Dimensional structure of posttraumatic stress disorder symptoms after cardiac arrest

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Protective positive psychology factors and emotional distress after cardiac arrest

BACKGROUND

There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA.

METHODS

We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor.

RESULTS

We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05).

CONCLUSIONS

Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.

Elucidating posttraumatic stress symptom dimensions and health correlates among postpartum women

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with interpersonal dysfunction and adverse maternal health during the perinatal period (extending from conception through one year postpartum). However, PTSD is a heterogeneous disorder, and little is known about which aspects of this disorder may be particularly deleterious to the health of new mothers. Such data may inform more personalized approaches to PTSD prevention and treatment among postpartum women.

METHODS

Using confirmatory factor analysis, we compared three models of PTSD symptom structure-the four-factor dysphoria model, four-factor emotional numbing model, and five-factor dysphoric arousal model-in 1,663 postpartum women from the Community and Child Health Network (CCHN). We examined associations between PTSD symptom dimensions of the best-fitting model with four correlates relevant to maternal health and functioning-parenting stress, partner relationship stress, relationship satisfaction, and contraceptive use.

RESULTS

Though all models fit well, the five-factor dysphoric arousal model provided optimal fit. Symptom dimensions from this model-re-experiencing, avoidance, numbing, dysphoric arousal, and anxious arousal-evidenced differential associations with the maternal health indicators. Numbing symptoms were most strongly associated with indicators of poor interpersonal functioning, whereas dysphoric arousal symptoms were most strongly related to low-efficacy contraceptive use.

LIMITATIONS

Our cross-sectional study assessed DSM-IV PTSD symptoms.

CONCLUSIONS

PTSD symptoms among postpartum women are best-represented by five factors. Numbing symptoms (e.g., restricted affect, detachment) are most strongly associated with interpersonal difficulties, whereas dysphoric arousal symptoms (e.g., agitation, irritability) are linked with low-efficacy contraceptive use. Screening for these symptoms may help promote the health of new mothers.

Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

BACKGROUND

Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome.

PURPOSE

To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge.

METHODS

PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm.

RESULTS

A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE.

CONCLUSIONS

Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.

Cannabinoid Receptor 1 rs1049353 Variant, Childhood Abuse, and the Heterogeneity of PTSD Symptoms: Results From the National Health and Resilience in Veterans Study

Background

Accumulating evidence implicates the endocannabinoid system, including variants in the cannabinoid-1 receptor gene (CNR1), in the pathophysiology of posttraumatic stress disorder (PTSD). The synonymous G1359A variant (rs1049353) in the CNR1 gene has been linked to PTSD in individuals exposed to childhood abuse. In this study, the effects of the rs1049353 genotype and childhood abuse on overall PTSD symptoms, as well as PTSD symptom clusters were examined in order to examine how this interaction relates to the phenotypic expression of this disorder.

Method

Data were analyzed from 1,372 Caucasian U.S. veterans who participated in the National Health and Resilience in Veterans Study. Multivariable analyses were conducted to evaluate the association between rs1049353 genotype, childhood abuse, and their interaction in relation to PTSD symptoms.

Results

A significant interaction between rs1049353 genotype and childhood abuse was observed, with A allele carriers with histories of childhood abuse reporting greater severity of PTSD symptoms, most notably anxious arousal, relative to G/G homozygotes. Significant main effects of childhood abuse on overall PTSD symptoms, and re-experiencing, emotional numbing, and dysphoric arousal symptom clusters, as well as of A allele carrier status on anxious arousal symptoms were observed.

Conclusions

Results of this study replicate prior work and suggest that the rs1049353-by-childhood abuse interaction is particularly associated with the manifestation of anxious arousal symptoms of PTSD. Taken together, these findings underscore the importance of considering the phenotypic heterogeneity of PTSD in gene-environment studies of this multifaceted disorder.

Associations Between Baseline Total PTSD Symptom Severity, Specific PTSD Symptoms, and 3-Month Quality of Life in Neurologically Intact Neurocritical Care Patients and Informal Caregivers

BACKGROUND

The objective is to pilot test the feasibility of assessing severity of posttraumatic stress disorder (PTSD) symptoms, as well as specific lower-order PTSD symptoms, experienced during neurological intensive care unit (neuro-ICU) admission and their relationship with 3-month quality of life (QoL) scores in multiple domains (i.e., physical, psychological, social, and environmental) in both patients and caregivers.

METHODS

Between 2015 and 2016, we enrolled neurologically intact patients and informal caregivers of patients who reported demographics and PTSD symptoms (PTSD Checklist-Specific; PCL-S) during neuro-ICU admission and completed a QoL assessment (World Health Organization Quality of Life; WHOQOL-BREF) 3 months later. Clinical data were extracted from medical records. We ran two bivariate correlation matrices among PTSD symptom dimensions in patients and caregivers. Then, we used multiple linear regression to examine the prospective association of total PCL-S scores with each QoL domain in both patients and caregivers after adjusting for clinically important variables. Next, we explored differential associations between the 4 PTSD symptom dimensions and each QoL domain in both patients and caregivers, adjusting for sex and age.

RESULTS

A total of 70 patients (45.7% women, 84.3% white, mean age 52.08 years) and 64 caregivers (64.1% women, 90.6% white, mean age 53.12 years) were included. PTSD symptom dimensions were moderately strongly correlated among patients (r = 0.65-0.79, p < 0.001) and caregivers (r = 0.55-0.78, p < 0.001). For both patients and caregivers, greater PTSD symptom severity was prospectively associated with lower QoL in all domains (β = - 0.289 to - 0.622; p < 0.05). Our exploratory analysis revealed that greater numbing symptoms were associated with lower psychological QoL in patients (β: - 0.397, p = 0.038), and lower physical (β: - 0.409, p = 0.014), psychological (β: - 0.519, p = 0.001), and social QoL (β: - 0.704, p < 0.001) in caregivers. Greater re-experiencing symptoms were associated with lower physical QoL in both patients (β: - 0.422, p = 0.047) and caregivers (β: - 0.4, p = 0.041).

CONCLUSIONS

Our preliminary results indicated that greater severity of PTSD symptoms, and specifically numbing and re-experiencing symptoms, experienced by patients and caregivers during neuro-ICU admission was predictive of worse 3-month QoL. Continued study is needed to identify treatment targets for PTSD and QoL in this population.