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Deiber MP, Pointet Perizzolo VC, Moser DA, Vital M, Rusconi Serpa S, Ros T, Schechter DS. A biomarker of brain arousal mediates the intergenerational link between maternal and child post-traumatic stress disorder. J Psychiatr Res 2024; 177:305-313. [PMID: 39067254 DOI: 10.1016/j.jpsychires.2024.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/20/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
This study examined whether there is a biological basis in the child's resting brain activity for the intergenerational link between maternal interpersonal violence-related posttraumatic stress disorder (IPV-PTSD) and child subclinical symptoms. We used high-density EEG recordings to investigate the resting brain activity in a sample of 57 children, 34 from mothers with IPV-PTSD, and 23 from mothers without PTSD. These children were part of a prospective, longitudinal study focusing on the offspring of mothers with and without IPV-PTSD, reporting how the severity of a mother's IPV-PTSD can impact her child's emotional regulation and risk for developing mental illness. However, we had not yet looked into potential EEG biomarkers during resting state that might mediate and/or moderate effects of maternal IPV-PTSD severity on child mental health, and in particular the risk for PTSD. The alpha band spectral power as well as the aperiodic exponent of the power spectrum (PLE; power-law exponent) were examined as mediators of maternal IPV-PTSD and child PTSD. While there was no difference in alpha spectral power between the two groups, PLE was significantly reduced in children of mothers with IPV-PTSD compared to control children, indicating cortical hyper-arousal. Interestingly, child PLE was negatively correlated with the severity of maternal IPV-PTSD, suggesting an intergenerational interaction. This interpretation was reinforced by a negative correlation between child PLE and child PTSD symptoms. Finally, causal analyses using structural equation modelling indicated that child PLE mediated the relationship between maternal PTSD severity and child PTSD. Our observations suggest that maternal IPV-PTSD has an intergenerational impact on the child neurobehavioral development through a correlated abnormal marker of brain arousal (i.e. child PLE). These findings are potentially relevant to psychotherapy research and to the development of more effective psycho-neurobehavioral therapies (i.e. neurofeedback) among affected individuals.
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Affiliation(s)
- Marie-Pierre Deiber
- Department of Psychiatry, University of Geneva, Geneva, Switzerland; Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Dominik A Moser
- Institute of Psychology, University of Bern, Switzerland; University Service of Child and Adolescent Psychiatry, Lausanne University Medical Center, Switzerland
| | - Marylène Vital
- Child & Adolescent Psychiatry Service, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Tomas Ros
- Department of Psychiatry, University of Geneva, Geneva, Switzerland; Department of Neuroscience, University of Geneva, Switzerland; CIBM, Center for Biomedical Imaging, Lausanne and Geneva, Switzerland
| | - Daniel S Schechter
- University Service of Child and Adolescent Psychiatry, Lausanne University Medical Center, Switzerland; Department of Psychiatry, Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland; Department of Child & Adolescent Psychiatry, Grossman School of Medicine, New York University, USA.
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Schutz CA, Herbert J. Review of the Evidence for Neurofeedback Training for Children and Adolescents Who Have Experienced Traumatic Events. TRAUMA, VIOLENCE & ABUSE 2023; 24:3564-3578. [PMID: 36416067 DOI: 10.1177/15248380221134295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Neurofeedback training is an established treatment for children with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder and is an increasingly accepted modality of treatment in the context of child trauma. This treatment is typically delivered as a complement to more traditional talk therapy such as trauma-focused-cognitive behavioral therapy (TF-CBT). This review examined the evidence for the effectiveness of this intervention for children with trauma through a systematic search of the literature. A targeted search across databases identified 10 eligible studies that focused on children/young people who had experienced traumatic events and/or demonstrated symptoms of trauma, and which conducted a repeated measures study at a minimum. While the included studies suggest some benefits from neurofeedback training, the available studies, including randomized trials, have to date been relatively small, involve dramatically different treatment length and intensity, and show inconsistent benefits relative to usual treatment conditions. To advance knowledge of this intervention further research is needed with a clear best practice protocol and with a clearer target group.
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Affiliation(s)
- Chantelle Alysse Schutz
- Australian Centre for Child Protection, Justice & Society, University of South Australia, Adelaide, Australia
| | - James Herbert
- Australian Centre for Child Protection, Justice & Society, University of South Australia, Adelaide, Australia
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Bounoua N, Sadeh N. Dimensions of childhood maltreatment and adult risky behaviors: Differential affective and inhibitory control mechanisms. CHILD ABUSE & NEGLECT 2022; 134:105877. [PMID: 36152530 DOI: 10.1016/j.chiabu.2022.105877] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND While childhood maltreatment has been identified as a robust risk factor for a myriad of poor outcomes, significant gaps in our understanding still remain regarding mechanisms of this risk transmission across the lifespan. OBJECTIVE Informed by recent dimensional models, the objective of this study was to examine how unique dimensions of childhood maltreatment relate to adult risky behaviors via interactions between cognitive control and affective processes across Positive and Negative Valence Systems. PARTICIPANTS AND SETTING Our sample consisted of 110 community adults (M/SDage = 31.92/10.58 years old, 52.7 % male). METHODS Participants completed a neuropsychological test of inhibitory control and self-report measures of childhood maltreatment, recent adult risky behaviors, and indices of affective processing. RESULTS Moderated-mediation analyses revealed that childhood experiences of neglect and abuse exhibited distinct mechanisms of risk transmission related to adult risky behaviors. Specifically, disruptions in inhibitory control and reward-related processes were linked to adult risky behavior in the context of Childhood Deprivation (95%CI = -0.166/-0.002), whereas negative affective processes were associated with adult risky behavior in the context of Childhood Threat (95 % CI = 0.015/0.157). CONCLUSIONS Findings provide empirical support for novel dimensional theories of childhood maltreatment and suggest that distinct regulatory processes are impacted by these early life experiences, which may confer risk into adulthood.
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Affiliation(s)
- Nadia Bounoua
- University of Delaware, Department of Psychological and Brain Sciences, United States of America.
| | - Naomi Sadeh
- University of Delaware, Department of Psychological and Brain Sciences, United States of America
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Cruz D, Lichten M, Berg K, George P. Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment. Front Psychiatry 2022; 13:800687. [PMID: 35935425 PMCID: PMC9352895 DOI: 10.3389/fpsyt.2022.800687] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary research on Developmental Trauma (DT), which is inextricably linked to disruptions in social cognition, physiological and behavioral regulation, and parent-child attachments. Developmental trauma associated with early experiences of abuse or neglect leads to multi-faceted and longstanding consequences and underscores critical periods of development, complex stress-mediated adaptations, and multilevel, trans-theoretical influences in the diagnostic formulation and treatment of traumatized children, adolescents, and adults. Psychological and medical correlates of Developmental Trauma Disorder are considered, and directions for future research are discussed.
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Affiliation(s)
- Daniel Cruz
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
| | | | - Kevin Berg
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
| | - Preethi George
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
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Hermosilla S, Forthal S, Van Husen M, Metzler J, Ghimire D, Ager A. The Child PTSD Symptom Scale: Psychometric Properties among Earthquake Survivors. Child Psychiatry Hum Dev 2021; 52:1184-1193. [PMID: 33247347 PMCID: PMC8155094 DOI: 10.1007/s10578-020-01097-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Evidence for a single underlying factor structure of posttraumatic stress disorder (PTSD) in children remains elusive. We assessed the underlying factor structure of the Child PTSD Symptom Scale through exploratory (EFA) and confirmatory factor analyses (CFA) in 570 survivors of the 2015 Gorkha earthquake in Nepal. The EFA suggests that the three-factor DSM-IV model fit these data best. The CFA suggests that while the DSM-IV model adequately fit these data, the four-factor King model fit them better. There was no evidence of differential item functioning by age or gender, and internal consistency of the scale was high. PTSD (overall or by factor) was not correlated with functional impairment. Inconsistent psychometric results across contexts and methodologies suggest that our current theoretical conceptualizations and empirical models of posttraumatic stress are lacking. Future studies must both document the instrument properties to assure internal validity and cross-study comparisons and, bolstered by increased psychometric data and analyses, rework theoretical models of PTSD with improved cross-cultural validity.
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Affiliation(s)
- Sabrina Hermosilla
- Institute for Social Research, University of Michigan, 426 Thompson Street, 1006E, Ann Arbor, MI, 48104, USA.
| | - Sarah Forthal
- Columbia-WHO Center for Global Mental Health, Department of Psychiatry, Columbia University Irving Medical Center, New York, USA
| | - Madeline Van Husen
- Columbia-WHO Center for Global Mental Health, Department of Psychiatry, Columbia University Irving Medical Center, New York, USA
| | - Janna Metzler
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
| | - Dirgha Ghimire
- Institute for Social Research, University of Michigan, 426 Thompson Street, 1006E, Ann Arbor, MI, 48104, USA
| | - Alastair Ager
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK
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Scharpf F, Mueller SC, Masath FB, Nkuba M, Hecker T. Psychopathology mediates between maltreatment and memory functioning in Burundian refugee youth. CHILD ABUSE & NEGLECT 2021; 118:105165. [PMID: 34171582 DOI: 10.1016/j.chiabu.2021.105165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The detrimental impact of child maltreatment on children and adolescents' academic achievement and later socioeconomic wellbeing is well known. However, it is still unclear (1) whether maltreatment is actually linked to youth's long- and short-term memory deficits and (2) whether potential impairments are due to maltreatment per se or related psychopathology. OBJECTIVE Based on the Attentional Control Theory, we investigated a mediational model in which maltreatment would be related to psychopathology (internalizing symptoms, posttraumatic stress symptoms, posttraumatic cognitions), which would in turn be related to impaired memory functioning. PARTICIPANTS AND SETTING We drew on a sample of 155 Burundian refugee youth (aged 11 to 15) currently living in refugee camps in Tanzania and at high risk of experiencing ongoing maltreatment by parents. METHODS Youth reported on their experiences of maltreatment and psychopathology in structured clinical interviews and completed visuospatial memory tasks involving a short-term and a working memory component (Corsi Block Tapping Test) and delayed recall from long-term memory (Rey-Osterrieth Complex Figure). RESULTS Structural equation modeling showed that psychopathology mediated the association between increased maltreatment and reduced working memory capacity (β = -0.07, p = .02), with a trend towards mediation for short-term memory (β = -0.05, p = .06). Higher levels of maltreatment, but not psychopathology, were directly linked to long-term memory deficits (β = -0.20, p = .02). CONCLUSIONS Preventive efforts targeting maltreatment and interventions focusing on related psychopathology are needed to counter memory deficits and their potential negative implications for academic and socioeconomic outcomes.
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Affiliation(s)
| | - Sven C Mueller
- Department of Experimental Clinical and Health Psychology, Ghent University, Belgium; Department of Personality, Psychological Assessment and Treatment, University of Deusto, Bilbao, Spain
| | - Faustine Bwire Masath
- Department of Psychology, Bielefeld University, Germany; Department of Educational Psychology and Curriculum Studies, Dar es salaam University College of Education, Tanzania
| | - Mabula Nkuba
- Department of Educational Psychology and Curriculum Studies, Dar es salaam University College of Education, Tanzania
| | - Tobias Hecker
- Department of Psychology, Bielefeld University, Germany; Department of Psychology, University of Zurich, Switzerland
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Schröder M, Lüdtke J, Fux E, Izat Y, Bolten M, Gloger-Tippelt G, Suess GJ, Schmid M. Attachment disorder and attachment theory - Two sides of one medal or two different coins? Compr Psychiatry 2019; 95:152139. [PMID: 31706154 DOI: 10.1016/j.comppsych.2019.152139] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts. We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9. METHODS A total of 135 children aged between 5 and 9 years (M=7.17 years, SD=1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development. RESULTS The prevalence of AR in children with AD was 28.6% for the 'secure' form of AR, 17.1% for the 'insecure-avoidant' form, 25.7% for the 'insecure-ambivalent' form, and 28.6% for the 'disorganized' form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills. CONCLUSIONS Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models.
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Affiliation(s)
- Martin Schröder
- Psychiatric University Clinics (UPK), Department of Child and Adolescent Psychiatry (UPKKJ), University of Basel, Research Department, Schanzenstrasse 13, 4056, Basel, Switzerland; University of Lüneburg, Faculty of Education, Institute of Social work and Social Education, Universitätsallee 1, 21339, Lüneburg, Germany.
| | - Janine Lüdtke
- Psychiatric University Clinics (UPK), Department of Child and Adolescent Psychiatry (UPKKJ), University of Basel, Research Department, Schanzenstrasse 13, 4056, Basel, Switzerland
| | - Elodie Fux
- Psychiatric University Clinics (UPK), Department of Child and Adolescent Psychiatry (UPKKJ), University of Basel, Research Department, Schanzenstrasse 13, 4056, Basel, Switzerland
| | - Yonca Izat
- Vivantes Clinic Friedrichshain, Child and Adolescent Psychiatry Berlin, Child and Adolescent Psychiatry, Psychotherapy, Psychosomatic, Zadekstrasse 53, 12351, Berlin, Germany
| | - Margarete Bolten
- Psychiatric University Clinics (UPK), Department of Child and Adolescent Psychiatry (UPKKJ), University of Basel, Research Department, Schanzenstrasse 13, 4056, Basel, Switzerland
| | | | - Gerhard J Suess
- Hamburg University of Applied Sciences, Faculty Business & Social Sciences, Department Social Work, Alexanderstraße 1, 20099, Hamburg, Germany
| | - Marc Schmid
- Psychiatric University Clinics (UPK), Department of Child and Adolescent Psychiatry (UPKKJ), University of Basel, Research Department, Schanzenstrasse 13, 4056, Basel, Switzerland
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Resilience and cognitive biases mediate the relationship between early exposure to traumatic life events and depressive symptoms in young adults. J Affect Disord 2019; 254:26-33. [PMID: 31082628 DOI: 10.1016/j.jad.2019.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/18/2019] [Accepted: 05/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early trauma is an important risk factor for depression. However, little is known about the mechanisms of how traumatic life events shape the risk of depression. The present study focused on the mediating role of cognitive biases and mental resilience between early trauma and depressive symptoms in young men and women. METHODS 2218 non-clinical young adults completed an online Computer Assisted Web Interview (CAWI). It comprised selected items from several questionnaires including: a short version of the Center for Epidemiological Studies-Depression (CES-D, five items) questionnaire, the Traumatic Experience Checklist (TEC, three items) and the Childhood Experience of Care and Abuse Questionnaire (CECA.Q, three items), a short version (nine items) of Davos Assessment of Cognitive Biases Scale (DACOBS-18), the abridged version of the Connor-Davidson Resilience Scale (CD-RISC-10). Parallel mediation analyses were performed. The role of gender was considered. RESULTS A significant standardized indirect effect of childhood trauma on depressive symptoms through cognitive biases and resilience was found in the total sample. A standardized direct effect of childhood traumatic life events on depressive symptoms remained also significant, meaning that mediation is complementary. An analysis by gender showed similar results for women and men. LIMITATIONS Sample was limited to non-clinical young adults. The questionnaires were shortened, and items were selected arbitrarily due to the nature of the study (online screening). The data may include biases resulting from the use of self-report scales. CONCLUSIONS Cognitive biases and resilience are important, but not exclusive, mechanisms of the relationship between early trauma and depressive symptoms.
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Ewing-Cobbs L, DeMaster D, Watson CG, Prasad MR, Cox CS, Kramer LA, Fischer JT, Duque G, Swank PR. Post-Traumatic Stress Symptoms after Pediatric Injury: Relation to Pre-Frontal Limbic Circuitry. J Neurotrauma 2019; 36:1738-1751. [PMID: 30672379 DOI: 10.1089/neu.2018.6071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pre-frontal limbic circuitry is vulnerable to effects of stress and injury. We examined microstructure of pre-frontal limbic circuitry after traumatic brain injury (TBI) or extracranial injury (EI) and its relation to post-traumatic stress symptoms (PTSS). Participants aged 8 to 15 years who sustained mild to severe TBI (n = 53) or EI (n = 26) in motor vehicle incidents were compared with healthy children (n = 38) in a prospective longitudinal study. At the seven-week follow-up, diffusion tensor imaging was obtained in all groups; injured children completed PTSS ratings using a validated scale. Using probabilistic diffusion tensor tractography, pathways were seeded from bilateral amygdalae and hippocampi to estimate the trajectory of white matter connecting them to each other and to targeted pre-frontal cortical (PFC) regions. Microstructure was estimated using fractional anisotropy (FA) in white matter and mean diffusivity (MD) in gray matter. Pre-frontal limbic microstructure was similar across groups, except for reduced FA in the right hippocampus to orbital PFC pathway in the injured versus healthy group. We examined microstructure of components of pre-frontal limbic circuitry with concurrently obtained PTSS cluster scores in the injured children. Neither microstructure nor PTSS scores differed significantly in the TBI and EI groups. Across PTSS factors, specific symptom clusters were related positively to higher FA and MD. Higher hyperarousal, avoidance, and re-experiencing symptoms were associated with higher FA in amygdala to pre-frontal and hippocampus to amygdala pathways. Higher hippocampal MD had a central role in hyperarousal and emotional numbing symptoms. Age moderated the relation of white and gray matter microstructure with hyperarousal scores. Our findings are consistent with models of traumatic stress that implicate disrupted top-down PFC and hippocampal moderation of overreactive subcortical threat arousal systems. Alterations in limbic pre-frontal circuitry and PTSS place children with either brain or body injuries at elevated risk for both current and future psychological health problems.
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Affiliation(s)
- Linda Ewing-Cobbs
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Dana DeMaster
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher G Watson
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary R Prasad
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles S Cox
- 2 Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Larry A Kramer
- 4 Department of Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jesse T Fischer
- 5 Department of Psychology, University of Houston, Houston, Texas
| | - Gerardo Duque
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Paul R Swank
- 3 School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
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Carvajal C. Posttraumatic stress disorder as a diagnostic entity – clinical perspectives. DIALOGUES IN CLINICAL NEUROSCIENCE 2018. [PMID: 30581285 PMCID: PMC6296390 DOI: 10.31887/dcns.2018.20.3/ccarvajal] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Throughout history the consequences of psychological trauma and characteristic symptoms have involved clinical presentations that have had different names. Since the inclusion of the category of Posttraumatic Stress Disorder (PTSD) in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) with the symptomatic triad of re-experiencing the traumatic event, avoidance behaviors, and hypervigilance, this entity has been a source of controversy. Indeed, some authors have denied its existence, even considering it a diagnostic invention. In this article we review, from the clinician's perspective, historical aspects as well as the development of the nosological classifications and the contributions from the neurosciences that allow the consideration of the full validity of this diagnosis as a form of psychobiological reaction to psychological trauma.
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Affiliation(s)
- César Carvajal
- Clínica Universidad de los Andes, Santiago de Chile, Chile
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