Stages of decompensation in combat-related posttraumatic stress disorder: a new conceptual model

Defense Mechanisms and Borderline Personality Organization Among COVID-19 Believers and Non-believers During Complete Lock-Down

The aim of the current study was to investigate whether a specific social perception of the pandemic-believing or not in COVID-19-predicts borderline personality organizations and whether this relationship is mediated by more primitive maladaptive mechanisms-splitting, denial, and dissociation. The online study included 720 organization aged 25-45. Participants were diverse in terms of place of residence, being in a relationship, and education level. Approximately 30% of the general population reported not believing in the COVID-19 pandemic. Non-believers scored slightly higher on borderline symptoms and used more maladaptive defense mechanisms than believers. Individuals who deny COVID-19 are more likely to show characteristics of borderline personality organization. Splitting is an important mechanism in this relationship.

Service Dogs for Veterans and Military Members With Posttraumatic Stress Disorder: Replication With the PTSD Checklist for DSM-5

Psychiatric service dogs are an emerging complementary intervention for veterans and military members with posttraumatic stress disorder (PTSD). Recent cross-sectional studies have documented significant, clinically relevant effects regarding service dogs and PTSD symptom severity. However, these studies were conducted using the PTSD Checklist (PCL) for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The present study aimed to replicate and advance these findings using the latest version of the PCL for the fifth edition of the DSM (PCL-5). Participants included 186 military members and veterans who had received a PTSD service dog (n = 112) or who were on the waitlist to receive one in the future (n = 74). A cross-sectional design was used to investigate the association between having a service dog and PCL-5 total and symptom cluster scores. After controlling for demographic variables, there was a significant association between having a service dog and lower PTSD symptom severity both in total, B = -14.52, p < .001, d = -0.96, and with regard to each symptom cluster, ps < .001, ds = -0.78 to -0.94. The results replicated existing findings using the largest sample size to date and the most recent version of the PCL. These findings provide additional preliminary evidence for the efficacy of service dogs as a complementary intervention for military members and veterans with PTSD and add to a growing body of foundational research serving to rationalize investment in the further clinical evaluation of this emerging practice.

Status of glucocorticoid alterations in post-traumatic stress disorder

The current status of glucocorticoid alterations in post-traumatic stress disorder (PTSD) will be described in this chapter. Emphasis will be placed on data that suggest that at least some glucocorticoid-related observations in PTSD reflect pretraumatic glucocorticoid status. Recent observations have provided some evidence that pretraumatic glucocorticoid alterations may arise from genetic, epigenetic, and possibly other environmental influences that serve to increase the likelihood of developing PTSD following trauma exposure, as well as modulate attendant biological alterations associated with its pathophysiology. Current studies in the field of PTSD employ glucocorticoid challenge strategies to delineate effects of exogenously administered glucocorticoids on neuroendocrine, cognitive, and brain function. Results of these studies have provided an important rationale for using glucocorticoid strategies in the treatment of PTSD.

Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts

Medically unexplained symptoms (MUS) are frequently associated with a history of traumatization. The first purpose of the present review paper was to investigate systematically the evidence for such relation in a subset of clinical samples with MUS presenting with functional somatization: chronic pelvic pain, irritable bowel syndrome and conversion and somatization disorder. The second purpose was to critically review three dominant models explaining the relation between trauma and MUS (i.e. dissociation, conversion and hierarchical cognitive models). The latter model in particular adequately accounts for the non-volitional and non-intentional character of MUS and explains how traumata can affect the development of MUS without assuming that previous trauma is a necessary prerequisite of MUS. The cognitive model, however, lacks integration with current neurobiological findings, indicative of central stress-and central nervous system alterations in MUS. The final purpose of the present paper was, therefore, to review current neurobiological studies focused on trauma and MUS and to formulate a research agenda to integrate these neurobiological developments with cognitive models for MUS.

Thyroid hormone levels and psychological symptoms in sexually abused adolescent girls

OBJECTIVE

To explore the relationships between psychological symptoms and thyroid hormone levels in adolescent girls who had experienced the traumatic stress of sexual abuse.

METHOD

The study design was cross-sectional/correlational. Subjects (N=22; age range=12-18 years) had their blood drawn, and they completed 2 psychological tests (depression and general distress/posttraumatic stress disorder [PTSD]). A pediatrician completed a sexual abuse questionnaire after reviewing law enforcement and Child Protective Services reports and conducting forensic interviews and medical examinations.

RESULTS

Girls' average free T4, total T4, free T3, total T3, and TSH levels were within age-specific laboratory reference range limits, as were most individual concentrations. The strongest correlations (p<.05) were between free T3 and PTSD total score (-.50), PTSD-avoidance/numbing (-.49), and general distress (-.48); and between total T3 and depression (-.46), general distress (-.45), and PTSD-arousal (-.44).

CONCLUSIONS

Our findings support one of the two contemporary models of the relationships between thyroid hormones (i.e., free and total T3) and psychological symptoms (i.e., depression, general distress, and PTSD)--one of "shutting down" (vs. "activation") in the face of trauma.

Dissociation: An insufficiently recognized major feature of complex posttraumatic stress disorder

The role of dissociation in (complex) posttraumatic stress disorder (PTSD) has been insufficiently recognized for at least two reasons: the view that dissociation is a peripheral, not a central feature of PTSD, and existing confusion regarding the nature of dissociation. In this conceptual article, the authors address both issues by postulating that traumatization essentially involves some degree of division or dissociation of psychobiological systems that constitute personality. One or more dissociative parts of the personality avoid traumatic memories and perform functions in daily life, while one or more other parts remain fixated in traumatic experiences and defensive actions. Dissociative parts manifest in negative and positive dissociative symptoms that should be distinguished from alterations of consciousness. Complex PTSD involves a more complex structural dissociation than simple PTSD.

Non-termination of sickness behavior as precipitating factor for mental disorders

Sickness behavior can be defined as a combination of coordinated behavioral and physiological changes that develop in response to any condition that elicits pro-inflammatory activity. It is an adaptational homeostasis initiated by the influence of pro-inflammatory cytokines on central nervous system neurohormonal functioning. This paper introduces the concept of non-termination of sickness behavior as a potential threat to mental health. In view of the similarities between the behavioral symptoms, the neuroendocrine and the cytokine profiles of sickness behavior and that of a number of mental disorders it is hypothesized that the inappropriate continuation of sickness behavior, (i.e., non-termination), after recovery from the initial disease, could form the basis for mental disturbances. This would be particularly relevant in individuals with alterations in stress vulnerability (altered activation threshold and impaired negative feedback), which may occur due to the combination of genetic disposition and priming by early life experiences.

Neuroendocrine aspects of PTSD

This chapter discussed how neuroendocrine findings in posttraumatic stress disorder (PTSD) potentially inform hypothalamic-pituitary-adrenal (HPA) alterations in PTSD and highlight alterations relevant to the identification of targets for drug development. Most studies demonstrate alterations consistent with an enhanced negative feedback inhibition of cortisol on the pituitary, an overall hyperreactivity of other target tissues (adrenal gland, hypothalamus), or both in PTSD. However, findings of low cortisol and increased reactivity of the pituitary in PTSD are also consistent with reduced adrenal output. The observations in PTSD are part of a growing body of neuroendocrine data providing evidence of insufficient glucocorticoid signaling in stress-related neuropsychiatric disorders.

Current status of cortisol findings in post-traumatic stress disorder

This article summarizes findings of hypothalamic-pituitary-adrenal axis alterations in post-traumatic stress disorder (PTSD) and evaluates likely reasons for the lack of agreement among published studies. Sources of variance caused by methodologic and interpretative differences are highlighted, but the disparate findings are explained as illustrating a more complex neuroendocrinology of PTSD than has previously been described.

Marked lability in urinary cortisol levels in subgroups of combat veterans with posttraumatic stress disorder during an intensive exposure treatment program

OBJECTIVE

The objective of this study was to obtain longitudinal data on lability of cortisol levels in posttraumatic stress disorder (PTSD) because previous studies have largely been based on sampling at a single time point and have yielded varying results.

METHODS

This study measured urinary cortisol levels at admission, midcourse, and discharge during a 90-day hospitalization period in male Vietnam combat veterans with PTSD (N = 51).

RESULTS

Although there were no significant differences in the mean +/- SEM urinary cortisol levels between the admission (59.4 +/- 3.0 microg/d), midcourse (55.6 +/- 3.9 microg/d), and discharge (53.4 +/- 3.4 microg/d) values, marked lability of cortisol levels in individual patients was observed over time, with changes ranging from +93 to -58 microg/d from admission to midcourse. In addition, this hormonal lability defined discrete subgroups of patients on the basis of the longitudinal pattern of cortisol change during exposure treatment, and there were significant psychometric differences in the level of social functioning between these subgroups.

CONCLUSIONS

The findings do not support the concept of either a static "hypocortisolism" or "hypercortisolism" in PTSD, but rather suggest a psychogenic basis for cortisol alterations in PTSD in relation to psychosocial stress and indicate a central regulatory dysfunction of the hypothalamic-pituitary-adrenal axis characterized by a dynamic tendency to overreact in both upward and downward directions. The longitudinal findings fit with recent observations that cortisol elevations occur when acutely superimposed stressful conditions emotionally engage patients and overwhelm the usually dominating disengaging coping mechanisms associated with suppression of cortisol levels in PTSD. The findings emphasize the importance of longitudinal data in studies of the hypothalamic-pituitary-adrenal axis in PTSD.

Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder

OBJECTIVE

This review integrates recent advances in attachment theory, affective neuroscience, developmental stress research, and infant psychiatry in order to delineate the developmental precursors of posttraumatic stress disorder.

METHOD

Existing attachment, stress physiology, trauma, and neuroscience literatures were collected using Index Medicus/Medline and Psychological Abstracts. This converging interdisciplinary data was used as a theoretical base for modelling the effects of early relational trauma on the developing central and autonomic nervous system activities that drive attachment functions.

RESULTS

Current trends that integrate neuropsychiatry, infant psychiatry, and clinical psychiatry are generating more powerful models of the early genesis of a predisposition to psychiatric disorders, including PTSD. Data are presented which suggest that traumatic attachments, expressed in episodes of hyperarousal and dissociation, are imprinted into the developing limbic and autonomic nervous systems of the early maturing right brain. These enduring structural changes lead to the inefficient stress coping mechanisms that lie at the core of infant, child, and adult posttraumatic stress disorders.

CONCLUSIONS

Disorganised-disoriented insecure attachment, a pattern common in infants abused in the first 2 years of life, is psychologically manifest as an inability to generate a coherent strategy for coping with relational stress. Early abuse negatively impacts the developmental trajectory of the right brain, dominant for attachment, affect regulation, and stress modulation, thereby setting a template for the coping deficits of both mind and body that characterise PTSD symptomatology. These data suggest that early intervention programs can significantly alter the intergenerational transmission of posttraumatic stress disorders.

Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamus-pituitary-adrenal axis

Following the assumption that stressors play an important part in the etiology and maintenance of psychiatric disorders, it is necessary to evaluate parameters reflecting stress-related physiological reactions. Results from these examinations may help to deepen the insight into the etiology of psychiatric disorders and to elucidate diagnostic uncertainties. One of the best-known stress-related endocrine reactions is the hormonal release of the hypothalamic-pituitary-adrenal (HPA) axis. Dysregulations of this axis are associated with several psychiatric disorders. Profound hyperactivity of the HPA-axis has been found in melancholic depression, alcoholism, and eating disorders. In contrast, posttraumatic stress disorder, stress-related bodily disorders like idiopathic pain syndromes, and chronic fatigue syndrome seem to be associated with diminished HPA activity (lowered activity of the adrenal gland). Hypotheses referring to (a) the psychophysiological meaning and (b) the development of these alterations are discussed.

Psychogenic lowering of urinary cortisol levels linked to increased emotional numbing and a shame-depressive syndrome in combat-related posttraumatic stress disorder

OBJECTIVE

The purpose of the study was to search for the intrapsychic correlates of individual differences in cortisol levels in male Vietnam combat veterans with posttraumatic stress disorder.

METHODS

The study involved measurement of urinary cortisol levels and clinical assessment with a broad profile of psychometric tests during a single 48-hour period in 30 inpatients.

RESULTS

The main finding by both correlation and t test analyses was a significant inverse relationship between urinary cortisol levels and a symptom complex composed of two closely interrelated clinical subgroupings, "disengagement" (principally involving emotional numbing) and "shame-laden depression."

CONCLUSIONS

The findings support the concept that cortisol levels reflect the ongoing balance between the undifferentiated emotional arousal state of engagement (associated with higher cortisol levels) and opposing antiarousal disengagement defense mechanisms (associated with lower cortisol levels). It appears that the low cortisol levels often seen in patients with posttraumatic stress disorder are psychogenic and reflect a dominating effect of disengagement coping strategies, which represent secondary compensatory adaptations during the chronic course of this disorder to counteract primary arousal symptoms, especially those related to an intractable shame-laden depressive syndrome. The psychoendocrine findings suggest that the relatively inconspicuous clinical feature of shame resulting from both the primary and secondary traumatizations is a particularly powerful, preoccupying, and overwhelming source of emotional engagement. Shame may represent a "sleeper" that is worthy of greater attention in both research and clinical efforts to understand the pathogenesis and psychopathology of this devastating stress-related disorder.

The experience of chronic illness and post-traumatic stress disorder: the consequences of cumulative adversity

In this paper the experiences of the chronically ill are examined to explore the impact of post-traumatic stress disorder (PTSD), accumulated burden of adversity and trauma spectrum disorder on subsequent illness and coping behaviors. Individuals experiencing chronic diseases have been studied with regard to depression, anxiety and a variety of coping maladaptions, but negligible attention has been given to the PTSD potential of chronic disease over the life course. Yet, growing evidence suggests that the traumatogenic potential of chronic diseases, some sudden and unexpected onsets, and the traumatogenic changes in life circumstance, may produce maladaptive illness coping over the life course. More importantly, attention needs to focus on the additive effect of co-morbid life events and the traumatic potential of invasive medical therapies. Consideration of PTSD and a continuum of cumulative adversity provide a more complex and fully drawn understanding of the circumstances surrounding chronic illness coping and reasons for maladaptive coping following invasive therapies and changes in the disease trajectory. The pathophysiology that produces a chronic diseases does not begin at symptom onset, and the psychosocial strategies to cope with a chronic illness, whether efficacious or maladaptive, also do not begin at symptom onset, but develops over the life course.

The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders

Representing a challenge for current concepts of stress research, a number of studies have now provided convincing evidence that the adrenal gland is hypoactive in some stress-related states. The phenomenon of hypocortisolism has mainly been described for patients, who experienced a traumatic event and subsequently developed post-traumatic stress disorder (PTSD). However, as presented in this review, hypocortisolism does not merely represent a specific correlate of PTSD, since similar findings have been reported for healthy individuals living under conditions of chronic stress as well as for patients with several bodily disorders. These include chronic fatigue syndrome, fibromyalgia, other somatoform disorders, rheumatoid arthritis, and asthma, and many of these disorders have been related to stress. Although hypocortisolism appears to be a frequent and widespread phenomenon, the nature of the underlying mechanisms and the homology of these mechanisms within and across clinical groups remain speculative. Potential mechanisms include dysregulations on several levels of the hypothalamic-pituitary adrenal axis. In addition, factors such as genetic vulnerability, previous stress experience, coping and personality styles may determine the manifestation of this neuroendocrine abnormality. Several authors proposed theoretical concepts on the development or physiological meaning of hypocortisolism. Based on the reviewed findings, we propose that a persistent lack of cortisol availability in traumatized or chronically stressed individuals may promote an increased vulnerability for the development of stress-related bodily disorders. This pathophysiological model may have important implications for the prevention, diagnosis and treatment of the classical psychosomatic disorders.

The interaction of posttraumatic stress disorder and depression among older combat veterans

The question whether depression is related to trauma as part of posttraumatic stress disorder (PTSD) itself or whether it represents autonomous symptoms occurring separately (from PTSD) has not been answered. We addressed two issues: (a) What is the relationship between PTSD and depression as measured by continuous measures on outcomes? and (b) By removing depression components from the PTSD diagnosis, what is the impact on standard outcomes? Older veterans from World War II or Korea were interviewed and given self-report measures on PTSD and depression. The CAPS-1 and the MMPI-D were used as the continuous measures for PTSD and depression. The outcome measures were health status, overall adjustment, social support, and physiological status. Results showed that depression influenced health status and social support: PTSD did not contribute to the equation. The CAPS-1 also was further divided into CAPS-PTSD and CAPS-D (depression) based on item content. For adjustment and health status, PTSD asserted a greater influence; for social support and heart rate, depression was the greater influence. Discussion addressed the fact that depression is an important consideration in the expression of PTSD.

Anniversary reactions in Gulf War veterans: a follow-up inquiry 6 years after the war

OBJECTIVE

The goal of this study was to assess the occurrence of anniversary reactions in Gulf War veterans 6 years after the conclusion of the war.

METHOD

Subjects were administered questionnaires and asked to identify specific months of best and worst functioning and months of least or most symptoms of posttraumatic stress disorder (PTSD) for the 12 months before the study. Months of negative experiences were compared with previously documented dates of exposure to traumatic events during the war. Similar reports were also obtained from the veterans' spouses in order to assess corroborative evidence for the occurrence of anniversary reactions.

RESULTS

Anniversary reactions occurred with a frequency greater than chance and most often in individuals exposed to a greater number of traumatic events. Overall, spouse reports matched the veterans' reports of anniversary reactions. In addition, spouses identified anniversary reactions that were not endorsed by their veterans.

CONCLUSIONS

These data suggest that anniversary reactions occur in numbers greater than those expected by chance, are correlated to the occurrence of traumatic events, and may be a part of the syndrome of PTSD.

Suffering: the contributions of persistent pain

Pain is a perceived threat or damage to one's biological integrity. Suffering is the perception of serious threat or damage to the self, and it emerges when a discrepancy develops between what one expected of one's self and what one does or is. Some patients who experience sustained unrelieved pain suffer because pain changes who they are. At a physiological level, chronic pain promotes an extended and destructive stress response characterised by neuroendocrine dysregulation, fatigue, dysphoria, myalgia, and impaired mental and physical performance. This constellation of discomforts and functional limitations can foster negative thinking and create a vicious cycle of stress and disability. The idea that one's pain is uncontrollable in itself leads to stress. Patients suffer when this cycle renders them incapable of sustaining productive work, a normal family life, and supportive social interactions. Although patients suffer for many reasons, the physician can contribute substantially to the prevention or relief of suffering by controlling pain. Suffering is a nebulous concept for most physicians, and its relation to pain is unclear. This review offers a medically useful concept of suffering that distinguishes it from pain, accounts for the contributory relation of pain to suffering by describing pain as a stressor, and explores the implications of these ideas for the care of patients.

Physiological and emotional response to psychological stressors in psychiatric and psychosomatic disorders

Deviations from emotional and physiological homeostasis in humans occur under episodic, chronic, or traumatic stress experiences. These dysregulations can provoke emotional and physical disturbances that may result in stress-related psychiatric or psychosomatic disorders. This brief review discusses a variety of both naturally occurring and experimental stressors and the complexity of intervening variables on cardiovascular and hormonal dysregulations of the hypothalamic-pituitary-adrenal (HPA) axis. In addition to the type, intensity, and duration of the stressor, subject variables such as dispositional factors (e.g., age and sex), personality traits, and coping styles are considered. Finally, emotional and physiological stress responses to naturally occurring stressors and psychological challenge tests in depressed patients and anxiety disorder patients are presented and discussed. Stressors in humans induce emotional arousal, which leads to physiological activation of the central nervous system, an increase of hormones of the HPA axis, and coping reactions on the psychological and behavioral level. Depending on the type, intensity, and duration of the stressor, on personal and psychosocial resources of the individual, stressful situations may provoke emotional and physical disturbances. These dysfunctions may result in psychosomatic or psychiatric disorders. The following brief review intends to discuss a variety of stressors that have been examined in humans in order to gain insight into the complex relationship between physiological and behavioral stress reactions and the occurrence or maintenance of stress related psychosomatic and psychiatric disorders.