Emotional disturbances in trauma patients during the rehabilitation phase: studies of posttraumatic stress disorder and alexithymia

Quality of Life of Patients With Major Amputations in the Tertiary Care Center of Western Rajasthan: A Prospective Observational Study in 2019-2020

Introduction Amputation of a limb is a loss of physical integrity that has disastrous consequences for a person's mental, physical, and social well-being. Aim We aim to analyze the quality of life (QoL) after major amputations and long-term outcomes. Method and materials A prospective, observational study has been conducted in a health care institute in western Rajasthan from January 2019 to July 2020. This study included 64 patients who had major upper or lower limb amputations. We analyzed the sociodemographic factors of the patients, the type of procedure, postoperative hospital stay, complications, and follow-up status with both the SF-12 and the World Health Organization Quality of Life (WHOQOL)-BREF questionnaires. Mean, median, range, standard deviation, percentages, univariable, and multivariable logistic regression were analyzed with SPSS version 23.0 software (IBM Corp., Armonk, NY). Results The mean age of the study patients was 53.6 years (SD 2.6) and they were mostly male (71.9%). Atherosclerotic peripheral vascular disease (PVD) was the most common indication (37.5%) of amputation, and below-the-knee amputation (46.88%) was the most commonly performed procedure. There was a significant increment in both PCS (p-value= 0.001), MCS scores (p-value=0.0001) of SF-12 and physical (p-value=0.0001) and psychological domains (p-value=0.001) of the WHOQOL-BREF questionnaire in the postoperative period. A total of 83.9% of patients have used prostheses, and 15.6% had mortality. Conclusions Major amputations can significantly affect the quality of life of patients, and all efforts should be made to avoid factors that adversely affect their quality of life.

Secondary finger amputation after a work accident

INTRODUCTION

The main aim of the present study was to compare motives between patients requesting secondary finger amputation following or unrelated to a work accident. The secondary objective was to assess correlation between sick leave duration and motive for amputation following a work accident.

METHOD

A single-center retrospective study was conducted over an 11-year period in a hand clinic. Cases of secondary totalizing post-traumatic finger amputation at metacarpal base level were included. Exclusion criteria comprised non-traumatic amputation, age<16 years and thumb amputation. In all, 216 patients met the inclusion criteria. The main endpoints assessed motives in requests for secondary metacarpal base amputation: esthetic, functional or administrative. Secondary endpoints comprised accident-to-surgery interval, gender and age, amputated digit and dominant-side involvement.

RESULTS

Motive correlated significantly with gender (p<0.05). Administrative motives almost exclusively concerned males (21 males, 1 female) and predominantly concerned work accidents (19 vs. 3). Accident-to-surgery intervals were significantly longer in case of administrative motive (25.7 months, vs. 10.8 months for functional and 9 months for esthetic motives). Accident-to-surgery intervals were significantly longer in case of work accidents (15.2 vs. 9.5 months).

DISCUSSION

Age and gender influenced patients' attitudes in post-traumatic finger amputation. Work-accident status influenced attitudes in a quarter of cases; we consider it unlikely that this can be reduced to claims for compensation, but that it is rather a matter of undiagnosed pathological grief. These findings highlight the importance of early follow-up of victims of traumatic amputation and early screening for pathological grief.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Traumatic upper-limb amputation: The process toward acceptance

INTRODUCTION

After traumatic upper-limb amputation (TULA), one-third of patients develop traumatic pathological grief (PG). However, are the other two-thirds unscathed? The main aim of the present study was to assess the rate of TULA victims claiming to have dealt with the consequences and showing no PG. The secondary objective was to determine positive and negative factors enabling and preventing coping.

METHOD

A retrospective clinical study was conducted over an 11-year period in all adult TULA cases in our department. Assessment was on questionnaire. PG was assessed on the ICG (Inventory of Complicated Grief). Factors were assessed on physical, psychological, social, functional, esthetic and epidemiological criteria. Statistical analysis used StatView software, with the significance threshold set at p<0.05.

RESULTS

Functional and social impacts were significantly greater in case of PG. Thumb amputation was significantly associated with PG, while PG was significantly less frequent in case of amputation at the metacarpal base. Patients in PG had significantly more often undergone neuroma resection or stump revision surgery.

DISCUSSION

Fewer than a half of TULA victims achieved cure. Long-term prognosis depends on the patient's ability to accept the new situation, much more than on amputation level. Patients need support from the very first minutes, with follow-up extended well belong scar healing. Onset and healing of the narcissistic wound are inevitably delayed compared to skin healing.

Psychological effects of traumatic upper-limb amputations

INTRODUCTION

The main aim of the present study was to determine the existence of pathological grief in victims of traumatic upper-limb amputation. The secondary objective was to determine risk factors for onset of pathological grief.

METHOD

A retrospective clinical study was conducted for an 11-year period, including all cases of traumatic upper-limb amputation in adults. Patients were assessed on a questionnaire including an adaptation of the Inventory of Complicated Grief (ICG). Risk factors were assessed on surgical, personal occupational and subjective criteria. Statistical analysis on StatView software used matched Chi² tests for comparisons, with the significance threshold set at p<0.001.

RESULTS

With 1058 questionnaires sent out, the response rate was 52%; 3% of returned questionnaires were non-interpretable. Thirty-nine percent showed a state of pathological grief. Risk factors comprised lack of attempted replantation (p<0.001), isolated thumb amputation (p<0.001), and multi-digit or macro-amputation (p<0.001). Subjective esthetic blemish or the feeling of being mutilated was significantly associated with pathological grief (both p<0.001).

DISCUSSION

Traumatic upper-limb amputation victims incurred a risk of pathological grief (main endpoint), with identifiable risk factors (secondary endpoint). Victim accompaniment and screening for risk of pathological grief are essential to limit the psychological impact of trauma and promote social and occupational reintegration.

Posttraumatic Stress and Interpersonal Sensitivity: Alexithymia as Mediator and Emotional Expressivity as Moderator

This study examined 1) the link between PTSD from past trauma, interpersonal sensitivity and psychiatric co-morbidity, 2) mediational effects of alexithymia on 1), and 3) moderated mediational effects with emotional expressivity as the moderator. Five hundred and fifteen Kazakh students completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28, Toronto Alexithymia Scale-20, Berkeley Expressivity Questionnaire and Interpersonal Sensitivity Measure. The results showed that 28% met the criteria for full-PTSD. Controlling for academic year, age and university major, PTSD from past trauma was significantly correlated with interpersonal sensitivity and psychiatric co-morbidity. Alexithymia mediated the impact of PTSD on interpersonal sensitivity and psychiatric co-morbidity. Alexithymia, however, did not interact with type of emotional expressivity to influence outcomes. Moderated mediational effects were not found. To conclude, following trauma, Kazakh students can experience heightened levels of interpersonal sensitivity and psychological symptoms. These problems are particularly severe for those who have difficulty getting in touch with their emotions.

The Relationship Between Gender, Posttraumatic Stress Disorder from Past Trauma, Alexithymia and Psychiatric Co-morbidity in Chinese Adolescents: A Moderated Mediational Analysis

This study focused on a group of Chinese adolescents and examined whether the degree of alexithymia would mediate the effect of PTSD from past trauma onto psychiatric co-morbidities and whether gender differences would moderate the mediational effects of alexithymia. Three hundred and twenty-six adolescents were recruited from two schools and completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28 and Toronto Alexithymia Scale-20. The results showed that 54 % had no trauma in their lives; 10, 21 and 15 % met the criteria for full, partial and no-PTSD respectively. After adjusting the number of traumatic events, difficulty identifying feelings mediated the path between PTSD from past trauma and psychiatric co-morbidity. Gender moderated the mediational effect of difficulty identifying feelings. To conclude, adolescents can develop PTSD symptoms and psychiatric co-morbidity following exposure to a traumatic event. For both males and females, difficulty getting in touch with feelings can influence the impact of PTSD onto psychiatric co-morbidity.

How do maternal PTSD and alexithymia interact to impact maternal behavior?

Maternal interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) is known to be associated with impairment of a mother's capacity to participate in mutual emotion regulation during her child's first years of life. This study tested the hypothesis that maternal difficulty in identifying feelings in self and other, as an important dimension of the construct of alexithymia, together with maternal IPV-PTSD, would be negatively associated with maternal sensitivity. Maternal sensitivity to child emotional communication is a marker of maternal capacity to engage in mutual regulation of emotion and arousal. Following diagnostic interviews and administration of the Toronto Alexithymia Scale, 56 mothers and their toddlers (ages 12-42 months) were filmed during free-play and separation/novelty-exposure. Observed maternal sensitivity was coded via the CARE-Index. Maternal IPV-PTSD severity, difficulty in identifying emotions, and lower socio-economic status were all associated with less maternal sensitivity, and also with more maternal controlling and unresponsive behavior on the CARE-Index.

Alexithymia is linked to neurocognitive, psychological, neuroendocrine, and immune dysfunction in persons living with HIV

The neuropathological changes resulting from Human Immunodeficiency Virus (HIV) infection may manifest in alexithymia (AL), a multidimensional trait characterized by impairments in the cognitive assimilation of feelings and emotions. A sample of 93 HIV survivors scoring high, i.e., ⩾74 on the 26-item Toronto Alexithymia Scale (TAS-26), were compared to 79 low AL (TAS-26⩽54) survivors on measures of neurocognitive, psychological, neuroendocrine and immune function. Neurocognitive function was evinced by a standardized test of psychomotor speed, cognitive flexibility and task switching ability, HIV Dementia and general cognitive status. Patients were also screened for levels of depression, anxiety and psychological stress. A 24-h urinary norepinephrine (NE) and cortisol (CORT) collection was taken; blood was drawn for T lymphocyte subset counts (CD4+CD3+) and HIV-1 viral load. Alexithymic patients exhibited higher levels of executive dysfunction, psychological distress, norepinephrine-to-cortisol (NE/CORT) ratio and viral load. Linear regression models accounting for sociodemographic and disease-related variables revealed two AL subscales, difficulties identifying and describing feelings, predicted and explained a significant proportion of variance in the outcome measures. Specifically, poorer executive task-switching/cognitive flexibility was associated with greater difficulty describing feelings; dysregulated autonomic response (high NE/CORT ratio) and depressive symptoms were predicted by difficulty identifying feelings; higher levels of anxiety and psychological stress were both predicted by greater difficulty describing and identifying feelings. Overall, the psychoneuroimmunological profile of alexithymia in HIV positive persons at mid-stage of infection suggests a greater vulnerability for disease progression.

Traumatic experiences, alexithymia, and posttraumatic symptomatology: a cross-sectional population-based study in Germany

OBJECTIVE

Previous studies have established an association between number of traumatic experiences and alexithymia. The present study examines this relationship in a large-scale representative sample of the German general population (N=2,507) and explores the potential mediating effects of posttraumatic symptomatology, particularly avoidance/numbing.

METHODS

Alexithymia was assessed with the German version of the Toronto Alexithymia Scale (TAS-20). Posttraumatic symptomatology was operationalized by the symptom score of the modified German version of the Posttraumatic Symptom Scale, and traumatic experiences were assessed with the trauma list of the Munich Composite International Diagnostic Interview. Two mediation analyses were conducted.

RESULTS

Of the total sample, 24.2% (n=606) reported at least one traumatic experience, 10.6% (n=258) were classified as alexithymic, and 2.4% (n=59) fulfilled the criteria of posttraumatic stress disorder (PTSD). Participants who had survived five or more traumatic experiences had significantly higher alexithymia sum scores. The PTSD symptom cluster avoidance/numbing mediated the association between the number of traumatic experiences and alexithymia.

CONCLUSIONS

Our findings illustrate an association between number of traumatic experiences and alexithymia and the influence of emotional avoidance and numbing within this relationship. The significant relationship between alexithymia and number of traumatic experiences in a general population sample further supports the concept of multiple and complex traumatization as associated with alexithymia. The results suggest the importance of further investigations determining the causal impact of alexithymia both as a potential premorbid trait and as consequence of traumatization. Lastly, future investigations are needed to clarify alexithymia as a distinct trauma-relevant characteristic for better diagnostics and specialized trauma-integrative therapy.

Alexithymia and posttraumatic stress disorder following asthma attack

This study examined the levels of posttraumatic stress disorder (PTSD) following asthma attack (post-asthma attack PTSD) and psychiatric co-morbidity among college students. It also investigated the association between these variables and alexithymia. One hundred and six college students participated in the study and completed an on-line survey comprising the Asthma Symptom Checklist, PTSD Checklist, General Health Questionnaire-28 and Toronto Alexithymia Scale. Ninety-one students without asthma and major illness formed the control group. 2 % met the diagnostic criteria for full-PTSD, while 42 and 56 % met the partial and no-PTSD criteria respectively. Compared with the control, the asthma group reported significantly more somatic problems, social dysfunction and depression and was five times more likely to have an elevated risk of developing a general psychiatric disorder. After adjusting age, marital status, asthma experience and symptoms, alexithymia did not predict PTSD, while difficulty identifying feelings predicted psychiatric co-morbidity. Mediational analyses showed that asthma symptoms partially mediated the link between difficulty identifying feelings and psychiatric co-morbidity. People can develop PTSD symptoms and other psychological difficulties following asthma attack. Alexithymia influenced general psychological difficulties independently of PTSD symptoms.

Posttraumatic stress disorder following asthma attack (post-asthma attack PTSD) and psychiatric co-morbidity: the impact of alexithymia and coping

This study investigated the prevalence of post-asthma attack posttraumatic stress disorder (PTSD) and the severity of psychiatric co-morbidity among a group of college students and whether alexithymia and coping strategies would relate to health outcomes. This is a cross-sectional study in which 156 college students who had previously experienced asthma attack were recruited. They completed a demographic page, Asthma Symptom Checklist, PTSD Checklist, General Health Questionnaire-28, Toronto Alexithymia Scale and the COPE. They were also matched with 141 students without asthma. The results showed that 3% met the criteria for full-PTSD, 44% for partial and 53% for no-PTSD. There were no significant differences between the asthma and control groups in severity of psychiatric co-morbid symptoms. Path analyses showed that asthma severity was significantly correlated with PTSD and psychiatric co-morbidity. It was also correlated with alexithymia which was in turn associated with psychiatric co-morbidity but not PTSD. Coping strategies were not correlated with health outcomes. To conclude, people can develop PTSD symptoms and degrees of psychiatric co-morbid symptoms after suffering asthma attack. The severity of these symptoms relates to people's perceptions of asthma severity and alexithymia.

Biopsychosocial factors that interfere in the rehabilitation of burn victims: integrative literature review

This study aimed to identify the biopsychosocial factors that influence the rehabilitation of burn victims, through an integrative literature review, from January 1987 to January 2007. Articles were searched in databases Scielo, Pubmed and Lilacs, resulting in 982 articles, of which 45 were selected, after the analysis and categorization processes. Most studies were descriptive and qualitative. The most frequently associated factors to the rehabilitation process were: mental health state before the accident, coping strategies and family support, besides the severity of the burn and the total body surface area burned. The quality of the selected studies, most classified as evidence level VI, shows the scarce production of strong evidences in this knowledge area, which needs more investment, considering the important implications of the sequelae of burns in the social reintegration of these people.

Personality factors and psychopathy, alexithymia and stress

The present study investigated the relations between the Five-Factor Model of personality, psychopathy, alexithymia and stress in 205 technology students. Students completed four tests: the NEO Personality Inventory Revised, the Levinson Self-report Psychopathy Scale, the Toronto Alexithymia Scale and the Recognize Sign of Stress. Multiple regression analyses revealed that Agreeableness and Conscientiousness were significant predictors of total scores of psychopathy, and Openness was a significant predictor of alexithymia. Path analyses indicated that apart from Openness, all personality traits were significant to the model, and stress acted as a mediator between Neuroticism and alexithymia.

Mindfulness and experiential avoidance as predictors of posttraumatic stress disorder avoidance symptom severity

Mindfulness reflects an awareness of present moment experiences through an attitude of acceptance and openness (Bishop et al., 2004; Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008). Experiential avoidance, by contrast, refers to attempts to change, alter, or avoid private experiences (e.g., thoughts, feelings, sensations), and it is believed to underlie a number of psychopathologies, including PTSD (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). We were interested in the ability of mindfulness to predict the variance of PTSD avoidance symptom severity above and beyond experiential avoidance. 378 introductory psychology students were administered self-report measures of PTSD, mindfulness, experiential avoidance, thought suppression, alexithymia, and avoidant coping. Mindfulness, specifically nonjudgment of experiences, accounted for a unique portion of the variance in PTSD avoidance symptoms.

Type 1 diabetes is associated with alexithymia in nondepressed, non-mentally ill diabetic patients: a case-control study

OBJECTIVE

Alexithymia refers to difficulty in identifying and expressing emotions, and it is a characteristic common to several psychiatric and medical conditions, including autoimmune disorders. Type 1 diabetes (T1D) is an autoimmune disorder with increased psychiatric comorbidity. Previously reported associations between alexithymia and T1D may have been confounded by the presence of depression. The central aim of this study was to examine alexithymia levels in psychiatrically uncomplicated T1D outpatients with that of nondiabetic controls.

METHODS

Ninety-six T1D patients without any DSM-IV Axis I diagnoses and 105 age- and sex-matched healthy controls entered the study. Alexithymia and depressive symptoms were assessed with the Toronto Alexithymia Scale (TAS-20) and the Beck Depression Inventory (BDI-21), respectively. Multivariate regression models were used to evaluate the association of alexithymia with the presence of diabetes, duration of diabetes, diabetes control, parameters of treatment intensification, and diabetic complications.

RESULTS

T1D was positively associated with the TAS-20 "identifying feelings" (beta coefficient=2.64, P=.003) and "externally oriented thinking" (beta coefficient=1.73, P=.011) subscales. The prevalence of overall alexithymia (TAS-20 total score, > or =60) was 22.2% in T1D patients and 7.6% in the controls (OR, 4.6; 95% CI, 1.7-12.8). TAS-20 scores were positively associated with diabetes duration and negatively with treatment intensification parameters.

CONCLUSIONS

Alexithymia is higher in psychiatrically uncomplicated T1D patients than in healthy controls even after adjustment for confounding depressive symptoms; it is greater with longer diabetes duration and is associated with some reduced parameters of treatment intensification but not with worse outcome in terms of glycemic control or somatic complications.

The assessment of alexithymia in medical settings: implications for understanding and treating health problems

The construct of alexithymia encompasses the characteristics of difficulty identifying feelings, difficulty describing feelings, externally oriented thinking, and a limited imaginal capacity. These characteristics are thought to reflect deficits in the cognitive processing and regulation of emotions and to contribute to the onset or maintenance of several medical and psychiatric disorders. In this article, we review recent methods for assessing alexithymia and examine how assessing alexithymia can inform clinical practice. Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviors. Alexithymic patients may respond poorly to psychological treatments, although perhaps not to cognitive-behavioral techniques, and it is unclear whether alexithymia can be improved through treatment. Interpretive problems regarding alexithymia include its overlap with other traits, whether it is secondary to illness or trauma, the possibility of subtypes, and low correlations among multiple measures. Nonetheless, we encourage the assessment of alexithymia in applied settings.

Empathic deficits and alexithymia in trauma-related impulsive aggression

Our long term interest is to develop a developmental model of impulsive aggression based on a confluence of social, psychological and biological features. This approach incorporates neurobiological research, which has identified language processing deficits as a unique characteristic of impulsive aggressors and extends it to include emotional deficits. As an initial test of this hypothesis, we examined whether empathy and alexithymia were associated with impulsive aggression. Regressions were performed to explore the associations among impaired empathy, alexithymia, impulsive aggression, verbal and physical general aggression. Among impulsive aggressive veterans (n=38) recruited from a VA trauma clinic, alexithymia predicted impulsive aggression and empathic deficits predicted verbal aggression. Neither emotional awareness deficit predicted general physical aggression in this middle-aged sample. Results suggested that empathic deficits were associated with general verbal aggression, but alexithymia was uniquely associated with impulsive aggression. Consideration of alexithymia in impulsive aggression has implications for its etiology, prevention and treatment.

A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms

This study examined the relationship between posttraumatic stress (PTS) symptoms and particular aspects of emotion regulation difficulties among trauma-exposed individuals. Participants were an ethnically diverse sample of 108 undergraduates from an urban university. PTS symptom severity was found to be associated with lack of emotional acceptance, difficulty engaging in goal-directed behavior when upset, impulse-control difficulties, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall difficulties in emotion regulation were associated with PTS symptom severity, controlling for negative affect. Finally, individuals exhibiting PTS symptoms indicative of a PTSD diagnosis reported greater difficulties with emotion regulation than those reporting PTS symptoms at a subthreshold level. The implications of these findings for research and treatment are discussed.

The role of negative affect intensity and the fear of emotions in posttraumatic stress symptom severity among victims of childhood interpersonal violence

Heightened negative affect (NA) intensity and the tendency to negatively evaluate emotions may be associated with the development and maintenance of posttraumatic stress symptoms. However, the specific role of these vulnerabilities has yet to be explored. Thus, this study was conducted to examine the influence of NA intensity and the fear of emotions in posttraumatic symptom severity among 102 childhood interpersonal violence victims. Fear of emotions significantly predicted posttraumatic symptom severity above and beyond NA intensity and NA. Findings suggest that posttraumatic outcomes may not be influenced by an underlying vulnerability of heightened NA intensity, but instead, are affected by the extent to which emotional responses are negatively evaluated. Results are discussed in terms of their implications for interventions and future research on posttraumatic responding.

Psychiatric and emotional sequelae of surgical amputation

The prevalence of posttraumatic stress symptoms after the experience of amputation is not well established. The current study gathered data on the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders after amputation. Participants were recruited from a large Northeastern rehabilitation hospital and were assessed with structured clinical interviews. The data suggest that planned surgical amputations resulting from chronic illness do not frequently lead to PTSD symptoms. In contrast, data suggest that amputation resulting from accidental injury may lead to a higher prevalence of PTSD, in part because of the emotional stress surrounding the accident.

Gender-specific association of alexithymia and norepinephrine/cortisol ratios. A preliminary report

OBJECTIVE

Alexithymia and posttraumatic stress disorder (PTSD) might share a neuroendocrine pattern characterized by increased urinary norepinephrine (N) and decreased cortisol (C) levels, resulting in a high N/C ratio, at least among male alcoholics. We aimed to explore if this association can also be found in other populations.

METHODS

Twenty-four-hour urine samples were obtained from 12 major depressive disorder (MDD) patients and 23 healthy controls (HC) and tested for N and free C. Participants completed the 20-item Toronto Alexithymia Scale (TAS) and the Symptom Check List (SCL).

RESULTS

Controlling for depression, the neuroendocrine parameters did not differ between the MDD and HC participants nor between women and men. The TAS was not associated with N, C or the N/C ratio in the MDD and HC participants nor in females alone. However, in men, the N/C ratio correlated significantly with the TAS (r = .80).

CONCLUSIONS

Our preliminary findings indicate that alexithymia is associated with an increased noradrenergic activity and a decreased basal activity of the hypothalamic-pituitary-adrenal (HPA) axis among men. This gender difference may reflect divergent underlying neurobiological processes of alexithymia in men and women.

Psychopathology and psychological problems in patients with burn scars: epidemiology and management

Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses. Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13-23% and 13-45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury. Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life.In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.

Return to work outcomes after work-related hand trauma: the role of causal attributions

PURPOSE

This study examined the relationship between workers' judgments of responsibility for their accidents (causal attributions) and work-site avoidance after work-related injuries.

METHODS

Ninety-two hand-injured workers referred for psychologic treatment of posttraumatic stress and depressive symptoms were assessed for their beliefs about the cause(s) of their accidents. Causal attributions were obtained before and after psychologic intervention.

RESULTS

Workers who blamed coworkers or equipment for their injuries were more likely to resist returning to former work activities than workers who judged themselves responsible for their accidents. In addition those with relatively minor injuries were as much at risk for work-site avoidance as those with more severe injuries. Age, gender, and length of employment with current employer were unrelated to avoidance.

CONCLUSIONS

These results suggest the importance of causal attributions as potential predictors of work-site avoidance after traumatic work-related hand injuries, and support the risk for psychologic symptom development after less-severe injuries.

A review of the history of traumatic stress studies in Japan: from traumatic neurosis to PTSD

Based on available literature, this review article investigates traumatic stress studies in Japan from the late 19th century to the present for English speaking audiences. First, traumatic neuroses of war victims, A-bomb survivors, and victims of work-related accidents are discussed. Second, traumatic stress studies of victims of other manmade disasters, such as the sarin gas attacks in Tokyo, domestic violence, and burn injuries. Third, psychological outcomes of natural disaster studies are discussed in relation to social support and help-seeking tendencies of Japan disaster victims.

Association of alexithymic characteristics and posttraumatic stress responses following medical treatment for children with refractory hematological diseases

Recent research has examined posttraumatic stress disorder (PTSD) following medical treatment for children with refractory hematological diseases such as leukemia. However, much remains unknown. This study examined the association of alexithymic characteristics on the manifestation of posttraumatic stress responses in 33 children with refractory hematological diseases. Of 33 children, 27 (81.8%) exhibited posttraumatic stress responses following medical treatment for refractory hematological diseases. The frequency of posttraumatic stress responses was significantly higher than with children who experienced severe flood disaster. Also, the severity of posttraumatic stress responses was significantly stronger than for children who experienced severe flood disaster. Moreover, children with refractory hematological diseases were more likely to exhibit alexithymic characteristics. The alexithymic characteristics were significantly and positively correlated with avoidance and emotional numbing among posttraumatic stress responses. The results suggest the possibility that alexithymic characteristics may be predictive of the manifestation of avoidance and emotional numbing among posttraumatic stress responses following medical treatment for refractory hematological diseases.

Characteristics of tranquilizer use among Australian Vietnam War veterans

OBJECTIVE

To examine characteristics of tranquilizer use in a cohort of Australian Vietnam War veterans.

DESIGN

Prospective analysis of medication use and assessment of social and clinical variables, including tranquilizer dependence.

PATIENTS

Fifty-one Australian Vietnam War veterans were recruited from the department of psychiatry of an Australian teaching hospital. All subjects were men, with a mean +/- SD age of 52.2 +/- 3.3 years.

MAIN OUTCOME MEASURES

A structured interview was used to obtain details of medical and psychiatric history, medication use, substance use, forensic history, and health service utilization data. Anxiety was assessed using the Hamilton Anxiety Rating Scale (Ham-A). A validated tranquilizer dependence rating scale was administered for each patient.

RESULTS

Commonly used tranquilizers included diazepam (n = 19 patients) and zopiclone (26). Most patients (44) reported the use of one or more drugs for the purpose of nighttime sedation, while exclusive daytime use of tranquilizers for anxiolytic effect was uncommon. The median time spent in the hospital during the preceding year was 21.0 +/- 56.8 days. Symptoms of anxiety were prevalent, with a mean Ham-A score of 35.5 +/- 7.8. Screening criteria suggestive of tranquilizer dependence were met in 34 subjects. Health service utilization was correlated with tranquilizer intake and overall medication use. Tranquilizer dependence was independently associated with cigarette smoking (p = 0.039; odds ratio = 5.13, 95% CI 1.08 to 24.33).

CONCLUSIONS

This study provides insight into the nature of tranquilizer use in an Australian population of Vietnam War veterans. The extensive use of these drugs suggests that further research and possibly intervention in this area is needed.

Three screening tests for patients with psychological problems who undergo plastic and reconstructive surgery

To investigate their quality of life, screening tests of emotion, coping with stress, and personality were developed for use with patients in plastic and reconstructive surgery who had psychological problems. The validity and reliability of each test were examined in a sample of 329 patients who were admitted to the Department of Plastic and Reconstructive Surgery. The reliability of each test was supported by factor analysis, adequate internal consistency, and test-retest correlations. Also, validity was acceptable. Although further examination is required, these screening tests seem suitable for use in research among this type of patient in Japan.

Prolonged adjustment difficulties among those with acute posttrauma distress following burn injury

This study examined the impact of mild to moderate symptoms of in-hospital posttrauma distress (PTD) following severe burn injury on quality of life (QOL) at 2-month follow-up after controlling for preburn QOL, injury severity, and state Negative Affectivity (depression, body image dissatisfaction) and dispositional optimism-pessimism. Participants' (n = 86) self-report established PTD and non-PTD groups (median split on Davidson Trauma Scale). After covarying preburn level of psychosocial QOL, PTD groups differed on psychosocial functioning at follow-up. This effect remained after covarying injury severity, state NA, dispositional optimism-pessimism, and preburn Mental domain QOL. PTD groups also differed significantly on physical functioning at follow-up after covarying preburn physical functional status. This effect was removed by controlling preburn Physical domain QOL and either injury severity or state NA and dispositional optimism-pessimism. Therefore, PTD is related to significant impairments in the physical and psychosocial adjustment of survivors of severe burns regardless of pretrauma level of adjustment. Injury severity and state NA and dispositional optimism-pessimism moderate the impact of PTD on physical but not psychosocial adjustment.