic stress disorder in returning veterans: perspectives from cognitive neuroscience

A significant proportion of military personnel deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been exposed to war-zone events potentially associated with traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). There has been significant controversy regarding healthcare policy for those service members and military veterans who returned from OEF/OIF deployments with both mild TBI and PTSD. There is currently little empirical evidence available to address these controversies. This review uses a cognitive neuroscience framework to address the potential impact of mild TBI on the development, course, and clinical management of PTSD. The field would benefit from research efforts that take into consideration the potential differential impact of mild TBI with versus without persistent cognitive deficits, longitudinal work examining the trajectory of PTSD symptoms when index trauma events involve TBI, randomized clinical trials designed to examine the impact of mild TBI on response to existing PTSD treatment interventions, and development and examination of potential treatment augmentation strategies.

Treating clinically significant avoidance of public transport following the London bombings?

BACKGROUND

The present paper describes the cognitive-behavioural approach evolved and adapted to treat survivors of the London bombings experiencing fear and avoidance of public transport (travel phobia).

METHOD

Treatment outcomes for a consecutive case series (N = 11) are reported.

RESULTS

All individuals who completed treatment (N = 10) had returned to their pre-bombing use of transport and reported minimal symptoms.

CONCLUSIONS

The need for appropriately tailored treatment based on differential diagnosis and formulation and the importance of incorporating skills for treatment of posttraumatic stress disorder are discussed.

Negative self-appraisals in treatment-seeking survivors of motor vehicle accidents

Recent cognitive models stress the impact that negative appraisals have on the maintenance of posttraumatic stress disorder (PTSD). The aim of this study was to investigate the role of posttraumatic negative cognitions in 110 survivors of motor vehicle accidents (MVAs) and to examine the effect of cognitive-behavioral treatment on negative appraisals in a sample of 42 patients with full or sub-syndromal PTSD. We investigated whether posttraumatic negative cognitions predicted PTSD diagnosis and symptom severity, and whether treatment-related changes in negative appraisals were associated with PTSD symptom reduction. Negative posttraumatic cognitions were significantly associated with PTSD diagnosis and severity, and explained 54% of the variance of the PTSD severity. Furthermore, treatment-related reductions in negative appraisals about the self were highly associated with PTSD-symptom-reduction. Our results raise question about whether there are factors that make the self more vulnerable in some people but not in others.

What does the Driving and Riding Avoidance Scale (DRAS) measure?

Driving anxiety can have a significant impact on everyday functioning and usually results in some kind of avoidance behaviour. The Driving and Riding Avoidance Scale (DRAS; Stewart, A. E., & St. Peter, C. C. (2004). Driving and riding avoidance following motor vehicle crashes in a non-clinical sample: psychometric properties of a new measure. Behaviour Research and Therapy, 42, 859-879) shows promise in the self-report assessment of the degree of such avoidance. The present study investigated the psychometric properties of the DRAS in a sample of 301 university students. Internal consistency for the DRAS was 0.89 and temporal stability over two months was 0.71. The factor structure of the DRAS supported the use of the general and traffic avoidance subscales but not the weather and riding avoidance subscales in the present non-clinical sample. However, a significant limitation of the DRAS is that it does not assess the reasons for driving avoidance, and is therefore not a measure of avoidance that is due to driving anxiety. Some items may be rated highly for practical reasons, such as avoidance because of increasing fuel and other costs associated with driving. Modified instructions for the DRAS should ensure that it measures anxiety-related avoidance behaviour.

Amnesia for violent crime among young offenders

Amnesia for the perpetration of violent offences is an important issue in medico-legal proceedings. Previous studies of amnesia have mainly relied on selected groups of unconvicted offenders, which raises the question of how reliable the findings are. The purpose of this study was to examine the prevalence and phenomenological qualities of amnesia in violent offenders. In semi-structured interviews with 105 young offenders convicted of serious violence, 20 (19%) reported partial amnesia for their offence and only one (1%) reported complete amnesia. Amnesia was associated with high alcohol intake, emotional ties to the victim, and cognitive processing during the assault. Complete amnesia for violent crime appears to be less frequent than suggested by previous reports using unconvicted samples. The findings have implications for the clinical assessment of claimed amnesia for violent crime and are potentially of medico-legal significance.

Trajectories of resilience, resistance, and distress during ongoing terrorism: the case of Jews and Arabs in Israel

This is the 1st longitudinal examination of trajectories of resilience and resistance (rather than ill-being) among a national sample under ongoing threat of mass casualty. The authors interviewed a nationally representative sample of Jews and Arabs in Israel (N = 709) at 2 times during a period of terrorist and rocket attacks (2004-2005). The resistance trajectory, exhibiting few or no symptoms of traumatic stress and depression at both time points, was substantially less common (22.1%) than has previously been documented in studies following single mass casualty events. The resilience trajectory, exhibiting initial symptoms and becoming relatively nonsymptomatic, was evidenced by 13.5% of interviewees. The chronic distress trajectory was documented among a majority of participants (54.0%), and a small proportion of persons were initially relatively symptom-free but became distressed (termed delayed distress trajectory; 10.3%). Less psychosocial resource loss and majority status (Jewish) were the most consistent predictors of resistance and resilience trajectories, followed by greater socioeconomic status, greater support from friends, and less report of posttraumatic growth.

Cognitive abnormalities in posttraumatic stress disorder

PURPOSE OF REVIEW

The current review aims to describe and evaluate research on cognitive difficulties associated with posttraumatic stress disorder (PTSD) published between January 2007 and June 2008.

RECENT FINDINGS

The reviewed studies provide additional evidence that negative appraisals and decrements on verbal and autobiographical memory tasks are exhibited by individuals with PTSD relative to controls and may represent preexisting risk factors for PTSD rather than a result or concomitant of PTSD symptoms. In addition, the reviewed findings provide further evidence for source monitoring difficulties and attentional biases toward trauma-relevant information in PTSD. Recent research also provides evidence that, although memories of traumatic events differ in PTSD relative to other types of memories and memories of depressed individuals, they are likely on the same continuum as nontraumatic memories rather than qualitatively different.

SUMMARY

Individuals with PTSD experience cognitive alterations ranging from impairments in overall memory functioning to difficulties specific to trauma-related cues. These cognitive difficulties appear to be importantly related to the development and/or maintenance of the disorder. At this point, it is unclear whether common mechanisms may account for these diverse cognitive difficulties and whether cognitive impairments are attributable to comorbid depression.

Do acute psychological and psychobiological responses to trauma predict subsequent symptom severities of PTSD and depression?

The study investigated the relationship between the acute psychological and psychobiological trauma response and the subsequent development of posttraumatic stress disorder (PTSD) and depressive symptoms in 53 accident survivors attending an emergency department. Lower levels of salivary cortisol measured in the emergency room predicted greater symptom levels of PTSD and depression 6 months later, and lower diastolic blood pressure, past emotional problems, greater dissociation and data-driven processing predicted greater PTSD symptoms. Heart rate was not predictive. Low cortisol levels correlated with data-driven processing during the accident, and, in female participants only, with prior trauma and prior emotional problems. Higher evening cortisol 6 months after the accident correlated with PTSD and depressive symptoms at 6 months, but this relationship was no longer significant when levels of pain were controlled. The results support the role of the acute response to trauma in the development and maintenance of PTSD and provide promising preliminary evidence for a meaningful relationship between psychobiological and psychological factors in the acute trauma phase.

A preliminary study of negative appraisals and dysfunctional coping associated with post-traumatic stress disorder symptoms following myocardial infarction

OBJECTIVES

To investigate associations between post-traumatic stress disorder (PTSD) symptoms following myocardial infarction (MI) and subjective experience of MI, negative perception of consequences, negative appraisals of symptoms, and use of dysfunctional coping strategies, as described by Ehlers and Clark's (2000) model of PTSD.

DESIGN

Cross-sectional questionnaire study of people who experienced a MI within the previous 12 weeks (N=74; 51% response rate).

METHODS

Participants completed questionnaires assessing PTSD symptoms, subjective experience of MI, perception of consequences, appraisal of symptoms, and dysfunctional coping strategies.

RESULTS

Of the participants, 16% met DSM-IV criteria for PTSD and a further 18% reported moderate to severe PTSD symptoms. People with PTSD symptoms also had more somatic symptoms, anxiety, depression, and social dysfunction. PTSD symptoms were associated with perceived severity and danger of MI, a history of psychological problems, previous trauma, negative appraisal of symptoms, perceived severe consequences, and dysfunctional coping strategies. These variables were entered into a regression with MI and past history variables on Step 1, and appraisal and coping variables on Step 2. This showed that perceived consequences and dysfunctional coping were strongly associated with PTSD symptoms after controlling for MI and past history variables.

CONCLUSION

The results of this preliminary study suggest perception of consequences and dysfunctional coping may be important in PTSD symptoms following MI.

Post-traumatic stress disorder: the development of effective psychological treatments

Post-traumatic stress disorder (PTSD) has only relatively recently been introduced into the diagnostic classification of mental disorders. Building on advances in the treatment of other anxiety disorders, a range of effective psychological treatments for PTSD has been developed. The most effective of these treatments focus on the patient's memory for the traumatic event and its meaning. This paper briefly reviews the currently available evidence for these treatments. It then illustrates the process of developing effective psychological treatments by discussing how a combination of phenomenological, experimental and treatment development studies, and theoretical considerations was used to develop a trauma-focused cognitive-behavioral treatment, cognitive therapy (CT) for PTSD. This treatment program builds on Ehlers & Clark's (2000) model of PTSD, which specifies two core cognitive abnormalities in PTSD. First, people with chronic PTSD show idiosyncratic personal meanings (appraisals) of the trauma and/or its sequelae that lead to a sense of serious current threat. Second, the nature of the trauma memory explains the occurrence of re-experiencing symptoms. It is further proposed that the idiosyncratic appraisals motivate a series of dysfunctional behaviors (such as safety-seeking behaviors) and cognitive strategies (such as thought suppression and rumination) that are intended to reduce the sense of current threat, but maintain the problem by preventing change in the appraisals and trauma memory, and/or lead to increases in symptoms. CT addresses the cognitive abnormalities and maintaining behaviors in an individualized, but focused, way. Four randomized controlled trials and two dissemination studies showed that CT for PTSD is acceptable and effective.

The Role of Rumination and Reduced Concreteness in the Maintenance of Posttraumatic Stress Disorder and Depression Following Trauma

Rumination has been linked to posttraumatic stress disorder (PTSD) and depression following trauma. A cross-sectional (N = 101) and a prospective longitudinal study (N = 147) of road traffic accident survivors assessed rumination, PTSD and depression with self-report measures and structured interviews. We tested the hypotheses that (1) rumination predicts the maintenance of PTSD and depression and (2) reduced concreteness of ruminative thinking may be a maintaining factor. Rumination significantly predicted PTSD and depression at 6 months over and above what could be predicted from initial symptom levels. In contrast to the second hypothesis, reduced concreteness in an iterative rumination task was not significantly correlated with self-reported rumination frequency, and did not consistently correlate with symptom severity measures. However, multiple regression analyses showed that the combination of reduced concreteness and self-reported frequency of rumination predicted subsequent PTSD better than rumination frequency alone. The results support the view that rumination is an important maintaining factor of trauma-related emotional disorders.