Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

Early psychological interventions to treat acute traumatic stress symptoms

BACKGROUND

The amelioration of psychological distress following traumatic events is a major concern. Systematic reviews suggest that interventions targeted at all of those exposed to such events are not effective at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of treating acute traumatic stress problems.

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments and interventions commenced within three months of a traumatic event aimed at treating acute traumatic stress reactions. The review followed the guidelines of the Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches were performed of of CCDAN Registers up to August 2008. Editions of key journals were searched by hand over a period of two years; personal communication was undertaken with key experts in the field; online discussion fora were searched.

SELECTION CRITERIA

Randomised controlled trials of any psychological intervention or treatment designed to reduce acute traumatic stress symptoms, with the exception of single session interventions.

DATA COLLECTION AND ANALYSIS

Data were entered and analysed for summary effects using Review Manager 5.0 software. Standardised mean differences were calculated for continuous variable outcome data. Relative risks were calculated for dichotomous outcome data. When statistical heterogeneity was present a random effects model was applied.

MAIN RESULTS

Fifteen studies (two with long term follow-up studies) were identified examining a range of interventions.In terms of main findings, twelve studies evaluated brief trauma focused cognitive behavioural interventions (TF-CBT). TF-CBT was more effective than a waiting list intervention (6 studies, 471 participants; SMD -0.64, 95% CI -1.06, -0.23) and supportive counselling (4 studies, 198 participants; SMD -0.67, 95% CI -1.12, -0.23). Effects against supportive counselling were still present at 6 month follow-up (4 studies, 170 participants; SMD -0.64, 95% CI -1.02, -0.25). There was no evidence of the effectiveness of a structured writing intervention when compared against minimal intervention (2 studies, 149 participants; SMD -0.15, 95% CI -0.48, 0.17).

AUTHORS' CONCLUSIONS

There was evidence that individual TF-CBT was effective for individuals with acute traumatic stress symptoms compared to both waiting list and supportive counselling interventions. The quality of trials included was variable and sample sizes were often small. There was considerable clinical heterogeneity in the included studies and unexplained statistical heterogeneity observed in some comparisons. This suggests the need for caution in interpreting the results of this review. Additional high quality trials with longer follow up periods are required to further test TF-CBT and other forms of psychological intervention.

Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review

BACKGROUND

Acute stress disorder (ASD) predicts the development of posttraumatic stress disorder (PTSD), which in some sufferers can persist for years and lead to significant disability. We carried out a review of randomized controlled trials to give an update on which psychological treatments are empirically supported for these disorders, and used the criteria set out by Chambless and Hollon [1998: J Consult Clin Psychol 66:7-18] to draw conclusions about efficacy, first irrespective of trauma type and second with regard to particular populations.

METHODS

The PsycINFO and PubMed databases were searched electronically to identify suitable articles published up to the end of 2008. Fifty-seven studies satisfied our inclusion criteria.

RESULTS

Looking at the literature undifferentiated by trauma type, there was evidence that trauma-focused cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) are efficacious and specific for PTSD, stress inoculation training, hypnotherapy, interpersonal psychotherapy, and psychodynamic therapy are possibly efficacious for PTSD and trauma-focused CBT is possibly efficacious for ASD. Not one of these treatments has been tested with the full range of trauma groups, though there is evidence that trauma-focused CBT is established in efficacy for assault- and road traffic accident-related PTSD.

CONCLUSIONS

Trauma-focused CBT and to a lesser extent EMDR (due to fewer studies having been conducted and many having had a mixed trauma sample) are the psychological treatments of choice for PTSD, but further research of these and other therapies with different populations is needed.

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.

Earthquakes and Children: The Role of Psychologists with Families and Communities

The 2008 Sichuan Province earthquake and 2005 Pakistan earthquake are examples of natural disasters that took an unimaginable toll on children. In such disaster management contexts, family members as well as health care and school personnel are the first-line responders and are natural sources of continued social support as children recover. Although psychologists have increasingly sophisticated understandings of post-disaster reactions and strategies for helping children and adolescents cope with trauma, models for responding to mass catastrophes are limited, particularly in geographically remote communities and in regions where mental health services are stigmatizing. With children's well-being subsequent to earthquakes inextricably linked to family and community, psychologists can make important contributions in three spheres: (a) coordinating and activating collaborations within children's existing social contexts to develop post-earthquake interventions; (b) designing prevention and preparedness programs focused on the emotional needs of children in earthquake-prone communities; and (c) conducting research on interventions and recovery with particular attention to developmental stage, socio-cultural-economic contexts, and the similarities versus differences across various types of disasters.

Resettling refugees and safeguarding their mental health: lessons learned from the Canadian Refugee Resettlement Project

The Ryerson University Refugee Resettlement Project (RRP), a decade-long study of 1348 Southeast Asian refugees who came to Canada between 1979 and 1981, is one of the largest, most comprehensive and longest-lived investigations of refugee resettlement ever carried out. Knowledge gleaned from the RRP about research methodology, about the resettlement experience, about the social costs of resettling refugees, about factors that promote or hinder integration, about risk and protective factors for refugee mental health, and about the refugees' consumption of mental health and social services is summarized in the form of 18 "Lessons." The lessons are offered in order to encourage and stimulate further research, as well to suggest policy and practice innovations that could help make resettlement easier, less costly, more effective, and more humane.

Delayed extinction attenuates conditioned fear renewal and spontaneous recovery in humans

This study investigated whether the retention interval after an aversive learning experience influences the return of fear after extinction training. After fear conditioning, participants underwent extinction training either 5 min or 1 day later and in either the same room (same context) or a different room (context shift). The next day, conditioned fear was tested in the original room. When extinction took place immediately, fear renewal was robust and prolonged for context-shift participants, and spontaneous recovery was observed in the same-context participants. Delayed extinction, by contrast, yielded a brief form of fear renewal that reextinguished within the testing session for context-shift participants, and there was no spontaneous recovery in the same-context participants. The authors conclude that the passage of time allows for memory consolidation processes to promote the formation of distinct yet flexible emotional memory traces that confer an ability to recall extinction, even in an alternate context, and minimize the return of fear. Furthermore, immediate extinction can yield spontaneous recovery and prolong fear renewal. These findings have potential implications for ameliorating fear relapse in anxiety disorders.

Post-trauma symptoms following indirect exposure to the September 11th terrorist attacks: the predictive role of dispositional coping

Few data prospectively address the role of coping in the development of PTSD. In the present study, 308 undergraduates were assessed for coping prior to the 9/11 WTC attack and for PTSD symptomatology at one and three-months post-9/11. Multiple regression analyses indicated that emotion-focused coping was predictive of increased symptomatology at Month 1 and Month 3, whereas problem-focused and avoidance-focused coping were not. Specifically, analyses predicting PTSD symptom factors (Intrusions, Avoidance, Dysphoria, and Hyperarousal) indicated that greater emotion-focused coping predicted increased Dysphoria symptoms at both time points and, among females, increased levels of Hyperarousal symptoms at Month 1. The role of coping style in the development of PTSD symptomatology and its clinical implications are discussed.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual Psychological Debriefing is not an effective intervention at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of multiple session early psychological interventions commenced within three months of a traumatic event aimed at preventing PTSD. Single session individual/group psychological interventions were excluded.

SEARCH STRATEGY

Computerised databases were searched systematically, the most recent search was conducted in August 2008. The Journal of Traumatic Stress and the Journal of Consulting and Clinical Psychology were handsearched for the last two years. Personal communication was undertaken with key experts in the field.

SELECTION CRITERIA

Randomised controlled trials of any multiple session early psychological intervention or treatment (two or more sessions) designed to prevent symptoms of PTSD.

DATA COLLECTION AND ANALYSIS

Data were entered using Review Manager software. The methodological quality of included studies was assessed individually by two review authors. Data were analysed for summary effects using Review Manager 4.2. Mean difference was used for meta-analysis of continuous outcomes and relative risk for dichotomous outcomes.

MAIN RESULTS

Eleven studies with a total of 941 participants were found to have evaluated brief psychological interventions aimed at preventing PTSD in individuals exposed to a specific traumatic event, examining a heterogeneous range of interventions. Eight studies were entered into meta-analysis. There was no observable difference between treatment and control conditions on primary outcome measures for these interventions at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was a trend for increased self-report of PTSD symptoms at 3 to 6 month follow-up in those who received an intervention (k=4, n=292; SMD 0.23; 95% CI 0.00 to 0.46). Two studies compared a memory structuring intervention against supportive listening. There was no evidence supporting the efficacy of this intervention.

AUTHORS' CONCLUSIONS

The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used. Further, better designed studies that explore new approaches to early intervention are now required.

Expression of emotion: when it causes trauma and when it helps

The idea that clients should be encouraged to express strong emotion regarding the traumas they have suffered is widely assumed. This article asks whether the empirical literature supports the underlying assumption that emotional expression leads to positive outcomes (better health and dissipation of distress). Studies in which individuals who have been given an opportunity to express emotions about past traumas are compared with subjects placed in appropriate control conditions are reviewed. The empirical literature suggests that eliciting emotion is harmful when it is not associated with reappraisal of past trauma, but helpful when the reappraisal occurs. The following guideline emerges: if trauma is to be revisited, it should be accompanied by reappraisal. Since this is sometimes difficult to engineer, alternative approaches for working with victims of trauma, not involving revisiting the trauma, are offered. Additionally, it is suggested that it can be helpful to identify the nature of the problem arising from the traumatic experience and then provide therapeutic intervention that addresses the problem.

Individual differences in experiencing intrusive memories: the role of the ability to resist proactive interference

This study explored whether a relatively poor ability to resist or inhibit interference from irrelevant information in working memory is associated with experiencing undesirable intrusive memories. Non-selected participants (N=91) completed a self-report measure of intrusive memories, and carried out experimental tasks intended to measure two different types of inhibition: resistance to proactive interference and response inhibition (i.e., the ability to prevent automatically triggered responses). The results showed a significant relationship between inhibition at the cognitive level (i.e., resistance to proactive interference) and the frequency of intrusive memories (especially in the group of female participants) whereas no such relationship with measures of response inhibition emerged. These findings are consistent with the idea that deficient inhibitory control reflects a vulnerability factor for experiencing intrusive memories. Implications for research investigating risk factors for the development of posttraumatic stress disorder (PTSD) are discussed.

Academic/State/Federal collaborations and the improvement of practices in disaster mental health services and evaluation

Academic, state, and federal agencies collaborated over the last 9 years to improve disaster mental health services and evaluation. This process, which included literature reviews, a number of expert panels, and case studies, is described. The products resulting from this process have included the development of a systematic cross-site evaluation of the federally funded crisis counseling program and field guides for interventions aimed at providing services to distressed individuals in the immediate aftermath of disasters and to individuals needing resilience skills training weeks or months after the event. Future improvement of disaster mental health services calls for continued research, evaluation, training, and intervention development.

Cognitive-behavioral psychology: implications for disaster and terrorism response

Given the personal and societal costs associated with acute impairment and enduring post-traumatic stress disorder (PTSD), the mental health response to disasters is an integral component of disaster response planning. The purpose of this paper is to explore the compatibility between cognitive-behavioral psychology and the disaster mental health model, and explicate how cognitive-behavioral perspectives and intervention methods can enhance the effectiveness of disaster mental health services. It is argued that cognitive-behavioral methods, if matched to the contexts of the disaster and the needs of individuals, will improve efforts to prevent the development of PTSD and other trauma-related problems in survivors of disaster or terrorist events. First, the similarities between models of care underlying both disaster mental health services and cognitive-behavioral therapies are described. Second, examples of prior cognitive-behavioral therapy-informed work with persons exposed to disaster and terrorism are provided, potential cognitive-behavioral therapy applications to disaster and terrorism are explored, and implications of cognitive-behavioral therapy for common challenges in disaster mental health is discussed. Finally, steps that can be taken to integrate cognitive-behavioral therapy into disaster mental health are outlined. The aim is to prompt disaster mental health agencies and workers to consider using cognitive-behavioral therapy to improve services and training, and to motivate cognitive-behavioral researchers and practitioners to develop and support disaster mental health response.

Preclinical assessment for selectively disrupting a traumatic memory via postretrieval inhibition of glucocorticoid receptors

BACKGROUND

Traumatic experiences may lead to debilitating psychiatric disorders including acute stress disorder and posttraumatic stress disorder. Current treatments for these conditions are largely ineffective, and novel therapies are needed. A cardinal symptom of these pathologies is the reexperiencing of the trauma through intrusive memories and nightmares. Studies in animal models indicate that memories can be weakened by interfering with the postretrieval restabilization process known as memory reconsolidation. We previously reported that, in rats, intraamygdala injection of the glucocorticoid receptor antagonist RU38486 disrupts the reconsolidation of a traumatic memory. Here we tested parameters important for designing novel clinical protocols targeting the reconsolidation of a traumatic memory with RU38486.

METHODS

Using rat inhibitory avoidance, we tested the efficacy of postretrieval systemic administration of RU38486 on subsequent memory retention and evaluated several key preclinical parameters.

RESULTS

Systemic administration of RU38486 before or after retrieval persistently weakens inhibitory avoidance memory retention in a dose-dependent manner, and memory does not reemerge following a footshock reminder. The efficacy of treatment is a function of the intensity of the initial trauma, and intense traumatic memories can be disrupted by changing the time and number of interventions. Furthermore, one or two treatments are sufficient to disrupt the memory maximally. The treatment selectively targets the reactivated memory without interfering with the retention of another nonreactivated memory.

CONCLUSIONS

RU38486 is a potential novel treatment for psychiatric disorders linked to traumatic memories. Our data provide the parameters for designing promising clinical trials for the treatment of flashback-type symptoms of PTSD.

The Effects of Conceptual Processing Versus Suppression on Analogue PTSD Symptoms after a Distressing Film

Background:Researchers have begun to scrutinize the assumption that active processing in response to a traumatic event is beneficial whereas avoidance of thoughts, emotions and reminders about the traumatic event is detrimental. Indications that avoidance is not always detrimental come from studies on grief and debriefing.Aims:In an analogue experimental study, the hypothesis was tested that conceptually-driven processing immediately after a distressing film is more successful in reducing analogue PTSD symptoms than suppression of thoughts and images related to the film.Method:Ninety students watched a distressing film after which they were instructed to either elaborate on the meaning of the film (conceptual processing) (n= 31), suppress all thoughts and images of the film by performing a task (n= 29), or were given no instruction (n= 30). Four hours later, analogue PTSD symptoms were assessed.Results:The results showed that conceptually-driven processing does not result in fewer analogue PTSD symptoms than suppression.Conclusions:It is speculated that suppression may only be dysfunctional when individuals interpret their symptoms negatively or when suppression is believed to be dysfunctional.

Can playing the computer game "Tetris" reduce the build-up of flashbacks for trauma? A proposal from cognitive science

BACKGROUND

Flashbacks are the hallmark symptom of Posttraumatic Stress Disorder (PTSD). Although we have successful treatments for full-blown PTSD, early interventions are lacking. We propose the utility of developing a 'cognitive vaccine' to prevent PTSD flashback development following exposure to trauma. Our theory is based on two key findings: 1) Cognitive science suggests that the brain has selective resources with limited capacity; 2) The neurobiology of memory suggests a 6-hr window to disrupt memory consolidation. The rationale for a 'cognitive vaccine' approach is as follows: Trauma flashbacks are sensory-perceptual, visuospatial mental images. Visuospatial cognitive tasks selectively compete for resources required to generate mental images. Thus, a visuospatial computer game (e.g. "Tetris") will interfere with flashbacks. Visuospatial tasks post-trauma, performed within the time window for memory consolidation, will reduce subsequent flashbacks. We predicted that playing "Tetris" half an hour after viewing trauma would reduce flashback frequency over 1-week.

METHODOLOGY/PRINCIPAL FINDINGS

The Trauma Film paradigm was used as a well-established experimental analog for Post-traumatic Stress. All participants viewed a traumatic film consisting of scenes of real injury and death followed by a 30-min structured break. Participants were then randomly allocated to either a no-task or visuospatial ("Tetris") condition which they undertook for 10-min. Flashbacks were monitored for 1-week. Results indicated that compared to the no-task condition, the "Tetris" condition produced a significant reduction in flashback frequency over 1-week. Convergent results were found on a clinical measure of PTSD symptomatology at 1-week. Recognition memory between groups did not differ significantly.

CONCLUSIONS/SIGNIFICANCE

Playing "Tetris" after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact. Pathological aspects of human memory in the aftermath of trauma may be malleable using non-invasive, cognitive interventions. This has implications for a novel avenue of preventative treatment development, much-needed as a crisis intervention for the aftermath of traumatic events.

Psychometric properties of the Trauma Relevant Assumptions Scale

This article describes the psychometric properties of a novel questionnaire, i.e. the Trauma Relevant Assumptions Scale (TRAS). The added value of the TRAS over previous trauma relevant belief questionnaires is that the TRAS enables measuring valence and rigidity of beliefs simultaneously. Both aspects are thought to be predictive of the development of chronic PTSD symptoms. For the exploratory factor analysis, the TRAS was administered to 309 adult volunteers. Principal components analysis yielded two factors: Assumptions about Self and Assumptions about the World. The two-factor structure was confirmed in a sample of 185 traumatized individuals. The TRAS seems to be a valid and reliable instrument, which is strongly related to post-trauma symptoms and has good discriminative validity. Apart from research settings, the TRAS may also be suitable in therapeutic settings to identify the severity of dysfunctional assumptions, and to assess the progress in change from negative assumptions to more positive assumptions.

An Evaluation of a Police Debriefing Programme: Outcomes for Police Officers Five Years after a Police Shooting

To evaluate the effectiveness of a debriefing programme to reduce traumatic stress in a police organisation, officers involved in a shooting were surveyed by questionnaire, five years after the event. The results showed that 79 per cent of 57 officers had not received debriefing, despite its mandatory status. Those who had received debriefing had higher post-traumatic stress disorder (PTSD) scores; however, regression of PTSD and health scores, on stress perceptions, social support, other trauma, and debriefing, showed that debriefing had no significant effect. These results support those of other controlled studies suggesting that debriefing does not mitigate PTSD and may exacerbate symptoms. A number of limitations of the present study are discussed in terms of suggestions for urgent evaluation of such programs in organisational settings.

Chronic thought suppression and posttraumatic symptoms: data from the Madrid March 11, 2004 terrorist attack

Although a considerable number of people either witnessed directly or in the mass media the traumatic scenes of the terrorist attack that took place on March 11th, 2004 in Madrid, only a fraction of Madrid citizens developed posttraumatic symptoms. In this study, posttraumatic stress-related symptoms, degree of exposure, coping strategies related to the attack, and chronic attempts to avoid intrusive thoughts (i.e., thought suppression) were assessed in a general population Madrid sample (N=503) 2-3 weeks after the attacks. Our results showed that participants with higher scores in chronic thought suppression exhibited higher levels of PTSD symptoms. Higher scores in chronic thought suppression also correlated positively with the use of avoidant coping strategies after the attacks. We discuss the possible common roots of avoidance of intrusive thoughts and avoidant coping strategies and the implications of this relationship for the emergence of stress-related symptoms as well as for public health policies.

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.

Risk factors predict post-traumatic stress disorder differently in men and women

BACKGROUND

About twice as many women as men develop post-traumatic stress disorder (PTSD), even though men as a group are exposed to more traumatic events. Exposure to different trauma types does not sufficiently explain why women are more vulnerable.

METHODS

The present work examines the effect of age, previous trauma, negative affectivity (NA), anxiety, depression, persistent dissociation, and social support on PTSD separately in men and women. Subjects were exposed to either a series of explosions in a firework factory near a residential area or to a high school stabbing incident.

RESULTS

Some gender differences were found in the predictive power of well known risk factors for PTSD. Anxiety predicted PTSD in men, but not in women, whereas the opposite was found for depression. Dissociation was a better predictor for PTSD in women than in men in the explosion sample but not in the stabbing sample. Initially, NA predicted PTSD better in women than men in the explosion sample, but when compared only to other significant risk factors, it significantly predicted PTSD for both men and women in both studies. Previous traumatic events and age did not significantly predict PTSD in either gender.

CONCLUSION

Gender differences in the predictive value of social support on PTSD appear to be very complex, and no clear conclusions can be made based on the two studies included in this article.

Acute interventions for refugee children and families

This article describes the exposure of refugees, and particularly refugee children, to trauma, loss, and severe hardship in their countries of origin, while fleeing to their host countries, and after arrival in the host country. It then discusses acute psychosocial interventions for traumatized children and families, in particular the "Psychological First Aid" and "Skills for Psychological Recovery" guidelines developed by the National Child Traumatic Stress Network and the National Center for Posttraumatic Stress Disorder. It concludes by discussing the need to establish an evidence base for the effectiveness of such interventions.

Combat stress casualties in Iraq. Part 1: behavioral health consultation at an expeditionary medical group

PURPOSE

We review the role of military mental health professionals in consulting with inpatient medical patients and staff at a combat hospital and aeromedical evacuation staging facility in Iraq.

CONCLUSIONS

Behavioral health consultation with medical and surgical patients during hospitalization and prior to aeromedical evacuation can help identify patients with combat stress exposure that may require future mental health follow-up.

PRACTICE IMPLICATIONS

Extensive use of civilian mental health practitioners including nurse psychotherapists and psychiatric nurse practitioners will be needed to provide psychiatric care for the large number of U.S. veterans who return from deployment with combat stress related disorders.

Evidence for recovery of fear following immediate extinction in rats and humans

Fear responses can be eliminated through extinction, a procedure involving the presentation of fear-eliciting stimuli without aversive outcomes. Extinction is believed to be mediated by new inhibitory learning that acts to suppress fear expression without erasing the original memory trace. This hypothesis is supported mainly by behavioral data demonstrating that fear can recover following extinction. However, a recent report by Myers and coworkers suggests that extinction conducted immediately after fear learning may erase or prevent the consolidation of the fear memory trace. Since extinction is a major component of nearly all behavioral therapies for human fear disorders, this finding supports the notion that therapeutic intervention beginning very soon after a traumatic event will be more efficacious. Given the importance of this issue, and the controversy regarding immediate versus delayed therapeutic interventions, we examined two fear recovery phenomena in both rats and humans: spontaneous recovery (SR) and reinstatement. We found evidence for SR and reinstatement in both rats and humans even when extinction was conducted immediately after fear learning. Thus, our data do not support the hypothesis that immediate extinction erases the original memory trace, nor do they suggest that a close temporal proximity of therapeutic intervention to the traumatic event might be advantageous.

Variations in the spacing of expressive writing sessions

OBJECTIVES

In a test to determine whether a brief version of the expressive writing (EW) method was viable, 106 college students participated in an experiment dealing with the study of life transitions.

DESIGN

Individuals were randomly assigned to write for 15 minutes on three occasions: either three times separated by 10-min break (1-hour condition), 35-min break (3-hour condition), or 24-hour break (3-day condition).

METHODS

Participants were randomly assigned to write about their thoughts and feelings about the transitions (N=80), or to describe daily behaviours surrounding the transitions in a non-emotional way (N=26).

RESULTS

The three emotional writing conditions did not vary in terms of their engagement with writing, their emotional reactions, short- or long-term reactions to the intervention. Compared to controls, those in the experimental conditions evidenced fewer symptom reports 9 months after writing.

CONCLUSIONS

The findings suggest that a brief 1-hour EW is more emotionally demanding, but that it has comparable effects on physical symptoms as the traditional 3-day method.

Psychological factors associated with response to maxillofacial injury and its treatment

PURPOSE

This study evaluated symptoms of acute stress disorder (ASD), satisfaction with appearance postsurgery, and satisfaction with care in patients with maxillofacial injury at their first postsurgical physician visit. To determine the best predictors of patients' ASD symptoms and satisfaction, data also were obtained on the patients' strategies for coping with the stress of the injury, on the patients' and doctors' interpersonal appraisals of each other, and on the doctors' participatory behavior during the visits.

PATIENTS AND METHODS

A total of 47 patients who had sustained traumatic maxillofacial injury requiring emergency medical/surgical treatment were administered self-report measures immediately before and after their first postsurgical visit 10 to 12 days after trauma exposure. Doctors completed self-report measures after the visit and evaluated the patients' severity of injury.

RESULTS

Patients experienced high levels of ASD in the short-term period after surgery. Use of emotion-focused strategies by patients to cope with stress was associated with more ASD symptoms but better satisfaction with facial appearance. The more severely injured patients were less satisfied with their appearance and were viewed by their doctors as being more interpersonally controlling during the postsurgical visit.

CONCLUSIONS

Closer attention by doctors to patients' interpersonal behavior may aid in early identification of those patients with maxillofacial injury who may experience longer-term social problems related to their altered facial appearance.

Factors impacting trauma treatment practice patterns: the convergence/divergence of science and practice

OBJECTIVE

This study surveyed the practice patterns of behavioral health providers to determine the degree to which providers in this study utilized evidence-based approaches when dealing with traumatized individuals and the extent to which these practice methods vary as a result of population density or provider characteristics.

METHOD

A survey instrument was designed specifically for this study. The Trauma Practices Questionnaire (TPQ) a 22-item trauma treatment practice utilization scale was mailed to all licensed or certified behavioral health providers in a southern state (N=5752). Responses of 1121 professionals who represent seven disciplines are reported.

RESULTS

Gender and the acquisition of specialized trauma training impacted the way providers practice. Discipline-specific differences became statistically nonsignificant when controlling for gender. Several areas of guideline convergence were uncovered (e.g. the frequent use of CBT) as well as practices that were divergent from best practice recommendations, especially with regards to the use of psychopharmacological interventions.

CONCLUSIONS

Results highlight issues related to translational research dissemination and training practices, as well as factors that might affect clinician's acceptance of and compliance with evidence-based practices.

A randomised controlled trial of group debriefing

There has never been published a randomised controlled trial of group debriefing. In this study we employed an analogue study with students to conduct the first such trial. Sixty-four participants were shown a stressful video of paramedics attending to injured and dead victims of a road traffic accident. Half the participants were subsequently debriefed and half were provided with tea and biscuits and allowed to talk amongst themselves. A 1 month follow-up was administered. It was found that, while the video was rated as distressing, there were no significant differences between the debriefed and non-debriefed groups on measures of affective distress and trauma symptoms. Those who were debriefed later recalled having wanted to talk more to someone about the video than those who were not debriefed. It is suggested that cognitive dissonance may explain this result.

Tending Wounds

The authors extend the metaphor of wound healing in medicine to organizations and propose a model of organizational healing. Organizational healing differs from resilience, hardiness, and recovery and refers to the actual work of repairing and mending the collective social fabric of an organization after crisis. Using a qualitative research study based on interview data gathered after a shooting incident in a Midwestern university, the authors propose a model of organizational healing that includes three stages of healing and six key enablers: inflammation—prioritizing individual in need of urgent care and minimizing the potential for recriminations; proliferation—fostering high-quality connections and improvising on routines; and remodeling—strengthening a family organizational culture and initiating ceremonies and rituals. The authors offer implications for how organizations manage these enablers after crisis and suggest that organizations adopting these are more likely to experience healing.

Pre-stressor cognitive control is related to intrusive cognition of a stressful film

It has been suggested that relatively weak cognitive control existing prior to a stressful event may be associated with intrusive memories of that stressor afterwards. We explored this in two analog studies employing unselected participants who saw an emotional film fragment and completed behavioral (i.e., color-naming interference [CNI]) and self-report indices of intrusions. Prior to film presentation, several cognitive control tests were administered. Study 1 showed that better updating/monitoring was linked to less CNI from negative film-related words. However, better updating/monitoring was associated with more diary reports of intrusive memories. Study 2 showed that a better resistance to pro-active interference (PI) predicted less self-reported film-related intrusive cognition after 24h. However, after this delay, both self-reported intrusions and CNI were not related to updating/monitoring. Taken together, the results suggest that a specific pre-existing cognitive control function (i.e., resistance to PI) may be involved in the regulation of post-stressor intrusive memory phenomena.

Promoting mental health following the London bombings: a screen and treat approach

Following the 2005 London bombings, a novel public health program was instituted to address the mental health needs of survivors. In this article, the authors describe the rationale for the program, characteristics of individuals assessed within the program, and preliminary outcome data. In addition to validated screening instruments and routine service usage data, standardized questionnaire outcome measures were collected. Seventy-one percent of individuals screened positive for a mental disorder. Of those receiving a more detailed clinical assessment, PTSD was the predominant diagnosis. Preliminary outcome data on 82 patients revealed large effect sizes for treatment comparable to those previously obtained in randomized controlled trials. The program succeeded in its aim of generating many more referrals of affected individuals than came through normal referral channels.

Psychological interventions following terrorist attacks

BACKGROUND

Psychological reactions to terror attacks have been documented as ranging from no symptoms to transient behavioural symptoms to more serious posttraumatic stress.

SOURCES OF DATA

A review of representative studies is presented, with a critical analysis of the salient points of the various psychological intervention strategies for terrorist attacks.

AREAS OF AGREEMENT

Common aspects of both most intervention approaches include multifaceted models that foster social support and include a preparatory phase, a phase of 'psychological first aid' and a follow-up phase of referral for more severe cases.

AREAS OF CONTROVERSY

The notion of intervention for all who may show some symptoms is not universally accepted. Where treatment or intervention is used, the debriefing aspect of CISM (Critical Incident Stress Management) remains highly disputed, with the focus on intrusively revisiting the trauma appearing to have questionable value at best.

GROWING POINTS

Some data questions whether formal treatment or intervention is necessary or even desirable. For many who choose not to seek out any help following a trauma, clinical data shows no negative results. Moreover, the preponderance of data shows that conventional 'debriefing' is not recommended. If the debriefing mechanism is refined so that intrusive emotional rehashing of the traumatic event is eliminated, the resultant interventions resemble resilience based approaches.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further defining when intervention is called for and refining the mechanisms of intervention in multi-stage intervention.

Family context of mental health risk in Tsunami affected mothers: findings from a pilot study in Sri Lanka

This study investigated direct and indirect influences of Tsunami exposure on mothers' PTSD and depressive symptoms using survey data from 325 Tsunami-affected families living in two villages in southern Sri Lanka. Findings generally support the hypothesized model in that life and property destruction contributed to the PTSD and depressive symptoms of mothers. Detrimental influences of Tsunami exposure also operated through the generation of more proximal secondary Tsunami risks such as post-Tsunami family problems. In addition, religious participation, familism, number of children, intact family status, and community support reduced mothers' depressive symptoms. Finally, intact family status and high religious participation moderated the detrimental influence of Tsunami exposure on mothers' PTSD symptoms. These findings can contribute directly to improving ongoing recovery and reconstruction programs and help to formulate future programs for families affected by the Tsunami and other natural disasters.

Coping with loss and bereavement in post-war Tigray, Ethiopia

Drawing upon data collected through in-depth interviews with 20 victims of the Ethio-Eritrean war, this article addresses how psychosocial impacts of political violence are coped with in a Tigrayan context in northern Ethiopia. Qualitative procedures of condensation and categorization of interview texts revealed that informants presented three kinds of coping strategies, all aimed at avoiding indulging in sorrow: (1) diverted thinking, (2) distraction, and (3) future investment. As their main rationale for employing such coping strategies, informants reported the belief that grieving and crying would have negative impacts on their health, their household, and on their relationship with God. This belief is discussed in terms of how it is informed by sociocultural discourses of the Tigrayan community in general, and discourses of the Ethiopian Orthodox Church in particular. Some implications concerning the mismatch between the western trauma discourse and local discourses for psychosocial coping are discussed.