A diagnostic and family study of posttraumatic stress disorder

Post-traumatic stress disorder, resilience and vulnerability

Post-traumatic stress disorder (PTSD), recognised as a diagnostic entity in 1980, was originally associated with combat or war experiences. It has since been recognised that it is prevalent in any population exposed to traumatic events. Although much has been written about the management of PTSD, the concepts of resilience and vulnerability have not received the same attention. This article reviews the conceptualisation, epidemiology and comorbidities of PTSD and highlights the factors underlying vulnerability and conveying resilience.

Joint Effect of Childhood Abuse and Family History of Major Depressive Disorder on Rates of PTSD in People with Personality Disorders

Objective. Childhood maltreatment and familial psychopathology both lead to an increased risk of the development of posttraumatic stress disorder (PTSD) in adulthood. While family history of psychopathology has traditionally been viewed as a proxy for genetic predisposition, such pathology can also contribute to a stress-laden environment for the child. Method. Analyses were conducted to evaluate the joint effect of childhood abuse and a family history of major depressive disorder (MDD) on diagnoses of PTSD and MDD in a sample of 225 adults with DSM-IV Axis II disorders. Results. Results showed that the rate of PTSD in the presence of both childhood abuse and MDD family history was almost six-fold (OR = 5.89, P = .001) higher relative to the absence of both factors. In contrast, the rate of MDD in the presence of both factors was associated with a nearly three-fold risk relative to the reference group (OR = 2.75, P = .01). Conclusions. The results from this observational study contribute to a growing understanding of predisposing factors for the development of PTSD and suggest that joint effects of family history of MDD and childhood abuse on PTSD are greater than either factor alone.

Neuro-psychopharmacogenetics and Neurological Antecedents of Posttraumatic Stress Disorder: Unlocking the Mysteries of Resilience and Vulnerability

BACKGROUND AND HYPOTHESIS

Although the biological underpinnings of immediate and protracted trauma-related responses are extremely complex, 40 years of research on humans and other mammals have demonstrated that trauma (particularly trauma early in the life cycle) has long-term effects on neurochemical responses to stressful events. These effects include the magnitude of the catecholamine response and the duration and extent of the cortisol response. In addition, a number of other biological systems are involved, including mesolimbic brain structures and various neurotransmitters. An understanding of the many genetic and environmental interactions contributing to stress-related responses will provide a diagnostic and treatment map, which will illuminate the vulnerability and resilience of individuals to Posttraumatic Stress Disorder (PTSD).

PROPOSAL AND CONCLUSIONS

We propose that successful treatment of PTSD will involve preliminary genetic testing for specific polymorphisms. Early detection is especially important, because early treatment can improve outcome. When genetic testing reveals deficiencies, vulnerable individuals can be recommended for treatment with "body friendly" pharmacologic substances and/or nutrients. Results of our research suggest the following genes should be tested: serotoninergic, dopaminergic (DRD2, DAT, DBH), glucocorticoid, GABAergic (GABRB), apolipoprotein systems (APOE2), brain-derived neurotrophic factor, Monamine B, CNR1, Myo6, CRF-1 and CRF-2 receptors, and neuropeptide Y (NPY). Treatment in part should be developed that would up-regulate the expression of these genes to bring about a feeling of well being as well as a reduction in the frequency and intensity of the symptoms of PTSD.

Longitudinal associations between post-traumatic distress and depressive symptoms following a traumatic event: a test of three models

BACKGROUND

Symptoms of post-traumatic stress disorder (PTSD) and depression are highly co-morbid following a traumatic event. Nevertheless, decisive evidence regarding the direction of the relationship between these clinical entities is missing.

METHOD

The aim of the present study was to examine the nature of this relationship by comparing a synchronous change model (PTSD and depression are time synchronous, possibly stemming from a third common factor) with a demoralization model (i.e. PTSD symptoms causing depression) and a depressogenic model (i.e. depressive symptoms causing PTSD symptoms). Israeli adult victims of single-event traumas (n=156) were assessed on measures of PTSD and depression at 2, 4 and 12 weeks post-event.

RESULTS

A cross-lagged structural equation modeling (SEM) analysis provided results consistent with the synchronous change model and the depressogenic model.

CONCLUSIONS

Depressive symptoms may play an important role in the development of post-traumatic symptoms.

Genetics of anxiety and trauma-related disorders

Anxiety disorders are the most common psychiatric illnesses in the United States with approximately 30% of the population experiencing anxiety-related symptoms in their lifetime [Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005) Lifetime prevalence and age-of-onset distributions of Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:593-60]. Notably, a variety of studies have demonstrated that 30-40% of the variance contributing to these disorders is heritable. In the present review, we discuss the latest findings regarding the genetic and environmental influences on the development and symptomatology of anxiety disorders. Specific emphasis is placed on posttraumatic stress disorder (PTSD) due to its uniqueness as an anxiety disorder; its diagnosis is dependent on a precipitating traumatic event and its development appears to be mediated by both genetic and environmental contributions. The co-morbidity of anxiety disorders and the potential re-classification of anxiety disorders as part of DSM-V are reviewed given the potential impact on the interpretation and design of genetic investigations. Lastly, several keys to future genetic studies are highlighted. Thorough analyses of the gene by environment (GxE) interactions that govern one's vulnerability to anxiety disorder(s), the effectiveness of individual treatment strategies, and the severity of symptoms may lead to more effective prophylactic (e.g. social support) and treatment strategies.

Posttraumatic stress disorder and substance use disorder in adolescent bipolar disorder

OBJECTIVE

Anxiety disorders such as posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are increasingly recognized as comorbid disorders in children with bipolar disorder (BPD). This study explores the relationship between BPD, PTSD, and SUD in a cohort of BPD and non-BPD adolescents.

METHODS

We studied 105 adolescents with BPD and 98 non-mood-disordered adolescent controls. Psychiatric assessments were made using the Kiddie Schedule for Affective Disorders and Schizophrenia-Epidemiologic Version (KSADS-E), or Structured Clinical Interview for DSM-IV (SCID) if 18 years or older. SUD was assessed by KSADS Substance Use module for subjects under 18 years, or SCID module for SUD if age 18 or older.

RESULTS

Nine (8%) BPD subjects endorsed PTSD and nine (8%) BPD subjects endorsed subthreshold PTSD compared to one (1%) control subject endorsing full PTSD and two (2%) controls endorsing subthreshold PTSD. Within BPD subjects endorsing PTSD, seven (39%) met criteria for SUD. Significantly more SUD was reported with full PTSD than with subthreshold PTSD (chi(2) = 5.58, p = 0.02) or no PTSD (chi(2) = 6.45, p = 0.01). Within SUD, the order of onset was BPD, PTSD, and SUD in three cases, while in two cases the order was PTSD, BPD, SUD. The remaining two cases experienced coincident onset of BPD and SUD, which then led to trauma, after which they developed PTSD and worsening SUD.

CONCLUSION

An increased rate of PTSD was found in adolescents with BPD. Subjects with both PTSD and BPD developed significantly more subsequent SUD, with BPD, PTSD, then SUD being the most common order of onset. Follow-up studies need to be conducted to elucidate the course and causal relationship of BPD, PTSD and SUD.

Maternal, not paternal, PTSD is related to increased risk for PTSD in offspring of Holocaust survivors

BACKGROUND

A significant association between parental PTSD and the occurrence of PTSD in offspring has been noted, consistent with the idea that risk for the development of PTSD is transmitted from parent to child. Two recent reports linking maternal PTSD and low offspring cortisol prompted us to examine the relative contributions of maternal vs. paternal PTSD in the prediction of PTSD and other psychiatric diagnoses in offspring.

METHODS

One hundred seventeen men and 167 women, recruited from the community, were evaluated using a comprehensive psychiatric battery designed to identify traumatic life experiences and lifetime psychiatric diagnoses. 211 of these subjects were the adult offspring of Holocaust survivors and 73 were demographically comparable Jewish controls. Participants were further subdivided based on whether their mother, father, neither, or both parents met diagnostic criteria for lifetime PTSD.

RESULTS

A higher prevalence of lifetime PTSD, mood, anxiety disorders, and to a lesser extent, substance abuse disorders, was observed in offspring of Holocaust survivors than controls. The presence of maternal PTSD was specifically associated with PTSD in adult offspring of Holocaust survivors. However, other psychiatric diagnoses did not show specific effects associated with maternal PTSD.

CONCLUSION

The tendency for maternal PTSD to make a greater contribution than paternal PTSD to PTSD risk suggests that classic genetic mechanisms are not the sole model of transmission, and paves way for the speculation that epigenetic factors may be involved. In contrast, PTSD in any parent contributes to risk for depression, and parental traumatization is associated with increased anxiety disorders in offspring.

Gene-environment interaction in posttraumatic stress disorder: review, strategy and new directions for future research

The purpose of this article is to encourage research investigating the role of measured gene-environment interaction (G x E) in the etiology of posttraumatic stress disorder (PTSD). PTSD is uniquely suited to the study of G x E as the diagnosis requires exposure to a potentially-traumatic life event. PTSD is also moderately heritable; however, the role of genetic factors in PTSD etiology has been largely neglected both by trauma researchers and psychiatric geneticists. First, we summarize evidence for genetic influences on PTSD from family, twin, and molecular genetic studies. Second, we discuss the key challenges in G x E studies of PTSD and offer practical strategies for addressing these challenges and for discovering replicable G x E for PTSD. Finally, we propose some promising new directions for PTSD G x E research. We suggest that G x E research in PTSD is essential to understanding vulnerability and resilience following exposure to a traumatic event.

Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand?

Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.

Commentary: biological findings in PTSD -- too much or too little?

Summarizing the contributions in this section of the book, this chapter addresses questions regarding the complex etiology of PTSD, and the relative strength of discernable biological indicators of the disorder. It outlines two major approaches to exploring the biology of the disorder and discusses the reason for the many non-replications of findings. It defines the constructs of multicausality, equifinality, and multifinality, and evaluates their main implication for studies of PTSD, namely that no biological signal can be properly appraised without taking into account its context. Such context, in PTSD, includes both concurring biological systems and regulatory mechanisms, and environmental-psychosocial input. Studies of gene expression of PTSD exemplify one way of studying the context of putative biological signals. The role of biological alterations as templates for responding to psychosocial challenges is discussed.

A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents

Recent years have witnessed a rapid acceleration in the recognition and documentation of posttraumatic stress disorder (PTSD) and posttraumatic stress symptomatology (PTSS) in childhood cancer survivors and their parents. However, applicability of PTSD both diagnostically and conceptually to cancer-related traumatic responses remains poorly articulated within the current literature. Following an outline of childhood cancer and PTSD, this paper critically examines the applicability of such a diagnosis to this clinical population. It then systematically reviews the current evidence base (24 studies) on PTSD and PTSS in childhood cancer survivors and their parents. Prevalence of PTSD and PTSS, as well as associated predictors, in this clinical population varies widely. Findings are considered in the light of a number of contemporary theories of PTSD. Limitations within current conceptualizations of PTSD are highlighted with respect to the nature of cancer as a traumatic event and the specific features of traumatic stress manifestations in childhood cancer survivors and their parents. Finally, a number of pertinent research areas are elucidated which are argued to warrant further investigation.

Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use

This study examines the roles of post-traumatic stress disorder (PTSD) and drug dependence in non-fatal suicidality, i.e., suicidal ideation and suicide attempt, among Vietnam veterans in their adult years. The sample includes male veterans deployed to Vietnam, including an oversample of those who tested positive for opiates at their return (n = 642). PTSD, substance abuse, suicidality, and other psychopathology are analyzed using three waves of survey and military data covering the time period from early adolescence to middle adulthood. Measures include the onset and recency of each of the lifetime DSM-IV PTSD symptom criteria, and yearly symptom measures of DSM-IV dependence for alcohol and eight classes of psychoactive substances. Survival and hazard models are applied to assess the effects of drug dependence, PTSD, and other psychopathology on the duration of suicidality. Longitudinal models estimate the casual relationships among PTSD, drug dependence, and suicidality over a 25-year period. Results show evidence of strong continuity of PTSD, drug dependence, and suicidality over time. The causal role of drug dependence on PTSD and suicidality is limited to young adulthood. Evidence is stronger for self-medication in later adulthood. The results indicate that a life course perspective is needed for the combined treatment of PTSD and drug dependence for severely traumatized populations.

[Mental disorders in victims of terrorism and their families]

BACKGROUND AND OBJECTIVE

To find out whether victims of terrorism and their relatives have higher prevalence of affective, anxiety, and alcohol abuse disorders than the general population.

MATERIAL AND METHOD

Between January 1997 and January 2001, 544 families affected by terrorist violence in Spain were interviewed. Victims and their relatives (n = 1,021) were evaluated by means of the PRIME-MD. They were classified according to the degree of involvement in the attacks as: relatives of victims (RV), direct victims (DV) and direct victims who were also relatives of other victims (DVRV). Their scores were compared with those of a primary health-care sample.

RESULTS

Depressive symptoms were more prevalent among victims (DVRV, 59.2%; DV, 57.6%; RV, 50.2%) than among controls (40.0%) (p = 0.036) and their prevalence was directly related to the degree of involvement in the attacks. Similar results were obtained for anxiety disorders (DVRV, 52.6%; DV, 56.5%; RV, 45.0%, and controls 26.4%) (p = 0.017). Alcohol abuse prevalence (DVRV, 6.6%; RV, 5.9%) was very close to that of the primary health-care sample (4.8%) with the exception of direct victims (DV, 15.9%) in whom it was higher (p = 0.016).

CONCLUSIONS

The prevalence of psychopathology was higher among victims of terrorism than among primary health-care patients and it was directly related to the involvement in the attack. Low perceived social support, family and personal history of psychiatric disease, and type of attack (explosives) increased the risk of suffering mental disorders.

Transtorno de estresse pós-traumático em uma unidade de saúde de atenção primária

INTRODUÇÃO: O transtorno de estresse pós-traumático (TEPT) caracteriza-se pelo desenvolvimento de sintomas como a re-experienciação do evento traumático (pesadelos, idéias intrusivas, sintomas somáticos relacionados ao momento do trauma), evitação e embotamento (evitar situações, pessoas ou comportamentos que relembrem o trauma e ter dificuldade para lidar com novas situações ou sentimentos) e excitabilidade aumentada (insônia, irritação, dificuldade de concentração e um estado permanente de alerta e sobressalto). É importante saber a freqüência do transtorno numa comunidade pobre. OBJETIVO: Identificar a freqüência de TEPT e a presença de sintomas depressivos e alcoolismo em um serviço de atenção primária. METODOLOGIA: O estudo ocorreu na Unidade de Saúde Divina Providência, do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição. Realizou-se uma amostragem aleatória dos pacientes que consultaram no posto. Foram aplicados instrumentos para a identificação de TEPT, sintomas depressivos, alcoolismo e perfil sociodemográfico. RESULTADOS: Dos 54 pacientes entrevistados, 83,3% eram mulheres, e a média da idade foi de 39 anos. Os sintomas depressivos severos foram identificados em 28% dos pacientes; 59% tinham o critério de TEPT e 12,5% apresentavam problemas com álcool. CONCLUSÕES: A amostra do sexo feminino foi predominante e houve uma elevada prevalência de TEPT.

Comorbidade no transtorno de estresse pós-traumático: regra ou exceção?

O transtorno de estresse pós-traumático (TEPT) com frequência ocorre conjuntamente com outros transtornos psiquiátricos. Este artigo revisa o TEPT e comorbidades, tais como: transtornos de ansiedade, uso de substâncias, transtorno de humor, tentativas de suicídio, transtorno dissociativo e transtorno somatoforme.

Psychological mechanisms in acute response to trauma

Traumatic events are common, but posttraumatic stress disorder (PTSD) is relatively rare. These facts have prompted several questions: What variables increase risk for PTSD among trauma-exposed people? Can we distinguish between pathologic and nonpathologic responses to traumatic stressors? If so, what psychobiological mechanisms mediate pathologic responses? Prospective studies have identified certain individual difference variables as heightening risk (e.g., lower intelligence, negative personality traits). Studies on peritraumatic and acute-phase response have identified certain dissociative symptoms (e.g., time slowing, derealization) and cognitive appraisal (e.g., belief that one is about to die) as harbingers of later PTSD. Negative appraisal of acute symptoms themselves may foster chronic morbidity (e.g., that symptoms signify shameful moral weakness or prefigure impending psychosis). Further attempts to elucidate pathologic mechanisms in the cognitive psychology laboratory and via biological challenges are warranted.

Untangling the psychiatric comorbidity of posttraumatic stress disorder in a sample of flood survivors

This report empirically examines multiple explanations for the high rates of psychiatric comorbidity seen with posttraumatic stress disorder (PTSD). One hundred sixty-two St. Louis area survivors of the 1993 Great Midwest Floods were interviewed a few months after the flood subsided using the Diagnostic Interview Schedule (DIS) and its Disaster Supplement to assess psychiatric history relative to PTSD and five other psychiatric disorders. Thirty-five subjects (23%) met criteria for PTSD related to the flood. PTSD was frequently comorbid with other disorders. Seventeen subjects (10%) developed a new, non-PTSD psychiatric disorder after the flood. New non-PTSD disorders were rare in the absence of PTSD symptoms. Though prior psychiatric history was predictive of developing PTSD, no support was found that prior psychiatric history contributed to PTSD through social vulnerability. Thus, support was found for a model in which PTSD contributes to the development of other disorders following trauma, whereas no evidence was found to suggest that comorbid disorders develop independently of PTSD following trauma, or that comorbidity was due to symptom overlap among disorders. The lack of support for models in which psychosocial resources mediate the effect of psychiatric history on the development of PTSD indirectly confirms models of physiological vulnerability to PTSD development.

A pilot study of noradrenergic and HPA axis functioning in PTSD vs. panic disorder

The biological literature in the anxiety disorders has focused on comparisons between patient groups and normal volunteers, with relatively little comparative study of the anxiety disorders. We therefore conducted this pilot study to compare a group of patients with post-traumatic stress disorder (PTSD) (n = 7) to a contiguously studied panic disorder group (n = 17) and healthy control subjects (n = 16) on baseline levels of cortisol and 3-methoxy-4-hydroxyphenylglycol (MHPG), and response to clonidine challenge. Despite the small sample size, highly significant differences were found on the following measures: PTSD patients had lower cortisol, lower MHPG, reduced MHPG volatility to clonidine challenge, and marginally reduced cortisol volatility compared to patients with panic disorder. These biological findings support existing clinical, epidemiologic, family study, and clinical trial findings that distinguish these two disorders as distinct syndromes.

Patterns of incidence and psychiatric risk factors for traumatic events

Individual differences are thought to influence the propensity for exposure to trauma and the subsequent development of post-traumatic stress disorder (PTSD) symptoms. Prior research has identified pre-existing mood disorders as one such individual risk factor for traumatic events as well as for PTSD. The present study reports the incidence of traumatic events (and PTSD) and examines psychiatric risk factors for trauma exposure in a prospective community sample. Data come from a prospective, longitudinal epidemiological study of adolescents and young adults (age 14-24) in Munich, Germany. Respondent diagnoses (N = 2,548) at baseline and at follow-up 34-50 months later were considered. Psychiatric diagnoses at baseline were examined as predictors of qualifying trauma. Baseline prevalence of persons having experienced trauma meeting DSM-IV A1 and A2 criteria ('qualifying trauma') was 16.7%; during the follow-up period, 20.3% persons had experienced incident (new) qualifying traumata. The prevalence of PTSD, including subthreshold cases, at baseline was 5.6%; by the end of the follow-up period this had increased to 10.3%. Presence of an anxiety disorder at baseline predicted exposure to qualifying traumas during the follow-up period (adjusted ORs ranging from 1.36 for any trauma type to 3.00 for sexual trauma); this association was apparently due to an increased tendency to report events as being particularly horrific (meeting A2 criteria). In contrast, presence of illicit drug use predicted the onset of traumatic events (specifically assaultive and sexual trauma) meeting at least A1 criteria, suggesting an actual exposure to these types of traumatic events for this class of disorders. In this prospective study of urban adolescents and young adults, certain classes of pre-existing psychiatric disorders (most notably anxiety disorders and illicit drug use disorders) were associated with increased risk for qualifying traumatic events. The mechanisms by which premorbid psychiatric disorders promote exposure to traumatic events are unknown. Better understanding of these pathways may lead to novel strategies for primary and secondary prevention of PTSD.

A twin study of generalized anxiety disorder symptoms, panic disorder symptoms and post-traumatic stress disorder in men

Generalized anxiety disorder (GAD), panic disorder (PD) and post-traumatic stress disorder (PTSD) often co-occur. We investigated whether and to what degree genetic and environmental contributions overlap among symptoms of GAD, symptoms of PD and PTSD. Subjects were 3327 monozygotic and dizygotic male-male twin pair members of the Vietnam Era Twin Registry who participated in a 1992 telephone administration of the Diagnostic Interview Schedule Version 3 Revised (DIS3R). Genetic model fitting was performed to estimate the magnitude of genetic and environmental contributions to the lifetime co-occurrence of GAD symptoms, PD symptoms and PTSD. The liability for GAD symptoms was due to a 37.9% additive genetic contribution common to PD symptoms and PTSD. Liability for PD symptoms was due to a 20.7% additive genetic contribution common to GAD symptoms and PTSD, and a 20.1% additive genetic influence specific to PD symptoms. Additive genetic influences common to symptoms of GAD and PD accounted for 21.3% of the genetic variance in PTSD. Additive genetic influences specific to PTSD accounted for 13.6% of the genetic variance in PTSD. Remaining variance for all three disorders was due to unique environmental factors both common and specific to each phenotype. These results suggest that these disorders each have etiologically distinct components and also have significant genetic and unique environmental contributions in common.

Relationship of parental trauma exposure and PTSD to PTSD, depressive and anxiety disorders in offspring

This study examined the relationship of parental trauma exposure and PTSD to the development of posttraumatic stress disorder (PTSD), depressive and anxiety disorders in the adult offspring of Holocaust survivors. One hundred and thirty-five subjects (55 men and 80 women) were divided into three groups according to parental trauma exposure and PTSD: 60 subjects were offspring of Holocaust survivors who endorsed having at least one parent with PTSD, 33 were offspring of Holocaust survivors who reported having no parent with PTSD, and 42 were demographically similar subjects with no parental Holocaust exposure. All subjects underwent a comprehensive psychiatric interview in which information about lifetime psychiatric diagnoses and exposure to traumatic events was obtained. Subjects also completed a checklist based on the 17 DSM-IV symptoms of PTSD, to estimate the symptom severity of PTSD in their parents. A presumptive diagnosis of parental PTSD was assigned according to DSM-IV criteria. Forward and forced entry stepwise logistic regression analyses were used to determine the effects of parental exposure, parental PTSD, and the subject's own history of trauma in the development of PTSD, depressive, and anxiety disorders in the offspring. The findings demonstrate a specific association between parental PTSD and the occurrence of PTSD in offspring. Additionally, parental trauma exposure, more than parental PTSD, was found to be significantly associated with lifetime depressive disorder. The identification of parental PTSD as a risk factor for PTSD in offspring of Holocaust survivors defines a sample in which the biological and psychological correlates of risk for PTSD can be further examined.

Trauma: the impact of post-traumatic stress disorder

Trauma has an enormous impact on both individuals and society as a whole. Recognition of the extent of this impact by the medical profession has been relatively slow but, with our growing appreciation of the prevalence of trauma exposure in civilian as well as combat populations, the true scale of trauma-related psychiatric consequences is beginning to emerge. It has been reported that more than 60% of men and 51% of women experience at least one traumatic event in their lifetimes. Of these, 8% and 20%, respectively, fall victim to post-traumatic stress disorder (PTSD) indicating that more women are at risk for developing PTSD. Individuals experience severe psychiatric stress that is compounded by significant comorbid illness. This impacts critically upon quality of life resulting in grave functional and emotional impairment. In addition, there is a detrimental cost to society with high financial and social consequences from the significantly elevated rates of hospitalization, suicide attempts and alcohol abuse.

Genetic and environmental influences on posttraumatic stress disorder, alcohol and drug dependence in twin pairs

We investigated whether and to what degree genetic and environmental contributions overlap among posttraumatic stress disorder (PTSD), alcohol dependence (AD) and drug dependence (DD). Subjects were 3304 monozygotic and dizygotic male-male twin pair members of the Vietnam Era Twin Registry who participated in 1992 telephone administration of the Diagnostic Interview Schedule Version 3 Revised (DIS-3R). Genetic model fitting was performed to estimate the magnitude of genetic and environmental contributions to the lifetime co-occurrence of DSM-III-R PTSD, AD and DD. The liability for PTSD was partially due to a 15.3% genetic contribution common to AD and DD and 20.0% genetic contribution specific to PTSD. Risk for AD was partially due to a 55.7% genetic contribution common to PTSD and DD. Genetic influences common to PTSD and AD accounted for 25.2% of the total risk for DD. Specific family environmental influence accounted for 33.9% of the total variance in risk for DD. Remaining variance for all three disorders was due to unique environmental factors both common and specific to each phenotype. These results suggest that PTSD, AD and DD each have etiologically distinct components and also have significant genetic and unique environmental contributions in common.

A second look at comorbidity in victims of trauma: the posttraumatic stress disorder-major depression connection

BACKGROUND

We examine whether traumatic events increase the risk for major depression independent of their effects on posttraumatic stress disorder (PTSD).

METHODS

Data come from the Epidemiologic Study of Young Adults in southeast Michigan (N = 1007). Retrospective and prospective data were used to estimate the risk of major depression in persons with PTSD and persons exposed to trauma with no PTSD, compared with persons who did not experience a trauma. National Comorbidity Survey data were used to evaluate the influence of trauma type.

RESULTS

In the retrospective lifetime data, hazard ratios were, for first-onset major depression in exposed persons with PTSD, 2.8 and, in exposed persons with no PTSD, 1.3 (not significant), as compared with persons who were not exposed. Corresponding estimates from the prospective data were 11.7 and 1.4 (not significant). The difference in the risk for depression associated with PTSD versus exposure without PTSD is unlikely to be due to differences in trauma type.

CONCLUSIONS

The findings of a markedly increased risk for major depression in persons with PTSD, but not in exposed persons without PTSD, do not support the hypothesis that PTSD and major depression in trauma victims are influenced by separate vulnerabilities.

Treatment for posttraumatic stress disorder

OBJECTIVE

To thoroughly and critically review the pharmacologic treatment of posttraumatic stress disorder (PTSD) and to review the symptomatology, diagnosis, epidemiology, pathophysiology, and assessment of PTSD.

DATA SOURCES

A MEDLINE search (1966-October 1999) in the English language specifying PTSD drug treatment as the search term was used to identify articles.

STUDY SELECTION AND DATA EXTRACTION

All articles identified were reviewed; emphasis was given to randomized, double-blind, placebo-controlled studies.

DATA SYNTHESIS

It appears that a five-week medication trial is necessary to assess clinical effects on PTSD symptoms. The monoamine oxidase inhibitors appear to be superior to the tricyclic antidepressants in improving reexperiencing and avoidance symptoms. Most studies used assessment tools that neglected hyperarousal symptoms; therefore, no conclusions regarding this symptom cluster can be drawn. Other pharmacotherapeutic interventions reported in open-label trials have yielded varying success.

CONCLUSIONS

The current literature does not bear a sufficient number of double-blind, placebo-controlled studies using assessment tools that evaluate the three symptom clusters of PTSD to allow for a definite treatment modality to be formulated. Nonetheless, a treatment hierarchy appears to be in order based on the greatest number of double-blind, placebo-controlled studies evaluating antidepressants. Alternate modalities such as mood stabilizers, antipsychotics, anxiolytics, and adrenergic blockers should not be considered the mainstays of therapy.

The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders

Representing a challenge for current concepts of stress research, a number of studies have now provided convincing evidence that the adrenal gland is hypoactive in some stress-related states. The phenomenon of hypocortisolism has mainly been described for patients, who experienced a traumatic event and subsequently developed post-traumatic stress disorder (PTSD). However, as presented in this review, hypocortisolism does not merely represent a specific correlate of PTSD, since similar findings have been reported for healthy individuals living under conditions of chronic stress as well as for patients with several bodily disorders. These include chronic fatigue syndrome, fibromyalgia, other somatoform disorders, rheumatoid arthritis, and asthma, and many of these disorders have been related to stress. Although hypocortisolism appears to be a frequent and widespread phenomenon, the nature of the underlying mechanisms and the homology of these mechanisms within and across clinical groups remain speculative. Potential mechanisms include dysregulations on several levels of the hypothalamic-pituitary adrenal axis. In addition, factors such as genetic vulnerability, previous stress experience, coping and personality styles may determine the manifestation of this neuroendocrine abnormality. Several authors proposed theoretical concepts on the development or physiological meaning of hypocortisolism. Based on the reviewed findings, we propose that a persistent lack of cortisol availability in traumatized or chronically stressed individuals may promote an increased vulnerability for the development of stress-related bodily disorders. This pathophysiological model may have important implications for the prevention, diagnosis and treatment of the classical psychosomatic disorders.

Lifetime psychiatric comorbidity rate in Israeli non-help-seeking patients with combat-related post-traumatic stress disorder

BACKGROUND

Most of the data on lifetime psychiatric comorbidity in combat-related posttraumatic stress disorder (CR-PTSD) were collected in help-seeking patients.

METHODS

In the present study we used the Schedule for Affective Disorder and Schizophrenia-Lifetime Version to examine a relatively large sample (n=80) of Israeli non-help-seeking CR-PTSD patients. The diagnosis of PTSD was based on the DSM-III-R criteria.

RESULTS

We found a low rate of lifetime psychiatric comorbidity, especially drug dependence (2.25%), alcoholism (2.25%) and major depressive disorders (5%).

CONCLUSION

It seems that in contrast to help-seeking CR-PTSD, non-help-seeking CR-PTSD is associated with a low frequency of comorbid psychiatric disorders.

LIMITATION

Only non-help seeking CR-PTSD patients who agreed to participate in the study were included in this investigation.

CLINICAL RELEVANCE

The detection and diagnosis of CR-PTSD comorbidity is important for establishing appropriate psychotherapeutic and pharmacological treatment.

Review and critique of the new DSM-IV diagnosis of acute stress disorder

OBJECTIVE

A new diagnosis can greatly influence scientific research, access to resources, and treatment selection in clinical practice. The authors review the historical evolution, rationale, empirical foundation, and clinical utility to date of the recently introduced diagnosis of acute stress disorder.

METHOD

The conceptual basis and relevant methods for identifying a psychiatric syndrome are reviewed with respect to acute stress disorder, including selection of criteria for core symptoms; considerations of sensitivity and specificity of a syndrome definition; longitudinal course; and distinctions between normative and pathological phenomena. Particular attention is devoted to two major issues: the implications of the core feature requirement of three of five dissociative symptoms, and the question of whether there should be two separate diagnoses (acute stress disorder and post-traumatic stress disorder [PTSD]) describing posttraumatic syndromes. The widely divergent approaches in DSM-IV and ICD-10 are also reviewed.

RESULTS

The diagnosis of acute stress disorder does not appear to achieve the important objective of providing adequate clinical coverage for individuals with acute posttraumatic symptoms. The validity and utility of requiring peritraumatic dissociative symptoms as a core feature are questionable, as is the separation of essentially continuous clinical phenomena into two disorders with different criteria sets (acute stress disorder and PTSD) based on persistence of symptoms for 30 or more days.

CONCLUSIONS

Longitudinal studies using acute stress disorder criteria, as well as broader considerations of the clinical and scientific functions that posttraumatic diagnoses should serve, suggest a need to reevaluate the current DSM-IV approach to posttraumatic syndromes.

Role of locus coeruleus in attention and behavioral flexibility

Previous findings have implicated the noradrenergic locus coeruleus (LC) system in functions along the dimension of arousal or attention. It has remained uncertain what role this system has in attention, or what mechanisms may be involved. We review our recent work examining activity of LC neurons in monkeys performing a visual discrimination task that requires focused attention. Results indicate that LC cells exhibit phasic or tonic modes of activity, that closely correspond to good or poor performance on this task, respectively. A computational model was used to simulate these results. This model predicts that alterations in electrotonic coupling among LC cells may produce the different modes of activity and corresponding differences in performance. This model also indicates that the phasic mode of LC activity may promote focused or selective attention, whereas the tonic mode may produce a state of high behavioral flexibility or scanning attentiveness. The implications of these results for clinical disorders such as attention-deficit hyperactivity disorder, stress disorders, and emotional and affective disorders are discussed.

Biological factors associated with susceptibility to posttraumatic stress disorder

Because only a proportion of persons exposed to traumatic events develop posttraumatic stress disorder (PTSD), it has become important to elucidate the factors that increase the risk for the development of PTSD following trauma exposure as well as the factors that might serve to protect individuals from developing this condition. Putative risk factors for PTSD may describe the index traumatic event or characteristics of persons who experience those events. Recent data have implicated biological and familial risk factors for PTSD. For example, our recent studies have demonstrated an increased prevalence of PTSD in the adult children of Holocaust survivors, even though these children, as a group, do not report a greater exposure to life-threatening (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] Criterion A) events. These studies are reviewed. It is difficult to know to what extent the increased vulnerability to PTSD in family members of trauma survivors is related to biological or genetic phenomena, as opposed to experiential ones, because of the large degree of shared environment in families. In particular, at-risk family members, such as children, may be more vulnerable to PTSD as a result of witnessing the extreme suffering of a parent with chronic PTSD rather than because of inherited genes. But even if the diathesis for PTSD were somehow "biologically transmitted" to children of trauma survivors, the diathesis is still a consequence of the traumatic stress in the parent. Thus, even the most biological of explanations for vulnerability must at some point deal with the fact that a traumatic event has occurred.

Psychoneuroendocrinology of post-traumatic stress disorder

In 1980, the diagnosis of post-traumatic stress disorder (PTSD) was established to describe the long-lasting symptoms that can occur following exposure to extremely stressful life events. This article reviews the findings of neuroendocrinologic alterations in PTSD and summarizes the finding of hypothalamic-pituitary-adrenal (HPA), catecholamine, hypothalamic-pituitary-thyroid (HPT) and hypothalamic-pituitary-gonadal (HPG) systems. These are the neuroendocrine systems that have been studied in PTSD. Also included is a review of the basic facts about PTSD and biologic data.

Post-traumatic stress disorder and depression. An analysis of comorbidity

BACKGROUND

We examined psychiatric morbidity following war-related psychic trauma, with a special focus on the depressive comorbidity of post-traumatic stress disorder (PTSD).

METHOD

Subjects consisted of 60 Israeli veterans who sought psychiatric treatment 4-6 years after having been exposed to war trauma. PTSD and psychiatric comorbidity were diagnosed using the Structured Interview for PTSD and the Schedule for Affective Disorders and Schizophrenia.

RESULTS

Both lifetime (100%) and current (87%) PTSD were the most prevalent disorders. Comorbidity was extensive, with major depressive disorder (MDD) most prevalent (95% lifetime, 50% current), followed by anxiety disorders, minor affective disorders, and alcoholism or drug misuse.

CONCLUSIONS

Within post-traumatic psychiatric and MDD are the most prevalent disorders. In addition it appears that PTSD, although related to post-traumatic MDD beyond a mere sharing of common symptoms, is at the same time differentiated from it as an independent diagnostic category.

PTSD symptoms and comorbid mental disorders in Israeli war veterans

BACKGROUND

The purpose of this study was to investigate patterns of mental disorders co-morbid with PTSD symptoms in young Israeli men exposed to combat.

METHOD

Six hundred and seventeen subjects were selected via a general population sample and evaluated in a two-phase case-identification procedure, culminating in a modified SADS-L interview, administered by psychiatrists.

RESULTS

Major depressive disorder (OR = 3.2), substance use disorders (OR = 1.9) and personality disorders (OR = 3.0) occurred more frequently in men reporting symptoms of PTSD than in men who had been under fire who did not report symptoms. With the possible exception of personality disorders, comorbid disorders did not constitute risk factors for PTSD. Comorbid PTSD and RDC disorders were associated with increased help-seeking.

CONCLUSIONS

The results suggest similar rates and types of PTSD comorbidity in Israeli war veterans as in veterans in the US assessed in general population studies, and are consistent with shared risk factors for PTSD and comorbid disorders.

Unique patterns of comorbidity in posttraumatic stress disorder from different sources of trauma

While there are many studies of comorbidity in combat veterans with posttraumatic stress disorder (PTSD), studies of PTSD from other sources of trauma (e.g., disasters, crimes, and civil violence) are just beginning to emerge. This is the first formal review comparing patterns of comorbidity in PTSD from different sources of trauma. Specific attention is given to the relative frequencies of substance abuse, depression, generalized anxiety, phobic, panic, somatization, psychotic, and personality disorders. The findings reveal that although similarities exist, the comorbidity profiles differ according to the type of trauma experienced and the population studied. Additionally, the evidence suggests that the associated psychiatric disorders are not truly comorbid, but are interwoven with the PTSD.

Auditory startle response during exposure to war stress

This report describes the immediate effect of war stress on physiological measures of the auditory startle responses (ASRs). Ten healthy Israeli subjects were examined 4 months before the Gulf war, during a missile alert on the first day of the war, and 8 months after the war. The magnitude and rate of habituation of orbicularis oculi electromyogram (EMG), heart rate (HR), and skin conductance (SC) responses to 15 consecutive presentations of 95-dB, 0-rise time, 1,000-Hz pure tones were recorded on each occasion, along with self-reports of anxiety. The group's anxiety scores were significantly higher during the war. ASRs, in contrast, remained stable across exposure conditions. However, a decrease in SC habituation was observed in few individuals during the war, and may illustrate a distinctive vulnerability to stress. The results are discussed in light of recent findings of abnormal startle response in posttraumatic stress disorder (PTSD).

Incest revisited: delayed post-traumatic stress disorder in mothers following the sexual abuse of their children

The case histories of four women who developed symptoms of post-traumatic stress disorder following the disclosure of the sexual abuse of their daughters are presented. These individuals also exhibited comorbid symptoms of depression and personality disorders. Awareness of the sexual abuse of their daughters catalyzed a reliving of their own childhood victimization. The psychodynamics operating in these cases, as well as treatment strategies are also presented. A brief follow-up of three of the four cases is included.

Medium-term course of disaster victims. A naturalistic follow-up

BACKGROUND

Our aim was to describe the medium-term course (2-3 years) in a series of victims who had experienced severe trauma.

METHOD

We selected a consecutive series of 31 trauma victims and applied a structured clinical schedule (CAPS-2) to their psychiatric evaluations prepared for the court on two separate occasions approximately one year apart.

RESULTS

Post-traumatic stress disorder and depression were the commonest diagnoses, occurring in 39% and 16% of the victims respectively when they were first assessed. Most had improved between the assessments and this was especially the case for the re-experiencing of the trauma and over-arousal, but less so for avoidance; 20% of subjects showed no improvement, often being handicapped by secondary psychiatric illness.

CONCLUSION

Traumatised victims generally showed recovery in the 2-3 years after the trauma, but this was slow and was not universal.

REM latency, dexamethasone suppression test, and thyroid releasing hormone stimulation test in posttraumatic stress disorder

1. Twenty-one patients with post-traumatic stress disorder (PTSD) were included in a study utilizing baseline rapid eye movement (REM) latency measurements, the dexamethasone suppression test (DST), and the protirelin (thyroid releasing hormone; TRH) stimulation test. The DST and TRH stimulation test were repeated after double blind treatment with desipramine. 2. A high number of patients (75%) exhibited a REM latency of 60 min or less and blunted thyroid stimulating hormone (TSH) response to TRH (61.9%) on baseline tests while only one patient showed cortisol escape from dexamethasone suppression. 3. After four weeks of desipramine treatment, significant improvements were reported in the Hamilton Rating Scale for depression, but not for anxiety symptoms, PTSD symptoms, or self-rated depressive symptoms. 4. Desipramine treatment did not affect hormonal responses to TRH. 5. The findings of shortened REM latency and altered TRH stimulation test suggest PTSD and depression may share some pathophysiological abnormalities.

From the jumping Frenchmen of Maine to post-traumatic stress disorder: the startle response in neuropsychiatry

The startle response is a universal and phylogenetically ancient reflex. Pathological exaggerations and modifications of startle underlie the symptomatology of a surprisingly diverse range of neuropsychiatric disorders, a fact that seems to have gone largely unappreciated. We review the available literature on the physiology of the normal human startle response and examine the neuropsychiatric conditions characterized by pathological startle. Startle epilepsy and primary hyperekplexia are considered as neurological disorders involving abnormal startle. Patients with hyperstartle and exotic culture-bound syndromes characterized by excessive startle are considered by the authors to represent extreme variants of the normal startle response. Post-traumatic stress disorder, drug and alcohol withdrawal states and schizophrenia all have abnormal startle as a clinical feature secondary to increased arousal and presumed disturbance of central neurotransmitter systems. The neurophysiological mechanisms by which abnormalities of the startle response may occur are discussed and a system of classification of neuropsychiatric hyperstartles is suggested.

Hypothalamic-pituitary-adrenal dysfunction in posttraumatic stress disorder

Neuroendocrine studies examining the hypothalamic-pituitary-adrenal (HPA) axis under baseline conditions and in response to neuroendocrine challenges have supported the hypothesis of altered HPA functioning in posttraumatic stress disorder (PTSD). However, to date, there is much debate concerning the nature of HPA changes in PTSD. Furthermore, in studies showing parallel findings in PTSD and major depressive disorder there is controversy regarding whether the HPA alterations suggest a specific pathophysiology of PTSD, or, rather, reflect comorbid major depressive disorder. This review summarizes findings of HPA axis dysfunction in both PTSD and major depressive disorder, and shows distinct patterns of HPA changes, which are probably due to different mechanisms of action for cortisol and its regulatory factors.

Post-traumatic stress disorder in the community: an epidemiological study

Post-traumatic stress disorder (PTSD) was studied in the Piedmont region of North Carolina. Among 2985 subjects, the lifetime and six month prevalence figures for PTSD were 1.30 and 0.44% respectively. In comparison to non-PTSD subjects, those with PTSD had significantly greater job instability, family history of psychiatric illness, parental poverty, child abuse, and separation or divorce of parents prior to age 10. PTSD was associated with greater psychiatric comorbidity and attempted suicide, increased frequency of bronchial asthma, hypertension, peptic ulcer and with impaired social support. Differences were noted between chronic and acute PTSD on a number of measures, with chronic PTSD being accompanied by more frequent social phobia, reduced social support and greater avoidance symptoms.

Post-traumatic stress disorder: issues of co-morbidity

There is considerable controversy over whether or not post-traumatic stress disorder (PTSD) should be considered as a separate diagnostic entity. The present study utilized the Symptom Checklist-90 (SCL-90) in order to examine the degree of overlap between PTSD and the related diagnoses of anxiety, depression and obsession-compulsion in a group of Israeli Lebanon War PTSD casualties. We found that the SCL-90 was able both to identify and discriminate between the clinical groups. Multiple discriminant analysis showed that although there is overlap between PTSD and obsessive-compulsive disorder, PTSD is, in fact, discriminated from all the other patient groups.

A pilot study of a neuroendocrine test battery in posttraumatic stress disorder

Eight female patients who fulfilled DSM-III criteria for posttraumatic stress disorder (PTSD) took part in this study. They were each assessed using the dexamethasone suppression test, the desipramine/growth hormone stimulation test, which examines alpha-2-adrenoceptor functioning, and the buspirone/prolactin test, which is thought to examine 5-HT receptor functioning. A control group consisting of age- and sex-matched healthy subjects was also tested. For each subject the three tests were conducted over 5 days. Hormone assays were carried out blind to diagnosis. Overall no differences on any of the three tests were detected between the patients and controls. The results do not support a link between PTSD and major depression.

Posttraumatic stress disorder: somatic comorbidity and effort tolerance

To explore psychological and somatic distress following trauma, the authors compared 50 combat veterans with chronic posttraumatic stress disorder (PTSD) with 48 age-matched combat veterans without PTSD. Both groups were evaluated on symptom reports, physical examination findings, and laboratory tests. Subjects with PTSD reported significantly more symptoms, but they did not differ from controls on their physical examination and laboratory test findings. Adverse health practices (smoking, alcohol use, and deregulation of food intake) were significantly more frequent in the PTSD group. Low effort tolerance, as has been reported in panic disorder patients, was observed in the PTSD group.

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

Recently a spate of large scale disasters has caught public attention. Survivors of unexpected catastrophes find their lives radically changed. They may develop a characteristic pattern of symptoms in response to their exposure to overwhelming stress. Ten years ago, American psychiatrists introduced a new diagnostic category, post-traumatic stress disorder (PTSD), referring to the range of psychological symptoms survivors demonstrate after extreme trauma (Diagnostic and Statistical Manual of Mental Disorders, APA, Washington D.C.). Although the validity of this syndrome remains debatable, the term PTSD is increasingly in use, a practice likely to continue given its inclusion in the draft edition of ICD 10 (WHO, Geneva). This review looks at the evidence that PTSD describes a specific clinical entity. The historical background to the belief that individuals respond to stress is summarized. The criteria that must be fulfilled and methods of establishing a diagnosis are described. A discussion of aetiological factors and the natural history of the psychological response to stress follows, with reference to clinical management, including the provision of effective intervention for survivors to prevent a full blown stress reaction emerging.