Invited review: post-traumatic stress disorder; a new clinical entity?

Post traumatic stress disorder symptoms in prisoners following a cell mate's hanging

Post traumatic stress disorder (PTSD) is a well recognised condition which occurs in people who have been exposed to severe trauma as victims, potential victims or witnesses. A review of case notes of all prisoners transferred since 1988 to a national forensic psychiatric hospital following traumatic hanging events in prison revealed that all patients had psychological symptoms and four had symptoms probably fulfilling PTSD according to DSM III R criteria. Our findings are discussed with reference to the literature on PTSD, the nature of the prison environment, the premorbid personality of prisoners, and the implications for dealing with the effect of suicide within a prison setting.

Evolution of posttraumatic stress disorder and future directions

The knowledge that trauma can cause long-term physiological and psychological problems has been recognized for centuries. Today, such suffering would be classified as the characteristic symptoms of posttraumatic stress disorder (PTSD). Nurses in all practice settings are increasingly caring for individuals suffering from military trauma, natural disasters, and interpersonal violence such as childhood sexual, physical, and emotional abuse, intimate partner violence, and collective violence. This article discusses how the diagnosis of PTSD evolved over the course of history, limitations of the PTSD diagnostic category, and additional diagnostic categories for trauma. Implications for nursing practice and future directions for research are explored.

Approaching disaster mental health research after the 9/11 World Trade Center terrorist attacks

The article describes the author's experiences with disaster research in the post-9/11 period, first in application of prior research findings to the new situation and later in consultation on the design and development of new research specific to 9/11. The article begins by reviewing the important role of the science of disaster mental health, which was reinforced by the many requests for information from prior research for application to the post-9/11 situation. Next, the article summarizes enduring principles of disaster research application that apply across disaster sites, including 9/11. Addressing unique aspects of the post-9/11 setting, novel considerations for the disaster mental health field are introduced with a new model for conceptualization of subpopulations based on exposure level. Experience in developing research in the post-9/11 setting encountered a number of issues, suggesting need for new policy recommendations that may facilitate research in future disaster settings.

Platelet serotonergic markers in posttraumatic stress disorder

The neurobiological basis of posttraumatic stress disorder (PTSD) is believed to involve alterations in different neurotransmitter systems, and recent studies elucidated the role of serotonin (5-hydroxytryptamine, 5-HT) in PTSD. The data on the role of 5-HT have been obtained using blood platelets as a peripheral model for central serotonergic neurons. The reports suggested that platelet 5-HT concentration and monoamine oxidase (MAO) activity might serve as biological, even trait, markers for particular mental disturbances. Since the data on the peripheral serotonergic markers in PTSD subjects are controversial, the aim of the study was to determine platelet 5-HT concentration and platelet MAO activity in war veterans with PTSD, war veterans who did not develop PTSD, and in war veterans who were prisoners of war and developed PTSD. Platelet 5-HT concentration and MAO activity did not differ significantly between war veterans with or without PTSD, and prisoners of war with PTSD. Clinician-Administered PTSD Scale (CAPS) scores did not differ between war veterans with PTSD and prisoners of war, but Montgomery-Asberg Depression Rating Scale (MADRS) scores were significantly higher in prisoners of war who developed PTSD than in war veterans with PTSD. There was no significant correlation between platelet 5-HT concentration or platelet MAO activity and CAPS or MADRS scores within these groups. Platelet 5-HT concentration was slightly higher and platelet MAO activity slightly lower in prisoners of war with PTSD, than in all other groups. These findings suggest that platelet 5-HT concentration and platelet MAO activity are not altered in three drug-free groups--war veterans who did or did not develop PTSD, or in prisoners of war with PTSD--and that these platelet serotonergic markers are not associated with symptoms of PTSD or comorbid depression.

The psychiatric sequelae of civilian trauma

Much of the literature on the psychiatric consequences of stress has focused on wartime combat trauma. However, traumatic events also frequently occur in civilian life. Controlled studies on the psychiatric effects of noncombat trauma were reviewed and a meta-analysis of these data was conducted. Generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), substance abuse, phobia, and major depressive disorder (MDD) were significantly elevated compared with a pooled control group, whereas panic disorder and dysthymic disorder were not significantly increased. These data suggest that the psychiatric effects of civilian trauma include both anxiety and depressive disorders. The results are strikingly similar to those reported in combat veterans, suggesting that severe trauma, even in very different populations, may be associated with similar psychopathology.

Recognising post-traumatic stress in intensive care patients

'We may not be able to prevent stress or distress, but we can alter the intensity and duration of stress-related trauma by naming our demons, daring to struggle with them, and by creating healing communities.' (Chandler 1992, p 88) In order to create an environment in which the above process can take place it is incumbent upon nurses to assess patients in need and to institute appropriate intervention at an early stage. Critical care nurses have a particular responsibility to identify the seeds of post-traumatic stress and implement supportive and preventive strategies, primarily because of the numbers of traumatised victims passing through their care. Even so, there appears to be a dearth of critical care literature which addresses either assessment or intervention strategies relevant to this important aspect of practice. The purpose of this paper is to highlight aspects of assessment specific to post-traumatic stress through a critical analysis and explanation of its theoretical base. This will act as a precursor to providing direction on possible practice developments.

Long-term effects of trauma: post-traumatic stress among civilian internees of the Japanese during World War II

This study examined predictors and health-related effects of post-traumatic stress among 129 civilian internees of the Japanese during World War II. Post-traumatic stress disorder was noted in 36.7% within the 6 months after their release and in 15.0% within the most recent 6 months. Women were more likely than men to indicate post-traumatic stress disorder within the 6 months after their release. Higher incomes were associated with lower levels of post-traumatic stress within the most recent 6 months. After controlling for demographic and internment-related factors, higher levels of post-traumatic stress were associated with poorer physical health. This association was stronger among older internees than among their younger counterparts. Implications of the findings for clinical gerontology are discussed.

Psychological sequelae following the Gulf War. Factors associated with subsequent morbidity and the effectiveness of psychological debriefing

BACKGROUND

The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity.

METHOD

We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale.

RESULTS

After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf.

CONCLUSIONS

These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.

Psychiatric morbidity in bus crews following violent assault: a follow-up study

In a prospective study 22 bus crews who were victims of physical assault were assessed using standardized psychiatric instruments, followed up for 18 months and compared to a non-assaulted control group drawn from the same bus garage. At initial assessment the assaulted group, compared to the controls showed a significant increase in psychiatric impairment and distress (as measured by the GHQ-30 and IES respectively), with 23% of assault victims developing post-traumatic stress disorder as defined by DSM-III-R. At follow-up, while high levels of both psychiatric impairment and distress persisted there was evidence that they may be separate phenomena.

Railway suicide: the psychological effects on drivers

People have jumped (or fallen) in front of trains on the London Underground system in increasing numbers throughout the twentieth century. During the past decade there have been about 100 such incidents each year, of which around 90 would involve the train driver witnessing his train strike the person on the track. Most are suicides or attempts at suicide. They represent major unexpected and violent events in the lives of the train drivers and it might be expected that some of them would respond by developing a post-traumatic stress reaction of the type identified by Horowitz (1976) or other adverse psychological reactions or both. The research reported in this paper was designed to characterize the range of responses of drivers to the experiences of killing or injuring members of the public during the course of their daily work. It was found that 16.3% of the drivers involved in incidents did develop post-traumatic stress disorder and that other diagnoses, e.g. depression and phobic states, were present in 39.5% of drivers when interviewed one month after the incident.

Strategies for the study of long-term sequelae of oral and facial injuries

Measurement of morbidity after orofacial trauma is necessary to monitor progress and to enable decisions to be made concerning surgical intervention, compensation awards, and psychological support. Although some measurements are routinely made in the assessment of recovery after trauma, many are still in a developmental phase or have only been used in research work. There is a need for a rational, comprehensive, quantitative means of assessing morbidity after orofacial trauma. Such assessments need to include measures of social and psychological distress, as well as physical abnormalities. This article reviews available methods of measuring morbidity and identifies areas in which new methods and developments are necessary. This quantitative approach to the assessment of trauma patients is consistent with developments in traumatology and psychology, which include injury severity scoring and the use of psychomatic tests. A scoring system for assessing orofacial deformity and disability and the attendant psychosocial distress appears to be an attainable objective.

Distressing near-death experiences

Most reported near-death experiences include profound feelings of peace, joy, and cosmic unity. Less familiar are the reports following close brushes with death of experiences that are partially or entirely unpleasant, frightening, or frankly hellish. While little is known about the antecedents or aftereffects of these distressing experiences, there appear to be three distinct types, involving (1) phenomenology similar to peaceful near-death experiences but interpreted as unpleasant, (2) a sense of nonexistence or eternal void, or (3) graphic hellish landscapes and entities. While the first type may eventually convert to a typical peaceful experience, the relationship of all three types to prototypical near-death experiences merits further study. The effect of the distressing experience in the lives of individuals deserves exploration, as the psychological impact may be profound and long-lasting.