Posttraumatic Stress Disorder and Physical Illness: Results from Clinical and Epidemiologic Studies

Changes in mood predict disease activity and quality of life in patients with psoriasis following emotional disclosure

OBJECTIVE

The present study examined the effects of emotional disclosure (ED) intervention on both disease severity and quality of life in patients with psoriasis.

METHODS

Fifty-nine patients were recruited (mean age, 50 years; 32 men and 27 women; mean length of diagnosis, 22 years). Individuals were randomly assigned to receive ED intervention or standard control writing intervention. Disease severity, quality of life, and mood were assessed at baseline and at 2, 8, and 12 weeks postintervention.

RESULTS

Disease severity and quality of life improved in both groups over the follow-up period. Preliminary analysis suggested no differences in the magnitude of improvement between the groups. However, predictors of improvement were found to differ. Disease severity on Week 12 was predicted by changes in mood in intervention patients and seasonal variation in control patients. In contrast, quality of life on Week 12 was predicted by baseline quality of life in intervention patients, while seasonal variation approached significance for control patients.

CONCLUSIONS

Changes in mood following ED predicted improvements in disease severity in patients with psoriasis. However, the degree of improvement did not differ between intervention and control patients.

Growth Hormone Perturbations in Fibromyalgia: A Review

OBJECTIVE

Fibromyalgia (FM) is a syndrome characterized by chronic widespread pain, fatigue, disrupted sleep, depression, and physical deconditioning. In this article, we review the literature on the normal activity of the hypothalamic-pituitary-growth hormone-insulin-like growth factor-1 (HP-GH-IGF-1) axis and its perturbations in FM subjects.

METHODS

Studies included in this review were accessed through an English language search of Cochrane Collaboration Reviews. Keyword MeSH terms included "fibromyalgia," "growth hormone" (GH), or "insulin-like growth factor-1" (IGF-1).

RESULTS

Twenty-six studies enrolling 2006 subjects were reviewed. Overall, low levels of IGF-1 were found in a subgroup of subjects. Growth hormone stimulation tests often revealed a suboptimal response, which did not always correlate with IGF-1 levels. No consistent defects in pituitary function were found. Of the 3 randomized placebo controlled studies, only 9 months of daily injectable recombinant GH reduced FM symptoms and normalized IGF-1.

CONCLUSIONS

These studies suggest that pituitary function is normal in FM and that reported changes in the HP-GH-IGF-1 axis are most likely hypothalamic in origin. The therapeutic efficacy of supplemental GH therapy in FM requires further study before any solid recommendations can be made.

Disaster-related posttraumatic stress disorder and physical health

OBJECTIVE

To examine the relationship between posttraumatic stress disorder (PTSD) and self-reported as well as physician-recorded physical health in a sample of survivors (n = 896) of a man-made disaster, using a longitudinal design that included predisaster health data. Most studies on the relationship between PTSD and physical health are cross-sectional and use self-reported physical health outcomes.

METHODS

A surveillance using the electronic medical records of survivors' family practitioners (FPs), 1 year predisaster until 4 years postdisaster, was combined with a survey, 3 weeks and 18 months postdisaster. Self-reported PTSD and self-reported physical health were assessed at 18 months postdisaster. FP-recorded physical health problems in the subsequent 2 years were classified according to the International Classification of Primary Care. Multiple regression analyses were used to describe the relationships between PTSD and physical health.

RESULTS

After adjusting for demographics, smoking behavior, and predisaster physical health, PTSD was significantly associated with FP-recorded vascular, musculoskeletal, and dermatological problems, and with all self-reported physical health aspects. Prospectively, PTSD signaled an increased risk of new vascular problems (odds ratio = 1.92; 1.04-3.55).

CONCLUSIONS

This study suggests an effect of PTSD in the development of vascular problems. The results imply that clinicians should be alert that disaster survivors with PTSD can suffer from comorbid medical problems as well.

Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem

Introduction

Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors such as participation in combat, violent assault, and survival of natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear.

Methods

We conducted keyword searches of MEDLINE and Psych Info and investigations of secondary references for all articles pertaining to PTSD in medical intensive care unit (ICU) survivors.

Results

From 78 screened papers, 16 studies (representing 15 cohorts) and approximately 920 medical ICU patients met inclusion criteria. A total of 10 investigations used brief PTSD screening tools exclusively as opposed to more comprehensive diagnostic methods. Reported PTSD prevalence rates varied from 5% to 63%, with the three highest prevalence estimates occurring in studies with fewer than 30 patients. Loss to follow-up rates ranged from 10% to 70%, with average loss to follow-up rates exceeding 30%.

Conclusion

Exact PTSD prevalence rates cannot be determined due to methodological limitations such as selection bias, loss to follow-up, and the wide use of screening (as opposed to diagnostic) instruments. In general, the high prevalence rates reported in the literature are likely to be overestimates due to the limitations of the investigations conducted to date. Although PTSD may be a serious problem in some survivors of critical illness, data on the whole population are inconclusive. Because the magnitude of the problem posed by PTSD in survivors of critical illness is unknown, there remains a pressing need for larger and more methodologically rigorous investigations of PTSD in ICU survivors.

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.

Enhanced cortisol suppression in response to dexamethasone administration in traumatized veterans with and without posttraumatic stress disorder

BACKGROUND

While enhanced cortisol suppression in response to dexamethasone is one of the most consistent biological findings in posttraumatic stress disorder (PTSD), the relative contribution of trauma exposure to this finding remains unclear.

METHODS

Assessment of diurnal salivary cortisol levels and 1600 h salivary cortisol before and after oral administration of 0.5mg dexamethasone in veterans with PTSD, veterans without PTSD (trauma controls) and healthy controls. Assessment of 1600 h plasma cortisol, ACTH and corticotrophin binding globulin (CBG) in response to dexamethasone in PTSD patients and trauma controls.

RESULTS

Both PTSD patients and trauma controls demonstrated significantly more salivary cortisol suppression compared to healthy controls. Salivary cortisol, plasma cortisol and ACTH suppression as well as CBG levels did not differ between PTSD patients and trauma controls. PTSD patients showed a reduced awakening cortisol response (ACR) compared to healthy controls that correlated significantly with PTSD symptoms. No significant differences were observed in ACR between PTSD patients and trauma controls.

CONCLUSIONS

These data suggest that enhanced cortisol suppression to dexamethasone is related to trauma exposure and not specifically to PTSD. The correlation between the ACR and PTSD severity suggests that a flattened ACR may be a result of clinical symptoms.

Modulation operated by the sympathetic nervous system on jaw reflexes and masticatory movement

The sympathetic nervous system (SNS), that is activated under condition of physical, psychological and psychosocial stress, affects force production and fatigability of muscles by controlling both muscle blood flow and the intracellular contractile mechanism. In addition SNS may affect motor function by modulating afferent activity from muscle spindles that are highly concentrated in jaw-closing muscles. Possible implications of these actions on masticatory function and myofascial pain are discussed.

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

Disturbance of serum interleukin-2 and interleukin-8 levels in posttraumatic and non-posttraumatic stress disorder earthquake survivors in northern China

OBJECTIVE

It is evident that immune cytokines are involved in the pathophysiology of posttraumatic stress disorder (PTSD), but results of different studies are still inconsistent. Here, serum interleukin (IL)-2, IL-6 and IL-8 levels were compared between earthquake survivors with PTSD, those with non-PTSD and normal controls to investigate whether there is any relationship between cytokine levels and PTSD. In addition, the relationship of these cytokines with psychological parameters of the disorder was examined as well.

METHODS

Thirty-four earthquake survivors with PTSD (according to DSM-IV criteria), 30 earthquake survivors with non-PTSD and 34 controls were recruited in northern China using the Composite International Diagnostic Interview instrument. Serum IL-2, IL-6 and IL-8 levels were compared. IL-2 levels were measured by radioimmunometric assay, while serum IL-6 and IL-8 levels were measured using sandwich enzyme-linked immunosorbent assay. Psychological symptoms were assessed using 3 subscales of the Symptoms Checklist (SCL-90-R), including depression, anxiety and somatization.

RESULTS

Only earthquake survivors diagnosed with PTSD had significantly lower serum IL-8 levels. Also, we found that earthquake survivors (either with PTSD or non-PTSD) had significantly lower serum IL-2 levels and more severe psychological symptoms. The severity of depressive and anxiety symptoms in earthquake survivors was positively related to serum IL-6 levels.

CONCLUSIONS

PTSD may be associated with a reduced level of serum IL-8, and traumatic survivors may be associated with a lower level of serum IL-2.

Endocrine and inflammatory alterations in post-traumatic stress disorder

Post-traumatic stress disorder has frequently been found associated with alterations in endogenous stress hormone systems, for example the hypothalamus-pituitary-adrenal axis and sympatho-adrenal-medullary system. Hormonal alterations are observed at the central and peripheral level of the central nervous system, and in the periphery for inflammatory disinhibition. Both consequences bear significant hazards for the individual, the former by sustaining or exacerbating the psychiatric condition, the latter by its detrimental effects on somatic health. However, the role of hormonal modifications in the development and maintenance of post-traumatic stress disorder symptoms and in the accompanying cognitive and emotional impairments still remains quite unclear.

External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition

Research suggests that exposure to psychologic trauma is associated with mortality from external causes, including homicide, suicide, drug overdoses, and unintended injury. However, the etiology of this association is unclear. We examined the survival time and cause of death among a national sample of 15288 US Army veterans by posttraumatic stress disorder (PTSD) status 30 years after military service. In these analyses, we included demographic (age, race, marital status, service entry age, and birthplace), predisposing (army volunteer status, discharge status, history of drug abuse, early-age alcohol use, and intelligence), and combat exposure variables. After adjusting for demographic and predisposing factors, all-cause mortality was associated with PTSD for all veterans combined (hazards ratio [HR] = 2.1, P < .001), as well as for era veterans without Vietnam service (HR = 2.0, P = .001) and theater veterans with Vietnam service (HR = 2.1, P < .001). For theater veterans, PTSD remained significant for all-cause mortality, even after controlling for demographic, predisposition, and combat exposure measures (HR = 2.1, P < .001). For external mortality, the adjusted results indicated that PTSD was associated with death for all veterans combined (HR = 2.3, P < .001) and for theater veterans separately (HR = 2.2, P = .002). For era veterans, the adjusted external mortality results also approached statistical significance (HR = 2.2, P = .068). Among theater veterans, PTSD remained significant for external mortality, even after controlling for all variables and combat exposure (HR = 2.2, P = .002). Combat exposure was not associated with external mortality once all variables were controlled. In addition, theater veterans who volunteered for Vietnam and those with dishonorable discharges were at increased risk for external-cause mortality.

Individual reactivity to the open-field predicts the expression of cardiovascular and behavioural sensitisation to novel stress

Posttraumatic stress disorder (PTSD) is the fourth most common psychiatric disorder. It is associated with cardiovascular disorders and irritable bowel syndrome (IBS). Besides stressful life-events, a prior history of gastrointestinal infection is a predisposing factor for the development of IBS. Only a proportion of persons exposed to traumatic events develop PTSD. Several factors, like genetic predisposition, stressor intensity, cognitive appraisal mechanisms and coping processes influence the likelihood of developing PTSD after exposure to a trauma. We used a single session of footshocks in rats, an animal model with a high degree of validity for PTSD, to study whether transient colonic inflammation alters local and distal visceral sensitivity, and whether reactivity to the open-field (low (LA) or high (HA) active) predicts long-term stress-induced behavioural and cardiovascular sensitisation and altered visceral pain sensitivity. A distention series and noise challenge were given 2 weeks after foot-shocks, followed by a transient colonic inflammation period and a second distention series and noise challenge 4 weeks after foot-shocks. During exposure to noise, both before and after inflammation, footshocked rats showed increased immobility compared to controls, which was significantly greater in LA rats than in HA rats. LA preshocked rats also showed a greater blood pressure response to the noise test, but this only became evident in the second noise-test. Neither footshocks nor colonic inflammation affected duodenal pain sensitivity. The results provide additional evidence for long-lasting cardiovascular hyperresponsivity after a stressful event and indicate that its degree is predicted by personality traits or coping style.

Alcohol use, mental health status and psychological well-being 2 years after the World Trade Center attacks in New York City

Over the past 30 years, studies have shown that survivors of community-wide disasters suffer from a variety of physical and mental health problems. Researchers also have documented increased substance use in the aftermath of these disasters. In the present study, we examined the relationship between alcohol use and mental health status within the context of the terrorist attacks on the World Trade Center in New York City (NYC). The data for the present report come from a 2-wave panel study of adults living in NYC on the day of the attacks. Wave 1 (W1) and Wave 2 (W2) interviews occurred one year and two years after the attacks, respectively. Overall, 2,368 individuals completed the W1 survey (cooperation rate, 63%) and 1,681 completed the W2 survey (re-interview rate, 71%). The alcohol use variables examined were binge drinking, alcohol dependence, increased days drinking, and increased drinks per day. The outcomes examined included measures of posttraumatic stress disorder (PTSD), major depression, BSI-18-Global Severity and measures of SF12-mental and physical health status. After controlling for demographic, stress, and resource factors, multivariate logistic regressions indicated that all alcohol measures were related to one or more of these outcomes. In particular, binge drinking was related to partial PTSD, while alcohol dependence was associated subsyndromal PTSD, severity of PTSD, depression, BSI-18 global severity, and SF-12 poor mental health status. Increased post-disaster drinking was positively associated with subsyndromal PTSD and negatively associated with SF-12 physical health. We discuss reasons for these results and the negative consequences that heavy alcohol use may have on the postdisaster recovery process.

Influence of sympathetic nervous system on sensorimotor function: whiplash associated disorders (WAD) as a model

There is increasing interest about the possible involvement of the sympathetic nervous system (SNS) in initiation and maintenance of chronic muscle pain syndromes of different aetiology. Epidemiological data show that stresses of different nature, e.g. work-related, psychosocial, etc., typically characterised by SNS activation, may be a co-factor in the development of the pain syndrome and/or negatively affect its time course. In spite of their clear traumatic origin, whiplash associated disorders (WAD) appear to share many common features with other chronic pain syndromes affecting the musculo-skeletal system. These features do not only include symptoms, like type of pain or sensory and motor dysfunctions, but possibly also some of the pathophysiological mechanisms that may concur to establish the chronic pain syndrome. This review focuses on WAD, particular emphasis being devoted to sensorimotor symptoms, and on the actions exerted by the sympathetic system at muscle level. Besides its well-known action on muscle blood flow, the SNS is able to affect the contractility of muscle fibres, to modulate the proprioceptive information arising from the muscle spindle receptors and, under certain conditions, to modulate nociceptive information. Furthermore, the activity of the SNS itself is in turn affected by muscle conditions, such as its current state of activity, fatigue and pain signals originating in the muscle. The possible involvement of the SNS in the development of WAD is discussed in light of the several positive feedback loops in which it is implicated.

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life

BACKGROUND

Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.

OBJECTIVE

To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.

DESIGN

Thematic literature review.

RESULTS

The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.

CONCLUSIONS

Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.

Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms

BACKGROUND

Post-traumatic stress disorder (PTSD) may develop in the aftermath of an acute myocardial infarction (MI). Whether PTSD is a risk factor for cardiovascular disease (CVD) is elusive. The biological mechanisms linking PTSD with atherosclerosis are unclear.

DESIGN

A critical review of 31 studies in the English language pursuing three aims: (i) to estimate the prevalence of PTSD in post-MI patients; (ii) to investigate the association of PTSD with cardiovascular endpoints; and (iii) to search for low-grade systemic inflammatory changes in PTSD pertinent to atherosclerosis.

METHODS

We located studies by PubMed electronic library search and through checking the bibliographies of these sources.

RESULTS

The weighted prevalence of PTSD after MI was 14.7% (range 0-25%; a total of 13 studies and 827 post-MI patients). Two studies reported a prospective association between PTSD and an increased risk of cardiovascular readmission in post-MI patients and of cardiovascular mortality in combat veterans, respectively. In a total of 11 studies, patients with PTSD had increased rates of physician-rated and self-reported cardiovascular diseases. Various cytokines and C-reactive protein were investigated in a total of seven studies suggesting that PTSD confers a pro-inflammatory state.

CONCLUSIONS

Increasing evidence suggests that PTSD specifically related to MI develops considerably frequently in post-MI patients. More research is needed in larger cohorts applying a population design to substantiate findings suggesting PTSD is an atherogenic risk factor and to understand better the suspected behavioural and biological mechanisms involved.

Assessment of HPA-axis function in posttraumatic stress disorder: pharmacological and non-pharmacological challenge tests, a review

Posttraumatic stress disorder (PTSD) is typically accompanied by acute and chronic alterations in the stress response. These alterations have mostly been described in individuals under baseline conditions, but several studies have also used a challenge model to further assess the role of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response. This paper reviews common methodology and research findings on HPA function in PTSD, and discusses the pathophysiological mechanisms underlying these findings. We reviewed the literature and selected all English-language, human subject, data driven, pharmacological and non-pharmacological challenge studies pertaining to the HPA axis, and in vitro leukocyte glucocorticoid receptor studies in adult PTSD subjects. Studies using a non-pharmacological stress paradigm (cognitive stress, trauma reminders) to stimulate the HPA axis showed an exaggerated cortisol response in PTSD. The most widely used pharmacological challenge with consistent results was the low dose dexamethasone-suppression test (DST). These DST studies showed enhanced cortisol suppression in subjects with PTSD. Different hypotheses have been purported to explain the alterations in HPA axis functioning in PTSD. The results of the reviewed challenge tests, however, did not exclusively support one of the hypothesized mechanisms. Further research assessing hormones at all levels of the HPA axis at both baseline and at challenge conditions with a proper stratification of study population, will be necessary for a better understanding of stress-responsivity on the level of the HPA axis in PTSD.

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Altered blood coagulation in patients with posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been associated with an increased cardiovascular risk, though the pathophysiologic mechanisms involved are elusive. A hypercoagulable state before occurrence of coronary thrombosis contributes to atherosclerosis development. We investigated whether PTSD would be associated with increased coagulation activity.

METHODS

We measured resting plasma levels of clotting factor VII activity (FVII:C), FVIII:C, FXII:C, fibrinogen, and D-dimer in 14 otherwise healthy patients with PTSD and in 14 age- and gender-matched, trauma-exposed non-PTSD controls. Categorical and dimensional diagnoses of PTSD were made using the Clinician-Administered PTSD Scale (CAPS) interview. We also investigated to what extent the relationship between PTSD and coagulation measures would be confounded by demographics, cardiovascular risk factors, lifestyle variables, time since trauma, and mood.

RESULTS

Coagulation factor levels did not significantly differ between patients with a categorical diagnosis of PTSD and controls while controlling for covariates. In all subjects, FVIII:C was predicted by hyperarousal severity (beta = 0.46, p = .014) independent of covariates and by overall PTSD symptom severity (beta = 0.38, p = .045); the latter association was of borderline significance when separately controlling for gender, smoking, exercise, and anxiety (p values <.07). In patients, fibrinogen was predicted by hyperarousal severity (beta = 0.70, p = .005) and by overall PTSD symptom severity (beta = 0.61, p = .020), with mood partially affecting these associations. FVII:C, fibrinogen, and D-dimer showed no independent association with PTSD symptoms.

CONCLUSIONS

PTSD may elicit hypercoagulability, even at subthreshold levels, offering one psychobiological pathway by which posttraumatic stress might contribute to atherosclerosis progression and clinical cardiovascular disease.

Predictors of PTSD and delayed PTSD after disaster: the impact of exposure and psychosocial resources

In the present study we sought to identify factors associated with posttraumatic stress disorder (PTSD) following the World Trade Center Disaster (WTCD) and examine changes in PTSD status over time. Our data come from a two-wave, prospective cohort study of New York City adults who were living in the city on September 11, 2001. We conducted a baseline survey 1 year after the attacks (year 1), followed by a survey 1 year later (year 2). Overall, 2368 individuals completed the year 1 survey, and 1681 were interviewed at year 2. Analyses for year 1 indicated that being younger, being female, experiencing more WTCD events, reporting more traumatic events other than the WTCD, experiencing more negative life events, having low social support, and having low self-esteem increased the likelihood of PTSD. For year 2, being middle-aged, being Latino, experiencing more negative life events and traumas since the WTCD, and having low self-esteem increased the likelihood of PTSD. Exposure to WTCD events was not related to year 2 PTSD once other factors were controlled. Following previous research, we divided study respondents into four categories: resilient cases (no PTSD years 1 or 2), remitted cases (PTSD year 1 but not year 2), delayed cases (no PTSD year 1 but PTSD year 2), and acute cases (PTSD both years 1 and 2). Factors predicting changes in PTSD between year 1 and year 2 suggested that delayed PTSD cases were more likely to have been Latino, to have experienced more negative life events, and to have had a decline in self-esteem. In contrast, remitted cases experienced fewer negative life events and had an increase in self-esteem. We discuss these findings in light of the psychosocial context associated with community disasters and traumatic stress exposures.

The impact of the 1991 Gulf War on the mind and brain: findings from neuropsychological and neuroimaging research

Many veterans of the 1991 Gulf War (GW) have complained of somatic and cognitive symptoms that may be neurological in nature. However, whether or not changes in brain function are associated with GW service continues to be debated. Studies of GW veterans using objective, performance-based neuropsychological measures have yielded inconsistent findings, with those indicating deficits among GW veterans typically revealing only relatively mild levels of neuropsychological impairment. Further, performances on objective neuropsychological tasks show little correspondence to subjective perceptions of cognitive functioning. Although preliminary magnetic resonance spectroscopy (MRS) studies demonstrate reduced N-acetylaspartate-to-creatine (NAA/Cr) ratio in select brain regions among GW veterans who report health concerns, this work requires further replication with larger, more representative samples. There is no evidence from neuroimaging studies of a non-specific effect of GW service or of changes in brain structure or function related to health status when conventional radiological methods are used. Owing to the paucity of objective exposure, baseline health data, and the now significant time elapsed since the GW, aetiological issues may never be fully resolved. Therefore, research addressing clinical management of GW veterans with neuropsychological dysfunction and neuroimaging abnormalities may prove more fruitful than exclusive focus on aetiology.

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.

Residual indoor contamination from world trade center rubble fires as indicated by polycyclic aromatic hydrocarbon profiles

The catastrophic destruction of the World Trade Center (WTC) on Sept. 11, 2001 (9/11) created an immense dust cloud followed by fires that emitted smoke and soot into the air of New York City (NYC) well into December. Outdoor pollutant levels in lower Manhattan returned to urban background levels after about 200 days as the fires were put out and the debris cleanup was completed. However, particulate matter (PM) from the original collapse and fires also penetrated into commercial and residential buildings. This has created public concern because WTC dust is thought to cause adverse pulmonary symptoms including "WTC cough" and reduced lung capacity. Additionally, some recent studies have suggested a possible link between exposure to WTC contamination and other adverse health effects. Distinguishing between normal urban pollutant infiltration and residual WTC dust remaining in interior spaces is difficult; efforts are underway to develop such discriminator methods. Some progress has been made in identifying WTC dust by the content of fibers believed to be associated with the initial building collapse. There are also contaminants created by the fires that burned for 100 days in the debris piles of the building rubble. Using WTC ambient air samples, we have developed indicators for fire related PM based on the relative amounts of specific particle bound polycyclic aromatic hydrocarbons (PAHs) and the mass fraction of PAHs per mass of PM. These two parameters are combined, and we show a graphical method for discriminating between fire sources and urban particulate sources as applied to samples of settled dusts. We found that our PAHs based discriminator method can distinguish fire source contributions to WTC related particulate matter and dusts. Other major building fires or large open burn events could have similar PAHs characteristics. We found that random samples collected approximately 3.5 years after the WTC event from occupied indoor spaces (primarily residential) in the New York area are not statistically distinguishable from contemporary city background.

Well-being, physical functioning, and use of health services in the elderly with PTSD and subthreshold PTSD

OBJECTIVE

To measure the impact of PTSD and subthreshold PTSD on daily life functioning, well-being and health care use in a community based-sample of the elderly population in the Netherlands.

METHODS

Consequences of PTSD were investigated in an elderly community-based population (LASA study) by comparing three groups: subjects with PTSD, with subthreshold PTSD, and a reference group. Indicators of well-being (loneliness, self-perceived health and satisfaction with life), disability (days spent in bed and disability days) and use of health care (general practitioners, medical specialists, psychiatrists, mental health care, social workers and professional home care) were investigated.

RESULTS

In comparison to the reference group, subjects with PTSD or subthreshold PTSD spent more days in bed due to illness and had more disability days, even when corrected for concurring other diseases or functional limitations. They were less satisfied with life in general, used health care for predominantly somatic care and evaluated the care they received to be inadequate. Psychotropic drugs, if prescribed, were predominantly benzodiazepines and seldom antidepressants.

CONCLUSIONS

The findings strongly suggest that elderly with either PTSD or subthreshold PTSD suffer grave impairments in daily life, are less satisfied with life and do not receive optimum treatment. Especially elderly with PTSD frequently visit medical specialists but are rarely treated by psychiatrists or other mental health professionals, nor do they receive antidepressant treatment from their GP. Lack of adequate treatment may be the cause of dissatisfaction with the care they receive.

Evidence of resilience: neuroimaging in former prisoners of war

In this study, single voxel proton magnetic resonance spectroscopic imaging ((1)H-MRS) and volumetric analysis of hippocampal magnetic resonance imaging (MRI) images were used to determine if any differences in hippocampal biochemistry or volume were present between former prisoners of war (POWs) with and without posttraumatic stress disorder (PTSD) and control subjects matched for age and education. This study did not find lower hippocampal concentrations of N-acetylaspartate (NAA), smaller hippocampal volumes, or more impaired memory function in older veterans with PTSD compared with a group matched for traumatic experience or a nontraumatized control group.

Adverse reactions associated with studying persons recently exposed to mass urban disaster

This study assesses the psychological consequences of participation in a mental health study among people recently exposed to the September 11 attacks. Using cross-sectional telephone surveys, we interviewed random samples of English-speaking or Spanish-speaking adults living in New York City during the attacks 1 year after this event. Altogether, 2,368 people completed the surveys, including a random sample of 1,173 respondents who received mental health services after the attacks. Results indicated that 15% of New Yorkers found some of the survey questions stressful, whereas 28% of those who sought treatment found this to be the case. However, less than 2% reported being upset at survey completion, and among these persons, only four people consented to speak to the study's mental health consultant. Although the majority of those expressing adverse reactions had sought postdisaster treatment, even among these subjects, only 3% were still upset at survey completion, and 2% wanted more information about counseling services. In addition, more than 70% of participants expressed positive sentiments about survey participation. Predictive models indicated that respondents who met study criteria for posttraumatic stress disorder, depression, or anxiety were more likely to find questions stressful, with people having posttraumatic stress disorder or depression the most likely to be upset and to consent to psychiatric consultation at completion. We suggest that, with the proper safeguards, research with persons exposed to a resent mass urban disaster generally can be conducted safely and effectively.