Validation of the impact of event scale for psychological sequelae of combat

Is Oxytocin Administration During Childbirth Associated With Increased Risk for Postpartum Posttraumatic Stress Symptoms?: A Preliminary Investigation

INTRODUCTION

Synthetic oxytocin is one of the most regularly administered medications to facilitate labor induction and augmentation. The present study examined the associations between oxytocin administration during childbirth and postpartum posttraumatic stress symptoms (PTSS).

MATERIALS AND METHODS

In a multicenter longitudinal study, women completed questionnaires during pregnancy and at 2 months postpartum ( N = 386). PTSS were assessed with the Impact of Event Scale. Logistic regression was used to examine the difference in PTSS at Time 2 between women who received oxytocin and women who did not.

RESULTS

In comparison with women who did not receive oxytocin, women who received oxytocin induction were 3.20 times as likely to report substantial PTSS ( P = .036, 95% confidence interval: 1.08-9.52), and women who received oxytocin augmentation were 3.29 times as likely to report substantial PTSS ( P = .036, 95% confidence interval: 1.08-10.03), after controlling for being primiparous, preeclampsia, prior mental health diagnosis, mode of birth, postpartum hemorrhage, and satisfaction with staff.

DISCUSSION

Oxytocin administration was associated with a 3-fold increased risk of PTSS. The findings may reflect biological and psychological mechanisms related to postpartum mental health and call for future research to establish the causation of this relationship.

Examining distress among Saudi paramedics in responding to traumatic events: A mixed-methods study

INTRODUCTION

Paramedics are critical in providing timely medical care to injured patients and responding to trauma events. However, they are often exposed to traumatic events such as death, serious injuries, and violence, which can increase their risk of developing mental health disorders. The nature of their work, including uncontrolled environments and frequent exposure to trauma, as well as the severity of the patient's conditions, all contribute to this risk. This study aims to investigate the distress experienced by Saudi paramedics in response to traumatic events.

METHODS

An explanatory sequential mixed-methods approach was used to explore the experiences of distress among a sample of paramedics following traumatic events.

RESULTS

The study found that the participants ranked assaults and road traffic collisions as the most concerning traumatic events. Qualitative analysis of the data revealed several themes related to the participants' experiences, including emotional well-being, violence, road traffic collisions, death, personal limitations, culture, coping strategies, and professional support.

CONCLUSIONS

The study highlights the high levels of distress experienced by paramedics in response to road traffic collisions, with intrusion and avoidance symptoms being the most commonly reported.

Posttraumatic Stress Symptoms and Pain Sensitization After Whiplash Injury: A Longitudinal Cohort Study With Quantitative Sensory Testing

Posttraumatic stress symptoms (PTSS) are common after whiplash injury and are associated with poor recovery. The acute stress response may lead to pain sensitization and widespread pain, thereby compromising recovery. To our knowledge, no longitudinal study has assessed the associations between early PTSS and pain sensitization over time using quantitative sensory testing (QST). The aim of this study was to compare participants with different levels of PTSS, as measured by the impact of event scale (IES; subclinical 0–8, mild 9–25, and clinical ≥ 26) at baseline (<10-day post-injury) and at a follow-up of 1, 3, 6, and 12-month post-injury on pain sensitivity, neck mobility, pain distribution, and pain intensity. In total, 740 participants were recruited from emergency units or general practitioners with acute neck pain after a whiplash injury. The clinical PTSS group showed increased pain sensitivity on all QSTs at all time points compared to the subclinical PTSS group. Also, the clinical PTSS group showed significantly lower neck mobility at all time points except for a 3-month follow-up compared to the subclinical PTSS group. Moreover, the clinical PTSS group showed more widespread pain and self-reported headache and neck pain intensity at all time points compared to the subclinical PTSS group. This study emphasizes that participants with clinical levels of PTSS constitute a high-risk group that is sensitized to pain early after the injury. Hence, screening for PTSS within the 1st week after whiplash injury for those who experience high levels of pain intensity and distress may be an important clinical procedure in the assessment and treatment of whiplash-associated disorders (WAD).

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.

Mother-infant contact after birth can reduce postpartum post-traumatic stress symptoms through a reduction in birth-related fear and guilt

OBJECTIVES

Despite the well-documented negative effects of posttraumatic stress symptoms following childbirth (PTSS-FC), research on protective factors for PTSS-FC is still missing. Aiming to fill this gap, we proposed and examined a process model through which maternal-infant skin-to-skin contact after birth reduces PTSS-FC by decreasing negative emotions, especially for women who had operative births.

METHOD

In this longitudinal study, pregnant women (N = 1833) were recruited at community and hospital medical centres in the center of Israel and through internet forums. At Time 1, during pregnancy, they rated their prenatal depressive symptoms which served as an indicator for prenatal vulnerabilities. At Time 2, two-months postpartum (N = 1371, 75% of the sample), they reported their mode of birth, whether they had skin-to-skin contact with their newborn after birth, their emotions during birth, and rated their current PTSS-FC. A moderated mediation analysis was used to examine the proposed model.

RESULTS

Guilt and fear during birth mediated the association between mode of birth (instrumental or cesarean versus vaginal) and PTSS-FC. Skin-to-skin contact was related to reduced feelings of guilt and fear during birth, especially for women who had a cesarean section.

CONCLUSIONS

Our results recognize the specific emotions that contribute to the development of PTSS-FC following operative births and show how skin-to-skin contact can possibly reduce them. As such they emphasize the importance of the implementation of skin-to-skin contact following childbirth, and especially following a cesarean section as recommended by the Baby Friendly Health Initiative (World Health Organization & UNICEF, 2009).

Coping with war captivity: The role of sensation seeking

This study examines the implication of both sensation seeking and the subjective appraisal of captivity in the long‐term adjustment of ex‐prisoners of war (ex‐POWs). 164 Israeli ex‐POWs and 184 comparable controls were studied, 18 years after their participation in the Yom Kippur War. The findings indicate that high‐sensation seekers adjusted better than low‐sensation seekers to the stresses of captivity. Low‐sensation‐seeking ex‐POWs reported more PTSD symptoms, more severe psychiatric symptomatology, and more intense intrusive and avoidance tendencies. High‐ and low‐sensation‐seeking POWs differed also in feelings when taken prisoner, subjective assessment of suffering in prison, ways of coping with prison, and emotional states during captivity. The present study supports the postulation that sensation seeking is an important stress‐buffering personal resource. The role of coping styles in long‐term adjustment following war captivity is discussed.

Returning to work after a hand injury: Does ethnicity matter?

Background

Hand injuries (HI) are common and may limit participation in work. The objective of this study is to examine the effect of ethnicity and other prognostic variables on return-to-work (RTW) among male manual workers after acute HI.

Methods

A cohort of 178 subjects (90 Arabs, 88 Jews) aged 22 to 65 was studied. Trained bilingual occupational therapists evaluated and interviewed the subjects, using structured validated questionnaires for evaluating personal and environmental factors, body function and structure, and activity limitation and participation restrictions. Employment status 3 months post injury was assessed by a telephone interview. To establish a predictive model for RTW, ethnicity and certain variables of the four domains mentioned above were analyzed using logistic regression analysis.

Results

A significant difference in the rate of RTW between Jews and Arabs was found (45.5% for Jews, 28.9% for Arabs, p = 0.03) three months post HI. In the univariate regression analysis, ethnicity was associated with RTW (OR = 2.05; CI: 1.10–3.81) for Jews vs. Arabs. Using a multivariate analysis, only legal counseling, educational attainment, and the severity of disability were significantly associated with RTW.

Conclusion

RTW three months post HI among manual workers is directly related to variables such as education and legal counseling and only indirectly related to ethnicity. Patients with a lower level of education and those who were engaged in legal counseling need special attention and close guidance in the process of RTW.

Validation of the Impact of Event Scale With Modifications for COVID-19 (IES-COVID19)

Viral outbreaks can be experienced as disruptive and can be associated with trauma-related stress symptoms. In the current study, we adjusted the Dutch version of the Impact of Event Scale (IES) to assess traumatic stress symptoms related to the impact of the COVID-19 outbreak. The psychometric properties of this Impact of Event Scale with modifications for COVID-19 (IES-COVID19) were investigated by administering the IES-COVID19 to 380 university students who participated during the early stage of the COVID-19 outbreak, upon invitation via e-mail. Using confirmatory factor analysis, the factor structure of the IES-COVID19 was found to be similar to the original IES, indicating two latent factors: intrusion and avoidance, χ² (85) = 147.51, CFI = .92, TLI = .90, RMSEA = .044, SRMR = .049. Cronbach's alpha showed acceptable internal consistency of the total IES-COVID19, α = .75. Pearson's correlations of the IES-COVID19 over time were also sufficient, demonstrating adequate test-retest reliability, r = .62. Significant correlations (ranging between .15 and .50) between the IES-COVID19 and symptoms of depression, anxiety, stress, stress-related rumination, as well as negative social interactions, demonstrate adequate convergent validity. Overall, the IES-COVID19 shows to be a valid and reliable measure that can be utilized to investigate trauma-related stress symptoms of intrusion and avoidance related to the short- and long-term impact of the COVID-19 outbreak.

Suicidal Ideation Among Wives of Former Prisoners of War: A Longitudinal Dyadic Study

OBJECTIVES

The associations between posttraumatic stress disorder (PTSD) and suicidal ideation (SI) among ex-prisoners of war (ex-POWs) has recently been exemplified. Several studies have revealed the toll of war captivity in the secondary traumatization (ST) of ex-POWs' wives. This study aimed to assess SI among ex-POWs' wives and the longitudinal associations between their husbands' PTSD and their own ST.

METHOD

A sample of 233 Israeli couples (142 ex-POW couples and a comparison group of 91 veteran couples) completed self-report measures of PTSD symptoms, SI, and depression at two time points: T1 (2003) and T2 (2008), 30 and 37 years after the 1973 Yom Kippur War.

RESULTS

Among control wives, although not among ex-POWs' wives, the more ST symptoms they reported, the higher their level of SI. Furthermore, for both research groups, husbands' PTSD and wives' ST were positively associated with their own levels of SI, respectively. Autoregressive cross-legged (ARCL) analysis demonstrated that SI at T1 predicted ST at T2 among control wives but not among ex-POWs' wives. Surprisingly, an actor-partner interdependence modeling (APIM) analysis revealed, only among ex-POWs' couples, that the more the husbands suffered from PTSD and SI, the more moderate the increase of the wives' SI was between T1 and T2, thus, leading to better outcomes in terms of the wives' SI.

CONCLUSIONS

Ex-POWs' posttraumatic distress is longitudinally related to their spouses' ST and SI. Clinical implications of these findings of the relations between captivity trauma and suicidality for veteran couples are discussed.

The impact of events scale: a comparison of frequency versus severity approaches to measuring cancer-specific distress

OBJECTIVE

The Impact of Events Scale (IES) is one of the most widely used measures of event-specific distress. The IES assesses the frequency with which respondents experience intrusive thoughts and avoidant behaviors over the past week. Our aim is to demonstrate the benefit of a severity-based measurement approach of the IES compared with a frequency-based measurement approach.

METHODS

A mixed group of post-treatment cancer survivors (N = 325; M = 31.8 years old) completed measures assessing quality of life (Functional Assessment of Cancer Therapy-General), psychological adjustment (Mental Health Inventory), and cancer-related distress (IES). The IES was keyed to the cancer experience and administered with standard (frequency) and modified (severity) response options.

RESULTS

Classical reliability analyses and bifactor modeling were conducted on both versions of the IES. Reliability estimates suggest that the IES severity items were more highly intercorrelated than the IES frequency items. Both versions of the IES were highly correlated (r = 0.82), showing the presence of a dominant general factor. Bifactor modeling suggested that the severity items generally provided higher levels of discrimination than the frequency items. Validity correlations with the Functional Assessment of Cancer Therapy-General and Mental Health Inventory demonstrated that the IES severity performed as good as or better than the IES frequency.

CONCLUSIONS

Given the high correlations and similarity in content, the IES severity items largely assess the same construct as the IES frequency items. However, IES severity items generally showed improved psychometric properties and similar or higher correlations with quality of life and psychological adjustment. The IES severity approach appears to be a more informative method for assessing cancer-specific distress.

The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis

There is increasing evidence that adult attachment plays a role in the development and perseverance of symptoms of posttraumatic stress disorder (PTSD). This meta-analysis aims to synthesise this evidence and investigate the relationship between adult attachment styles and PTSD symptoms. A random-effects model was used to analyse 46 studies (N=9268) across a wide range of traumas. Results revealed a medium association between secure attachment and lower PTSD symptoms (ρˆ=-.27), and a medium association, in the opposite direction, between insecure attachment and higher PTSD symptoms (ρˆ=.26). Attachment categories comprised of high levels of anxiety most strongly related to PTSD symptoms, with fearful attachment displaying the largest association (ρˆ=.44). Dismissing attachment was not significantly associated with PTSD symptoms. The relationship between insecure attachment and PTSD was moderated by type of PTSD measure (interview or questionnaire) and specific attachment category (e.g. secure, fearful). Results have theoretical and clinical significance.

The Relationship between Severity of Combat Exposure and Army Status on Post-traumatic Stress Disorder among Australian Vietnam War Veterans

This study investigated the relationship between the level of combat exposure and army status (regular army soldiers vs national servicemen) and the subsequent development of combat-related post-traumatic stress disorder (PTSD). Sixty-four Australian infantrymen who were exposed to combat stress in Vietnam were used in this study. They were divided into four groups based on combat exposure and status as a regular or conscripted soldier. Subjects were assessed 23 years after their tour of duty in Vietnam for PTSD and psychiatric symptomatology using a PTSD inventory based on DSM-III-R criteria, the Self-report Checklist 90 (SCL-90), the Beck Depression Inventory (BDI), the Impact of Events Scale (IES), the Mississippi Scale for Combat-related PTSD (Mississippi Scale), the State and Trait Anxiety Inventory (STAI), and a demographic questionnaire. Results showed that 29.85% of the veterans have a positive diagnosis of PTSD according to self-report of symptoms based on the DSM-III-R criteria, while 54.89% of the remaining veterans suffer major symptoms of this disorder. MANOVA results show that neither the level of combat exposure nor the army status of the veterans had any significant effect on their psychiatric symptomatology as measured by the SCL-90, the BDI, the IES, and the STAI.

The clinical picture of late-onset PTSD: a 20-year longitudinal study of Israeli war veterans

Delayed-onset posttraumatic stress disorder (PTSD) has been under medico-legal debate for years. Previous studies examining the prevalence and clinical characteristics of delayed-onset PTSD have yielded inconclusive findings. This study prospectively examines the prevalence and clinical picture of late-onset PTSD among Israeli war veterans. It also evaluates whether or not late-onset PTSD erupts after a completely non-symptomatic period. 675 Israeli veterans from the 1982 Lebanon War, with and without antecedent combat stress reaction (CSR), have been assessed 1, 2 and 20 years post-war. They were divided into 4 groups, according to the duration of delay in PTSD onset. Participants completed self-report questionnaires tapping psychopathology, combat exposure and socio-demographics. 16.5% of the veterans suffered from late-onset PTSD. A longer delay in PTSD onset was associated with less severe psychopathology. Also, CSR was associated with a shorter delay in PTSD onset. Finally, the vast majority of veterans already suffered from PTSD symptoms prior to late PTSD onset. Our results offer further validation for the existence of delayed-onset PTSD. Delayed-onset PTSD appears to be a unique sub-type of PTSD, with an attenuated clinical picture. In addition, delayed-onset PTSD may be the result of an incubation process, wherein symptoms already exist prior to PTSD onset.

Family cohesion and posttraumatic intrusion and avoidance among war veterans: a 20-year longitudinal study

BACKGROUND

The bi-directional relationships between combat-induced posttraumatic symptoms and family relations are yet to be understood. The present study assesses the longitudinal interrelationship of posttraumatic intrusion and avoidance and family cohesion among 208 Israeli combat veterans from the 1982 Lebanon War.

METHODS

Two groups of veterans were assessed with self-report questionnaires 1, 3 and 20 years after the war: a combat stress reaction (CSR) group and a matched non-CSR control group.

RESULTS

Latent Trajectories Modeling showed that veterans of the CSR group reported higher intrusion and avoidance than non-CSR veterans at all three points of time. With time, there was a decline in these symptoms in both groups, but the decline was more salient among the CSR group. The latter also reported lower levels of family cohesion. Furthermore, an incline in family cohesion levels was found in both groups over the years. Most importantly, Autoregressive Cross-Lagged Modeling among CSR and non-CSR veterans revealed that CSR veterans' posttraumatic symptoms in 1983 predicted lower family cohesion in 1985, and lower family cohesion, in turn, predicted posttraumatic symptoms in 2002.

CONCLUSIONS

The findings suggest that psychological breakdown on the battlefield is a marker for future family cohesion difficulties. Our results lend further support for the bi-directional mutual effects of posttraumatic symptoms and family cohesion over time.

Intrusive thoughts and avoidance in breast cancer: Individual differences and association with psychological distress

Abstract Eighty-five women with newly diagnosed breast cancer were classified on the basis of high and low levels of cancer-related intrusive thoughts and avoidance at diagnosis, and their psychological adjustment was studied prospectively at 3 and 6 months post diagnosis. Patients who initially reported high levels of both intrusive thoughts and avoidance and those who reported high levels of intrusive thoughts but low avoidance experienced the highest levels of anxiety and depression symptoms, and continued intrusive thoughts and avoidance. Patients who were high in avoidance but low in intrusive thoughts also experienced adjustment problems, including increased intrusive thoughts, when compared with patients who were low in both types of symptoms. The findings highlight the value of considering subgroup differences in patterns of intrusion and avoidance as predictors of subsequent psychological adjustment to breast cancer.

The nature and structure of psychological distress in people at high risk for melanoma: a factor analytic study

OBJECTIVE

This study examined the psychometric properties of two commonly used measures of psychological distress, the Hospital Anxiety and Depression Scale (HADS) and the Impact of Events Scale (IES) in a sample of individuals at high risk of developing melanoma due to strong family history.

METHODS

One hundred thirty-two individuals with a known family-specific CDKN2A mutation (74% response rate) completed a mailed, self-administered questionnaire including the HADS and the IES. Initial correlational analyses were followed by both exploratory and confirmatory factor analyses, according to a predetermined procedure for order of analyses.

RESULTS

Exploratory factor analyses found that neither a two-, three- or four-factor solution satisfactorily accounted for all IES items in the present sample. By contrast, a unidimensional account of the data emerged to best account for all IES items, leaving no items unaccounted for. In contrast, the traditional two-factor (anxiety and depression) structure of the HADS appeared to fit the data well.

CONCLUSIONS

The traditional, two-factor (intrusion and avoidance) structure of the IES was not borne out within this familial melanoma cohort. Assessment of a single dimension of emotional distress in response to melanoma risk may facilitate more meaningful explorations of psychological adjustment in this context. These findings also raise questions about whether a post-traumatic stress framework is indeed the most appropriate framework to capture the unique nature of melanoma- or cancer-related distress.

Reliability and validity of the Impact of Event Scale (IES): version for Brazilian burn victims

AIMS

The aims of this study were to assess the internal reliability (internal consistency), construct validity, sensitivity and ceiling and floor effects of the Brazilian-Portuguese version of the Impact of Event Scale (IES).

DESIGN

Methodological research design.

METHOD

The Brazilian-Portuguese version of the IES was applied to a group of 91 burned patients at three times: the first week after the burn injury (time one), between the fourth and the sixth months (time two) and between the ninth and the 12th months (time three). The internal consistency, construct validity (convergent and dimensionality), sensitivity and ceiling and floor effects were tested.

RESULTS

Cronbach's alpha coefficients showed high internal consistency for the total scale (0·87) and for the domains intrusive thoughts (0·87) and avoidance responses (0·76). During the hospitalisation (time one), the scale showed low and positive correlations with pain measures immediately before (r=0·22; p<0·05) and immediately after baths and dressings (r=0·21; p<0·05). After the discharge, we found strong and negative correlations with self-esteem (r=-0·52; p<0·01), strong and positive with depression (r=0·63; p<0·01) and low and negative with the Bodily pain (r=-0·24; p<0·05), Social functioning (r=-0·34; p<0·01) and Mental health (r=-0·27; p<0·05) domains of the SF-36 at time two. Regarding the sensitivity, no statistically significant differences were observed between mean scale scores according to burned body surface (p=0·21). The floor effect was observed in most of the IES items.

CONCLUSION

The adapted version of the scale showed to be reliable and valid to assess postburn reactions on the impact of the event in the group of patients under analysis.

RELEVANCE TO CLINICAL PRACTICE

The Impact of Event Scale can be used in research and clinical practice to assess nursing interventions aimed at decreasing stress during rehabilitation.

Intrusive Traumatic Childhood Memories in Depression: A Comparison Between Depressed, Recovered and Never Depressed Women

The extent of intrusive traumatic memories of upsetting childhood experiences was investigated in independent samples of female subjects: out-patients with a primary diagnosis of unipolar major depression, women recovered from clinical depression, and healthy controls who had never experienced major depression. Subjects completed self-report questionnaires to measure levels of depression, and intrusive memories of traumatic childhood events. There were no differences between the groups in whether or not they experienced intrusive memories, but severity of intrusions varied significantly. The depressed sample reported significantly more intrusion and avoidance than the recovered or control groups, and the recovered sample reported normal levels of intrusion but higher levels of avoidance of traumatic memories than controls. Severely depressed subjects reported significantly higher levels of intrusion and avoidance than moderately depressed subjects. Implications for psychological models and for the treatment of depression are discussed.

Trajectories of self-rated health among veterans: a latent growth curve analysis of the impact of posttraumatic symptoms

OBJECTIVES

To examine the effects of combat stress reaction (CSR) and posttraumatic stress symptoms (PTS) on the level and trajectories of self-rated health (SRH) over 20 years after war exposure.

METHODS

A total of 675 veterans comprising two groups, a CSR group (n = 369) and a matched control group without CSR (n = 306), were assessed in a prospective longitudinal design, 1, 2, 3, and 20 years after their participation in the 1982 Lebanon War. SRH and PTS were assessed repeatedly, at each point of measurement.

RESULTS

The CSR participants showed more impaired initial SRH than the controls. Although the CSR group showed an improvement in SRH over time, its SRH level remained lower than that of the control group in all 4 points in time. Initial levels of PTS were associated with more impaired SRH and lower improvement over time. In addition, increased levels of PTS in the first follow-up period were related to poorer SRH, in comparison to the predicted trajectory on the basis of CSR and initial PTS.

CONCLUSIONS

Stress reaction to war trauma affected the trajectory of SRH over a 20-year period. Although the differences between veterans who had shown acute stress reaction and those who had not persisted over the entire period, there was slow improvement in SRH over time among the more impaired CSR group. PTS in the first years after the war slowed this improvement and thus played a key role in the relationship between war trauma and physical health.

Measuring child exposure to violence and mental health reactions in epidemiological studies: challenges and current issues

This paper examines challenges and current issues involved in measuring exposure to different types of violence which are associated mental health problems in children and adolescents. Standardized measures suitable for epidemiological studies, selected based on their relevance in the current literature, are briefly described and commented. The assessment of child's exposure to violence may focus on a specific event (e.g., kidnapping), a specific context (e.g., war) or even of a certain type of exposure (e.g., intrafamilial physical violence). The assessment of child mental health after exposure to violence has traditionally focused on posttraumatic stress disorder (PTSD) - most frequently measured through non-diagnostic scales. However, other mental health reactions may be present and screening as well as diagnostic instruments which may be used to assess these reactions are also described. Two issues of emerging importance - the assessment of impairment and of traumatic grief in children - are also presented. Availability of culturally appropriate instruments is a crucial step towards proper identification of child mental health problems after exposure to violence.

Posttraumatic stress disorder (PTSD) in young adult survivors of childhood cancer

BACKGROUND

Posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD) were assessed in young adult survivors of childhood cancer, including the role of four sets of variables in understanding PTSD in this population: demographic characteristics, disease and treatment factors, psychosocial and functional outcomes, and cancer-related beliefs.

PROCEDURE

One hundred eighty-two survivors of pediatric malignancies, ages 18-37 years old completed a psychiatric interview and self-report measures. Survivors were >or=5 years from diagnosis and >or=2 years from the completion of cancer treatment for a variety of cancers.

RESULTS

Nearly 16% of the sample had PTSD. Most survivors reported re-experiencing symptoms. There were no significant differences between survivors with and without PTSD on demographic or disease and treatment variables. Survivors with PTSD reported more psychological problems and negative beliefs about their illness and health status than those without PTSD. A logistic regression model predicted 50% of the variance in PTSD.

CONCLUSIONS

PTSD affects a subset of young adult cancer survivors. These survivors experience more psychological problems in general. Beliefs about the cancer experience are more potent predictors of PTSD than demographic or disease and treatment factors. Screening for PTSS and PTSD in cancer survivors is recommended.

Persistent psychological distress in long-term survivors of pediatric sarcoma: the experience at a single institution

BACKGROUND

The long-term psychological impact of pediatric sarcoma is largely unknown. As part of a cross-sectional study examining the late effects of pediatric sarcoma therapy, we examined whether psychological distress or posttraumatic stress symptoms are present in an adult cohort of pediatric sarcoma survivors.

METHOD

Thirty-four patients participated in the study, an average of 17 years after their treatment ended, each completing the SCID module for Posttraumatic Stress Disorder, Impact of Events Scale, Brief Symptom Inventory (BSI) and a questionnaire assessing sociodemographic variables and psychosocial issues.

RESULTS

Significant persistent psychological distress characterized this cohort of patients. Seventy-seven percent scored in the clinical range on the BSI. Twelve percent met diagnostic criteria for PTSD. Current psychological distress was associated with intrusive thoughts and avoidant behaviors, male gender, employment, difficulty readjusting to work/school after treatment, and enduring worries about health. No differences were found based on age, presence of metastatic disease or time since diagnosis.

CONCLUSIONS

This is the first report of a clinical evaluation of psychological distress in a cohort of pediatric sarcoma survivors treated with intensive multimodal cancer therapy. The results suggest that survivors of pediatric sarcoma might be at high risk for adverse psychological outcomes. Appropriate interventions are proposed.

Dimensionality of the posttraumatic stress response among police officers and fire fighters: an evaluation of two self-report scales

Confirmatory factor analyses were done to assess the dimensionality of the stress response in a sample of police officers and fire fighters (n = 1,168) involved in the 1992 air disaster in Amsterdam. The confirmatory factor analyses were applied to the responses on two psychometrically different instruments, i.e., the Self-Rating Inventory for Posttraumatic Stress Disorder (SRIP) and the Impact of Event Scale (IES). The previously found distinction between (active) avoidance and numbing in samples highly affected by posttraumatic stress disorder appears to be applicable to the stress response of a less affected sample. For the SRIP, a five-factor structure (i.e., intrusion, avoidance, hyperarousal, emotional numbing and sleep disturbance) appeared to fit slightly better than the four-factor structures from previous findings. For the IES, our results replicated findings of a four-dimensional structure (i.e., intrusion, avoidance, numbing and sleep disturbance) underlying the posttraumatic stress response. The factors of the best-fitting structure of both instruments proved reliable. Due to the psychometric properties of the two instruments, the relationship between similar factors in both instruments was only low to moderate. Compared with the IES, factors of the SRIP were, however, less discriminative from other symptoms of psychopathology. Replication in different traumatized or community samples is recommended.

Civilian PTSD scales: relationships with trait characteristics and everyday distress

Strong associations between civilian posttraumatic stress disorder (PTSD) scales and measures of general psychological distress suggest that the scales are nonspecific to PTSD. Three common PTSD scales were administered to 122 undergraduates who had experienced an emotionally salient, nontraumatic event: a college examination. Results indicated that normal levels of anxiety associated with the examination were positively correlated with scores on the Impact of Event Scale-Revised, Revised Civilian Mississippi Scale, and PTSD Checklist-Civilian Version. Multiple regression analyses indicated that substantial variance in the PTSD scales was accounted for by trait characteristics such as negative and positive affectivity and affect intensity (R2 .29 to .53). Negative affectivity correlated as highly with PTSD measures (r = .46 to .71) as those measures correlated with each other (r = .48 to .65). A high proportion of participants exceeded clinical cutoffs on these measures. The findings suggest that these PTSD scales may be overly sensitive to nontraumatic stressors such as everyday distress and trait characteristics.

Religiosity and secondary traumatic stress in Israeli-Jewish body handlers

This study investigated the relationship between religiosity and levels of secondary traumatic stress in Israeli-Jewish body handlers. The Impact of Event Scale (IES), the General Health Questionnaire, 12 Items (GHQ-12), and a prior exposure severity tool were used to assess secondary traumatic stress symptoms in 63 ultraorthodox male body handlers as they compared to 86 secular forensic identification technicians from the Israeli police. Excluding possible confounders of age and number of years at the job, there was no significant difference between the religious and nonreligious groups on the intrusion and avoidance scores, whereas the GHQ-12 scores were significantly higher among the religious group. Religiosity did not seem to have a salutary effect on secondary traumatic stress in this cohort.

Helping parents cope with the trauma of premature birth: an evaluation of a trauma-preventive psychological intervention

OBJECTIVE

To ascertain whether a trauma-preventive psychological intervention program for parents of premature infants during hospitalization in a level III NICU may reduce the severity of symptomatic response to the traumatic impact of premature birth.

METHODS

Mothers of premature infants were enrolled consecutively in a sequential control group design. Intervention group mothers received a structured psychological intervention in the first days after birth. Each mother could make use of additional psychological support if required and was actively approached at critical times during her infant's NICU stay. Control group mothers did not receive psychological intervention but could ask for counseling by the hospital minister. At discharge, mothers of both groups answered a questionnaire covering key outcome variables (symptoms of traumatization, emotions at discharge, and sample and control variables).

RESULTS

At discharge, intervention group mothers (N = 25) showed significantly lower levels of symptomatic response to the traumatic stressor "premature birth" than those in the control group (N = 25; mean overall symptom level 25.2 [SD: 13.9] vs 37.5 [SD: 19.2]).

CONCLUSIONS

This intervention program for parents after premature birth, combining early crisis intervention, psychological aid throughout the infant's hospitalization, and intense support at critical times, reduced the symptoms of traumatization relating to premature birth.

Holocaust survivors coping with open heart surgery decades later: posttraumatic symptoms and quality of life

OBJECTIVE

History of prolonged traumatization has been associated with reduced quality of life (QoL) and difficulties in coping with major life-threatening conditions. We assessed the association between the impact of Holocaust experience (posttraumatic symptoms) and QoL of patients before and after an open heart surgery.

METHOD

Sixty-three Holocaust survivors were interviewed before open heart surgery (at admission), 52 at follow-up at 1 week, and 58 at follow-up at 6 months. The interview included background data, Impact of Event Scale (IES), Mastery scale, and QoL measured by the Nottingham Health Profile. Medical data were retrieved from the patients' charts.

RESULTS

The total IES score indicate a high level of posttraumatic symptoms at all the time points (close to a mean of 18), but there was a clear trend of changes in the avoidance subscale: At admission, the patients manifested lower avoidance compared with the levels after the surgery and at the follow-up. No significant differences in IES were found by Holocaust experiences. Significant improvements in most components of QoL were found at the follow-up. In multivariate analyses at each time point, the findings show that those with higher levels of posttraumatic symptoms are more at risk for problems in pain and mobility domains of QoL at admission, for emotional reaction after the surgery, and at the follow-up, these associations are only at trend level, while lower sense of mastery became significant.

CONCLUSIONS

The improvement in QoL despite persistence of the impact of the Holocaust may indicate that past severe prolonged traumatization does not necessarily reduce the survivors' ability to cope with and regain physical and psychosocial functioning after a severe life-threatening medical condition. This may be further generalized to other significant crisis situations in life, such as prolonged periods of stress, suffered by many populations throughout the world.

Posttraumatic stress symptoms in adult survivors of childhood cancer

BACKGROUND

Previous research suggests that posttraumatic stress disorder (PTSD) is present in survivors of childhood cancer. The aim of the current study was to explore posttraumatic stress symptoms in a sample of young adult survivors of childhood cancer. In addition, the impact of demographic, medical and treatment factors on survivors' posttraumatic stress symptoms was studied.

PROCEDURE

Participants were 500 long-term survivors of childhood cancer. The median age at follow-up was 24 years (age range, 16- 49 years, 47% female). To assess symptoms of posttraumatic stress, all participants completed the Impact of Event Scale (IES), a self-report instrument consisting of two subscales, intrusion and avoidance.

RESULTS

Twelve percent of this sample of adult survivors of childhood cancer had scores in the severe range, indicating they are unable to cope with the impact of their disease and need professional help. Twenty percent of the female survivors had scores in the severe range as compared with 6% of the male survivors. Linear regression models revealed that being female, unemployed, a lower educational level, type of diagnosis and severe late effects/health problems were associated with posttraumatic stress symptoms.

CONCLUSIONS

The results indicate that, although the proportion of survivors reporting symptoms is well within the proportions found in the general population, a substantial subset of survivors report symptoms of posttraumatic stress. This finding supports the outcomes reported previously that diagnosis and treatment for childhood cancer may have significant long-term effects, which are manifested in symptoms of posttraumatic stress. The investigated factors could explain posttraumatic stress symptoms only to a limited extent. Further research exploring symptoms of posttraumatic stress in childhood cancer survivors in more detail is clearly warranted. From a clinical perspective, health care providers must pay attention to these symptoms during evaluations in the follow-up clinic. Early identification and treatment of PTSD symptoms can enhance the quality of life for survivors of childhood cancer.

Perceived social support and secondary traumatic stress symptoms in emergency responders

This study investigated prevalence rates of secondary traumatic stress symptoms in Israeli Police forensic technicians, and the relationship between these symptoms and perceived social support as well as perceived severity of prior trauma (combat, work, personal). Ninety technicians from the Israeli Police Forensic Investigation Unit participated in the study. Intrusion and avoidance measured within the medium range of severity, whereas distress symptoms were below clinical threshold. Intrusion was significantly related to avoidance, distress, and the perceived severity of prior personal and work-related exposure. No significant relationship was found between perceived social support and secondary traumatic stress symptoms. The data suggest that this cohort utilized avoidance effectively as a defense against intrusion.

Construct Validation of the Dutch Version of the Impact of Event Scale

The Impact of Event Scale (ES; M. J. Horowitz, N. Wilner, & W. Alvarez, 1979) is a worldwide-used self-report measure to assess the frequency of intrusive and avoidant phenomena after a variety of traumatic experiences. The purpose of this article is to assess the psychometric value of the Dutch version of the IES (D. Brom & R. J. Kleber, 1985) in several samples of individuals who had experienced various traumatic stressors. The reliability and structure of the IES were evaluated in 3 different samples (total N = 1.588). The reliability of the Dutch version of the IES was adequate across the various stressors. The construct validity was assessed by using confirmatory factor analyses. Outcomes revealed a robust structure over the various samples, generally supporting the composition of the original IES.

The Impact of Event Scale: validation of an Italian version

OBJECTIVE

To validate an Italian version of the Impact of Event Scale (IES) in patients addressing the emotional impact of a recent road accident.

METHODS

Seventy-nine subjects were examined within 1-34 weeks after an accident by means of (1). an Italian version of the IES, (2). a free description of the accident, and (3). a questionnaire assessing subjects' behaviour and feelings.

RESULTS

IES data were analysed by means of the principal component analysis (PCA) method, followed by a quartimax rotation, obtaining a two-factor solution interpreted as intrusion (Factor 1) and avoidance (Factor 2). Furthermore, the scores to the two subscales were considered in order to assess their predictive value on some variables linked to the traumatic event. Intrusion significantly discriminated the emotional intensity and fear level of subjects as a consequence of the accident.

CONCLUSIONS

The IES is a two-dimensional test capable of evaluating posttraumatic stress. The intrusion and avoidance factors explained 40% of the total variance. The two-factor solution has a psychological counterpart and is similar to the findings of earlier studies conducted on a larger number of subjects in other countries.

Horowitz's Impact of Event Scale evaluation of 20 years of use

OBJECTIVE

The main objective of this meta-analysis was to model the relations between a set of independent variables (age and gender of the trauma group, country where the study was performed, year of publication, type of event, time elapsed between event and measurement) and stress symptoms.

METHODS

Data from 66 studies that used Horowitz's IES to examine the psychological impact of a major life event were subjected to meta-analysis.

RESULTS

Results from hierarchical regression analysis indicated that type of event (episodes of illness and injury, natural and technological disaster, bereavement and loss, violence, sexual abuse, and war exposure) is a strong predictor of levels of intrusive and avoidant symptoms after a traumatic event. Intrusive and avoidant reactions reported by trauma victims tended to decrease linearly over time after the trauma. This finding was supported by the results reported by 20 different studies of stress reactions at two different time points after various events. Gender and cultural difference were relatively insignificant, whereas type of event induced different levels of stress reactions as measured with the IES.

CONCLUSION

These data provide evidence for the value of the IES as a measure of stress reactions in a number of different populations. Data summarized here will be useful as a comparison resource in future studies of stress response syndromes.

Gender differences in responses to traumatic events: a prospective study

Gender differences in psychological responses to motor vehicle accidents were examined as part of a large-scale prospective study of PTSD. Participants were recruited from an emergency room (n = 275) and interviewed 1 week, 1 month, and 4 months later. No gender differences were seen in the prevalence or recovery from PTSD, or in symptom levels at 1- and 4 months. Women had a higher prevalence of lifetime- and postaccident generalized anxiety disorder. Gender differences were found regarding the type, but not the total number, of potentially traumatic events previously experienced. These results suggest that gender differences in responses to traumatic events are not explained by exposure as such, but rather may result from gender-specific attributes of the event.

Impact of Event Scale: psychometric properties

BACKGROUND

For more than 20 years, the Impact of Event Scale (IES) has been widely used as a measure of stress reactions after traumatic events.

AIMS

To review studies that evaluated the IES's psychometric properties.

METHOD

Literature review.

RESULTS

The results indicated that the IES's two-factor structure is stable over different types of events, that it can discriminate between stress reactions at different times after the event, and that it has convergent validity with observer-diagnosed post-traumatic stress disorder. The use of IES in many psychopharmacological trials and outcome studies is supportive of the measure's clinical relevance.

CONCLUSIONS

The IES is a useful measure of stress reactions after a range of traumatic events, and it is valuable for detecting individuals who require treatment.

Children exposed to warfare: a longitudinal study

Following the 1991 Gulf War a group of 94 children in Iraq were interviewed at 6 months, 1 year, and 2 years after the war. The group was exposed to the bombing of a shelter where more than 750 were killed. Selected items from different inventories, including the Impact of Event Scale (IES) assessed children's reactions. Results reveal that children continue to experience sadness and remain afraid of losing their family. Although there was no significant decline in intrusive and avoidance reactions as measured by the IES from 6 months to 1 year following the war, reactions were reduced 2 years after the war. However, the scores were still high, indicating that symptoms persist, with somewhat diminished intensity over time.

"Transcend": initial outcomes from a posttraumatic stress disorder/substance abuse treatment program

This paper describes the development of a comprehensive treatment program for combat veterans diagnosed with posttraumatic stress disorder (PTSD) and substance abuse (SA). Outcome data are presented on 46 male patients who completed treatment between 1996 and 1998. The treatment approach, defined by a detailed manual, integrates elements of cognitive-behavioral skills training, constructivist theory approaches, SA relapse prevention strategies, and peer social support into a group-focused program. The Clinician-Administered PTSD Scale (CAPS) and the Addiction Severity Index (ASI) were used to assess treatment effectiveness at discharge and 6- and 12-month follow-up. Significant symptom changes revealed on CAPS and ASI scores at discharge and follow-up are analyzed. Discussion focuses on hypotheses regarding treatment effectiveness, study limitations, and suggestions for further research.