Individual differences in posttraumatic distress: problems with the DSM-IV model

Does cumulative exposure to traumatic stressors predict treatment outcome of community-implemented exposure-based therapy for PTSD?

Background: Posttraumatic Stress Disorder (PTSD) is associated with high levels of functional impairments such as difficulties in academic or occupational performance and in social relationships. With an increasing number of traumatic event types experienced (trauma load), PTSD risk increases in a dose-dependent manner. Accordingly, high rates of PTSD can impair the reconstruction process in post-conflict societies. In order to meet these high needs for mental health services in societies with little access to professional care, task shifting approaches and community-based interventions have been suggested. Narrative Exposure Therapy (NET) has been developed as a short and pragmatic exposure-based PTSD treatment that can be easily trained to lay personnel. Yet, it remains unclear whether NET can be effectively provided by trained lay counsellors even at high levels of trauma load. Objective: To investigate whether trauma load influences the treatment effectiveness of NET provided by trained and supervised local lay counsellors. Method: Linear mixed models were calculated to investigate the influence of trauma load on treatment effectiveness in a sample of N = 323 rebel war survivors from Northern Uganda with PTSD. Results: We found a strong reduction of PTSD symptoms following NET, which was not influenced by trauma load. However, individuals with higher levels of trauma load reported higher PTSD symptoms before therapy as well as 4 and 10 months following treatment completion compared to individuals with lower trauma load. Conclusions: Treatment with NET by lay counsellors is effective independent of trauma load. However, individuals with higher trauma load have a higher probability to show residual symptoms, which might require additional time, sessions or treatment modules.

Alienation Appraisals Mediate the Relationships between Childhood Trauma and Multiple Markers of Posttraumatic Stress

Rates of posttraumatic stress are elevated in individuals who have experienced childhood and/or cumulative trauma, and trauma appraisals have been suggested as a possible mediator of this effect. This study tested the proposed mediating role of trauma appraisals between both childhood and cumulative trauma, and two markers of trauma-related distress; posttraumatic stress and depression. Mediation models were developed and tested with data collected from a sample of trauma-exposed, treatment receiving adults (N = 106). Trauma appraisals fully mediated relationships between childhood trauma and PTSD/depression. Appraisals also mediated the relationships between cumulative trauma and depression. When appraisal subscales were simultaneously entered, alienation appraisals were the only significant mediator of these relationships. The study found support for the proposed mediating role of trauma appraisals between different forms of trauma and trauma related distress. Alienation appraisals were particularly emphasised.

An Examination of the Association Between Post-traumatic Growth and Stress Symptomatology in Cardiac Outpatients

This study examined the association between post-traumatic growth (PTG), post-traumatic stress disorder (PTSD), and trauma-related factors in cardiac outpatients. Participants recruited from four cardiology clinics between November 2014 and July 2015 (N = 52, 69.2% men, M_age = 65 years) completed self-assessments of PTG and PTSD along with demographic, cardiac health index, and trauma-related factors. In total, 75% of the sample endorsed their cardiac event as traumatic, while 17.2% reported their cardiac event as their 'worst trauma'; those endorsing the latter did not significantly differ from those endorsing 'other traumas' as their worst. Chi-square analyses indicated that the lifetime traumas of experiencing loss or abandonment, witnessing trauma, and experiencing a natural disaster were significantly related to PTG factors of new possibilities, relating to others, and spirituality. Bivariate correlations on all PTSD symptom clusters and factors of PTG revealed the strongest associations between the PTG factors of spiritual change and appreciation of life. Lifetime PTSD symptoms, duration of negative reactions, and re-experiencing symptoms were found to be significantly associated with higher PTG, and a unique independent effect emerged with avoidance symptoms. Our results suggest that PTG may be associated with particular facets of PTSD symptomatology.

Association between posttraumatic stress disorder (PTSD) severity and ego structure of the Nanai people

BACKGROUND

A man-made chemical disaster occurred in the Amur River, leading to posttraumatic stress disorder (PTSD) in the Nanai people indigenous to the river's surrounding area. PTSD severity measured by the total scores of Impact of Event Scale-Revised (IES-R) (Total-I) and Clinician-Administered PTSD Scale (CAPS) (Total-C) were not always identical in terms of demographic and ethnocultural characters. It is possible that the results derived using the Total-I and Total-C may differ for persons with different backgrounds and/or individual characteristics. In this study, the associations between PTSD severity and personal characteristics were evaluated.

METHODS

The study was a field-type survey including 187 randomly selected participants (75 males and 112 females). In addition to Total-I/Total-C, scores for each IES-R/CAPS item, Intrusion, Avoidance, and Hyperarousal, and Ego Structure Test by Ammon (ISTA) score were examined to evaluate their personal characteristics.

RESULTS

No specific trends in ISTA score were obvious among four groups defined according to Total-I/Total-C. The results of principal component analysis showed that all IES-R/CAPS items contributed positively to the 1st axis but to the 2nd axis in a different manner. ISTA items did not always show correlations to each other, but principal component analysis suggested that Construct contributed positively and Destruct and Deficient (with the exception of Destruct sexuality) contributed negatively. High IES-R scores were associated with Construct Aggression and Deficient Inner demarcation, but high CAPS score was less likely to exhibit Construct Narcissism.

CONCLUSION

To avoid the misdiagnosis of PTSD, usage of both IES-R/CAPS may be required. Simultaneous application of personality/ego tests may be helpful, but appropriate numbers of their questions would be important.

Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors

Background: Posttraumatic stress related with the childbirth experience of full-term delivery with health outcomes has been recently documented in a growing body of studies. The magnitude of this condition and the factors that might put a woman at risk for developing childbirth-related postpartum posttraumatic stress disorder (PP-PTSD) symptoms are not fully understood.

Methods: In this systematic review of 36 articles representing quantitative studies of primarily community samples, we set to examine PP-PTSD prevalence rates and associated predictors with a focus on the role of prior PTSD and time since childbirth.

Results: A significant minority of women endorsed PP-PTSD following successful birth. Acute PP-PTSD rates were between 4.6 and 6.3%, and endorsement of clinically significant PP-PTSD symptoms was identified in up to 16.8% of women in community samples of high quality studies. Negative subjective experience of childbirth emerged as the most important predictor. Endorsement of PTSD before childbirth contributed to PP-PTSD; nevertheless, women without PTSD also exhibited PP-PTSD, with acute rates at 4.6%, signifying a new PTSD onset in the postpartum period.

Conclusion: Although the majority of women cope well, childbirth for some can be perceived as a highly stressful experience and even result in the development of PP-PTSD symptoms. More research is needed to understand postpartum adaption and childbirth-related posttraumatic stress outcomes.

From Death Notification Through the Funeral: Bereaved Parents' Experiences and Their Advice to Professionals

Parents who experience the sudden death of a child will interact with many professionals in the period immediately following the death notification through to the funeral. The way these professionals respond to the parents during this critical period may be perceived as helpful, and thus support them in beginning the process of managing the trauma and starting a healthy grieving process. It may also be perceived as unhelpful, though, and contribute to more prolonged and complicated grieving. This article identifies the interventions that a sample of 20 parents who had experienced the sudden death of a child found helpful with different aspects of grieving. Specific advice is given to police, nurses, doctors, coroners, social workers, crisis counselors, funeral directors, and chaplains or clergy.

Expert Witness Testimony in the Criminal Trial of Eugene de Kock: A Critique of the Posttraumatic Stress Disorder (PTSD) Defence

The Diagnosis of Posttraumatic Stress Disorder (PTSD) was presented as the core testimony in mitigation of sentence in the Eugene de Kock criminal trial. Several hundred pages of expert witness testimony were assessed and the difficulties of diagnosing PTSD for forensic determination, especially when the client is familiar with the usually well-publicised symptoms, are presented. The obligation of expert witnesses to remain objective, testify within their areas of expertise, not assume the role of lie detectors and write accurate reports were emphasised.

Psychological Testimony during the Amnesty Application of Jeffrey Theodore Benzien

This paper provides an analysis of the psychological testimony in an amnesty application to the TRC based on the court record. Arguing that PTSD and its diagnostic criteria has become so well known that the DSTMIV caution regarding malingering and benefit eligibility should be given greater weight during psychological testimony than has occurred. Especially where potential beneficiaries of testimony have repeatedly perjured themselves even greater caution should be exercised rather than unequivocally endorsing their truthfulness as in the case of Mr Benzien.

Changes in Post-Traumatic Symptom Pattern during and after Exposure to Extreme War Stress: An Uncontrolled, Preliminary Study Supporting the Dose-Response Model

Introduction:

Exposure to prolonged war stress is understudied. While there is debate regarding the empirical data of the dose-response model for post-traumatic stress disorder (PTSD), little is known about how weekly changes in external stress influences the level of PTSD symptoms. The purpose of this study was to measure the relation between objective external stress and PTSD symptoms across time, and thus, gain a deeper understating of the dose-response model.

Hypothesis:

The study hypothesis postulates that the more severe the external stressor, the more severe the exhibition of traumatic symptoms.

Methods:

Thirteen special army administrative staff (SAAS) members from the Rambam Medical Center in Haifa attended seven intervention meetings during the war. These personnel answered a battery of questionnaires regarding demographics and PTSD symptoms during each session. A non-parametric test was used in order to measure the changes in PTSD symptoms between sessions. Pearson correlations were used in order to study the relationship between the magnitude of external stressors and the severity of PTSD symptoms.

Results:

The results suggested that there was a significant relationship between the magnitude of external stressors and the severity of PTSD symptoms. These results are in line with the dose-response model.

Conclusions:

The results suggest that a pattern of decline in PTSD symptoms confirm the dose-response model for PTSD.

Differences in posttraumatic stress reactions between witnesses and direct victims of motor vehicle accidents

The present study describes posttraumatic stress reactions in young witnesses of motor vehicle accidents (MVAs). This study investigated (a) whether witnesses of MVAs report fewer trauma symptoms than direct victims, but more than adolescents who were never exposed to an MVA; and (b) whether individual differences in sex, negative appraisal, avoidant coping, and social support account for variability in trauma symptoms beyond status as a witness as compared to a victim. Self-report data came from a community-based sample of 3,007 adolescents with an average age of 14.6 years and comprising 53% boys. Compared to direct victims of an MVA in which someone was injured, witnesses of MVAs with injury reported significantly less internalizing symptoms, such as symptoms of posttraumatic stress (d = 0.25), fear (d = 0.21), and depression (d = 0.17). Compared to adolescents who were never exposed to an MVA with injury, witnesses reported significantly more externalizing symptoms (d = 0.24). In multiple regression analyses the significant difference between witnesses and victims disappeared when sex, other stressful events, appraisals, and coping were added to the model. These findings suggest that adolescent witnesses, as well as direct victims, may be at risk for posttraumatic reactions.

Mental health of newly arrived Burmese refugees in Australia: contributions of pre-migration and post-migration experience

OBJECTIVE

This study documents the mental health status of people from Burmese refugee backgrounds recently arrived in Australia, then examines the contributions of gender, pre-migration and post-migration factors in predicting mental health.

METHOD

Structured interviews, including a demographic questionnaire, the Harvard Trauma Questionnaire, the Post-migration Living Difficulties Checklist and Hopkins Symptom Checklist assessed pre-migration trauma, post-migration living difficulties, depression, anxiety, somatization and traumatization symptoms in a sample of 70 adults across five Burmese ethnic groups.

RESULTS

Substantial proportions of participants reported psychological distress in symptomatic ranges including: post-traumatic stress disorder (9%), anxiety (20%) and depression (36%), as well as significant symptoms of somatization (37%). Participants reported multiple and severe pre-migration traumas. Post-migration living difficulties of greatest concern included communication problems and worry about family not in Australia. Gender did not predict mental health. Level of exposure to traumatic events and post-migration living difficulties each made unique and relatively equal contributions to traumatization symptoms. Post-migration living difficulties made unique contributions to depression, anxiety and somatization symptoms.

CONCLUSIONS

While exposure to traumatic events impacted on participants' mental well-being, post-migration living difficulties had greater salience in predicting mental health outcomes of people from Burmese refugee backgrounds. Reported rates of post-traumatic stress disorder symptoms were consistent with a large review of adults across seven western countries. High levels of somatization point to a nuanced expression of distress. Findings have implications for service provision in terms of implementing appropriate interventions to effectively meet the needs of this newly arrived group in Australia.

Low specificity of symptoms on the post-traumatic stress disorder (PTSD) symptom scale: A comparison of individuals with PTSD, individuals with other anxiety disorders and individuals without psychopathology

OBJECTIVES

Screening for post-traumatic stress disorder (PTSD) takes place in clinical and research settings where diagnostic interviews are not feasible, and typically relies on self-report instruments like the PTSD symptom scale (PSS). Concerns have been raised about the specificity of PTSD symptoms assessed by questionnaires. This study examined whether the PSS distinguishes between patients with PTSD and those with other anxiety disorders or healthy controls.

DESIGN

A between-participants design was employed.

METHODS

The participants were 65 individuals with PTSD, 40 individuals with other anxiety disorders and 40 healthy controls. They completed the PSS with respect to a range of stressful life-events.

RESULTS

Using this instrument, 86% of individuals with PTSD and 5% of healthy controls endorsed sufficient symptoms to meet the PTSD diagnosis. This was also the case for 43% of individuals with other anxiety disorders, and self-reported symptoms related to traumatic events and aversive events that are generally not considered traumatic.

CONCLUSIONS

The findings suggest that many people screened positive for PTSD may actually be suffering from another anxiety disorder.

Intimate relationships among returning soldiers: the mediating and moderating roles of negative emotionality, PTSD symptoms, and alcohol problems

Research examining relationship quality among combat veterans largely focuses on the role of posttraumatic stress disorder (PTSD), with less attention devoted to other correlates of PTSD and relationship quality, such as personality and problematic drinking. In a sample of combat-exposed National Guard soldiers recently returned from Iraq (N = 308), we examined (a) a meditational pathway from negative emotionality, to elevated postdeployment PTSD symptoms, to poorer relationship quality; and (b) the moderating role of problematic drinking. Moderated mediation regression strategies supported the mediating role of postdeployment PTSD symptoms, but not the moderating role of problematic drinking on soldiers' relationship quality. Findings suggest negative emotionality creates a vulnerability to more severe early postdeployment PTSD symptoms and poorer early postdeployment relationship quality.

Prevalence Estimates of Combat-Related PTSD: A Critical Review

The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.

PTSD and its treatment in people with intellectual disabilities: a review of the literature

Although there is evidence to suggest that people with intellectual disabilities (ID) are likely to suffer from Post-Traumatic Stress Disorder (PTSD), reviews of the evidence base, and the potential consequences of this contention are absent. The purpose of this article is to present a comprehensive account of the literature on prevalence, assessment, and treatment of PTSD in people with ID. Some support was found for the notion that people with ID have a predisposition to the development of PTSD. Differences in comparison with the general population may consist of the expression of symptoms, and the interpretation of distressing experiences, as the manifestation of possible PTSD seems to vary with the level of ID. Since reliable and valid instruments for assessing PTSD in this population are completely lacking, there are no prevalence data on PTSD among people with ID. Nine articles involve treatment of PTSD in people with ID. Interventions reported involve those aimed to establish environmental change, the use of medication and psychological treatments (i.e., cognitive behavioral therapy, EMDR and psychodynamic based treatments). Case reports suggest positive treatment effects for various treatment methods. Development of diagnostic instruments for assessment of PTSD symptomatology in this population is required, as it could facilitate further research on its prevalence and treatment.

Posttraumatic stress disorder in older people after a fall

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is a debilitating psychological condition, never studied in relation to falls in older people. This study determines the prevalence and correlates of PTSD in older people post-fall.

METHOD

A prospective survey study, with baseline data collected by interview in hospital post-fall and by postal self-completion at 12 and 24 weeks post-baseline. A convenience sample of 196 people (> or = 65 years) were serially recruited, 87.9% of those eligible. Information collected at baseline included falls-related data, activity problems, fear of falling, PTSD symptoms, anxiety and depression, and at follow-up PTSD symptoms, anxiety and depression, the receipt of rehabilitation and further falls.

RESULTS

In hospital, of 40 participants whose fall had occurred over 1 month previously 35% had full acute PTSD and 17.5% had partial acute PTSD. At follow-up full or partial chronic PTSD was found in 26.1% of participants at first follow-up, and in 27.4% of participants at second follow-up. Older age, pre-fall activity problems, fear of falling, and anxiety assessed at baseline were associated (p < 0.05) with follow-up PTSD diagnosis, as were anxiety and depression assessed concurrently.

CONCLUSION

PTSD occurs in a substantial minority of older people post-fall. No pattern emerged of factors predictive of PTSD, although the association between fear of falling and PTSD suggests some patients thought to have fear of falling may be manifesting PTSD, and require identification to enable therapeutic intervention.

Death Notification for Families of Homicide Victims: Healing Dimensions of a Complex Process

Family bereavement by homicide is one of the most challenging facets of crime victim intervention a medical care provider, mental health clinician, or law enforcement officer will face. But the process of healing can begin at the outset through intelligent, sensitive, competent, and compassionate death notification and body identification by trained and dedicated professionals. A practical system for death notification and body identification is presented that can be adapted and modified to the needs of law enforcement, military mental health, and notifiers from related disciplines; it can also be adapted to death notification in sudden, accidental deaths. Throughout, the emphasis is on how notifiers may often be the de facto first responders in the struggle to help traumatically bereaved family members survive their ordeal and reclaim their lives.

A memory-based model of posttraumatic stress disorder: evaluating basic assumptions underlying the PTSD diagnosis

In the mnemonic model of posttraumatic stress disorder (PTSD), the current memory of a negative event, not the event itself, determines symptoms. The model is an alternative to the current event-based etiology of PTSD represented in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The model accounts for important and reliable findings that are often inconsistent with the current diagnostic view and that have been neglected by theoretical accounts of the disorder, including the following observations. The diagnosis needs objective information about the trauma and peritraumatic emotions but uses retrospective memory reports that can have substantial biases. Negative events and emotions that do not satisfy the current diagnostic criteria for a trauma can be followed by symptoms that would otherwise qualify for PTSD. Predisposing factors that affect the current memory have large effects on symptoms. The inability-to-recall-an-important-aspect-of-the-trauma symptom does not correlate with other symptoms. Loss or enhancement of the trauma memory affects PTSD symptoms in predictable ways. Special mechanisms that apply only to traumatic memories are not needed, increasing parsimony and the knowledge that can be applied to understanding PTSD.

Relations among peritraumatic dissociation and posttraumatic stress: a critical review

This paper critically reviews the empirical literature addressing the relationship of peritraumatic dissociation to posttraumatic stress. PSYCHLIT and MEDLINE literature searches were conducted to identify relevant studies. The list of articles generated was supplemented by a review of their bibliographies, which resulted in a total of 53 empirical studies. These studies were classified according to the type of potentially traumatizing event investigated and discussed. In the majority of studies, evidence was found for a positive association between peritraumatic dissociation and posttraumatic stress. However, research in this area is limited by several methodological differences and shortcomings with respect to study design, sample characteristics, measurement instruments, and control for moderating or mediating variables. In addition, research is also limited by conceptual problems and the lack of specific time parameters for the occurrence of peritraumatic dissociation. The literature is evaluated according to these methodological differences or shortcomings, and directions for future research are provided.

Memory consistency for traumatic events in Dutch soldiers deployed to Iraq

Retrospective accounts of traumatic events are consistently associated with symptoms of post-traumatic stress disorder (PTSD). This has often been interpreted as causal impact of such events on psychological functioning, but recent studies suggest that the causal direction is (partly) reversed: high levels of PTSD symptoms may be associated with amplified recollections of precipitating traumatic events. The aim of this prospective study was to index the consistency with which Dutch Army soldiers reported traumatic stressors and nontraumatic stressors on their deployment to Iraq, and to examine to what extent PTSD symptoms and pre-existing reporting biases, such as that arising from neuroticism, affect memory inconsistency. Retrospective accounts of stressors were highly variable over time. Individuals with higher levels of PTSD symptoms and neuroticism, lower levels of extraversion, and fewer prior missions, were more prone to increased reporting over time.

Interaction between BDNF Val66Met and dopamine transporter gene variation influences anxiety-related traits

The involvement in neural plasticity and the mediation of effects of repeated stress exposure and long-term antidepressant treatment on hippocampal neurogenesis supports a critical role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of affective and other stress-related disorders. A previously reported valine to methionine substitution at amino-acid position 66 (BDNF Val66Met) seems to account for memory disturbance and hippocampal dysfunction. In the present study, we evaluated the impact of the BDNF Val66Met polymorphism on individual differences in personality traits in a sample of healthy volunteers in relation to other common gene variants thought to be involved in the pathophysiology of affective disorders, such as the serotonin transporter promoter polymorphism (5-HTTLPR) and a variable number of tandem repeat polymorphism of the dopamine transporter gene (DAT VNTR). Personality traits were assessed using the NEO personality inventory (NEO-PI-R) and Tridimensional Personality Questionnaire (TPQ). There was a significant DAT VNTR-dependent association between NEO-PI-R Neuroticism and the BDNF Val66Met polymorphism. Among individuals with at least one copy of the DAT 9-repeat allele, carriers of the BDNF Met allele exhibited significantly lower Neuroticism scores than noncarriers. This interaction was also observed for TPQ Harm Avoidance, a personality dimension related to Neuroticism. Our results support the notion that allelic variation at the BDNF locus--in interaction with other gene variants--influences anxiety- and depression-related personality traits.

The role of experiential avoidance in psychological functioning after war-related stress in Kosovar civilians

The current study examined the relationship between experiential avoidance and psychological distress after war-related traumatic experiences among 152 Kosovar civilian war survivors. Results showed significant correlations between experiential avoidance and psychological distress. Participants who scored high on experiential avoidance reported more impaired psychological functioning and lower subjective quality of life than those who scored low on experiential avoidance. Results of this study indicate that experiential avoidance may be a significant factor in understanding war-related psychological distress.

Preexisting neuroticism, subjective stressor severity, and posttraumatic stress in soldiers deployed to Iraq

OBJECTIVE

To investigate the extent to which preexisting neuroticism confounds the relation between appraisals of the severity of major and minor stressors and posttraumatic stress disorder (PTSD) symptoms.

METHOD

A sample of 383 Dutch army soldiers completed a neuroticism scale before their 4-month tour of duty in Iraq. About 5 months after deployment, most of them rated the severity of stressors on deployment. PTSD symptoms were also assessed.

RESULTS

Appraisal of major stressors in Iraq was significantly related to PTSD symptoms and was, for the most part, independent of neuroticism. However, the strength of the association between minor stressors and PTSD symptoms dropped by 31% after statistical control for neuroticism.

CONCLUSION

Neuroticism may partly compromise the relation between perceived minor stressors and PTSD symptoms.

Coping motives and trait negative affect: testing mediation and moderation models of alcohol problems among American Red Cross disaster workers who responded to the September 11,2001 terrorist attacks

This study explored the mechanism by which trait negative affect and alcohol coping motives are associated with alcohol-related problems in a sample of American Red Cross workers who participated in the relief operation following the attacks in New York City, the Pentagon, and the Pennsylvania crash site on Sept. 11th 2001. The results supported the mediation but not moderation model of coping motives. The support for the mediation model was fairly strong, including small to moderate associations between negative affect and alcohol problems, moderate to strong associations between negative affect and coping motives, and evidence of coping motives mediating the negative affect to alcohol problems relationships. The association between negative affect and coping motives was stronger among younger participants.

Incidence of posttraumatic stress disorder after prolonged surgical intensive care unit treatment

The purpose of the study was to investigate the prevalence of posttraumatic stress disorder (PTSD) after prolonged intensive care unit (ICU) treatment and to study the differences between trauma patients and patients who were admitted with other diagnoses. Survivors of surgical intensive care of at least 30 days' duration underwent follow-up examination at about 35 months after discharge from the ICU. Thirty-seven patients were investigated. Seven patients met full DSM-IV criteria for diagnosis of PTSD. All of them had sustained severe multiple injuries. Patients with trauma were at significantly higher risk for developing PTSD than were non-trauma patients. After prolonged ICU treatment, PTSD seems more likely to occur when the reason for admission to the ICU was severe physical injury. The prevalence of PTSD does not seem to be related to injury severity or duration of ICU treatment.

The longitudinal course of post-traumatic stress after childbirth

Post-traumatic stress was assessed in early and late pregnancy, and 1, 4, 7, and 11 months postpartum by means of questionnaires among 1224 women. Thirty-seven women (3%) had post-traumatic stress (meeting criteria B, C, and D for PTSD) at least once within 1-11 months postpartum. In pregnancy, depression, severe fear of childbirth, 'pre'-traumatic stress, previous counseling related to pregnancy/childbirth, and self-reported previous psychological problems were associated with an increased risk of having post-traumatic stress within 1-11 months postpartum. Sum-scores of post-traumatic stress did not decrease over time among women who at least once had post-traumatic stress (criteria B, C, and D) within 1-11 months postpartum. Women with post-traumatic stress also showed a decrease in perceived social support over time postpartum.

Chronic Pain and Posttraumatic Stress Symptoms in Litigating Motor Vehicle Accident Victims

OBJECTIVE

There has been little research examining chronic pain and posttraumatic stress symptoms in persons injured in motor vehicle accidents. The purpose of this study was to evaluate differences in physical injury and impairment, psychological distress, and pain coping strategies in litigating chronic pain patients low and high in motor vehicle accident-related posttraumatic stress symptoms.

DESIGN

A total of 160 consecutive chronic pain patients referred for psychological-legal assessment underwent semistructured interview and testing. The testing battery included the Minnesota Multiphasic Personality Inventory-2, the Multidimensional Pain Inventory, the Sickness Impact Profile, and the Coping Strategies Questionnaire. Using the sample-specific median split of 18 posttraumatic stress symptoms on the Minnesota Multiphasic Personality Inventory-2 Posttraumatic Stress Disorder scale, chronic pain patients were categorized as evidencing low or high levels of posttraumatic stress symptoms.

RESULTS

The findings indicate that participants evidencing high posttraumatic stress symptoms had more physical impairment, psychological distress, and maladaptive pain coping strategies and were more likely to be treated with antidepressants, other medications, and psychological management than participants evidencing low posttraumatic stress symptoms. A discriminant function analysis was performed using the full combination of physical injury and impairment, psychological distress, and pain coping variables in the prediction of posttraumatic stress symptom-defined group membership. The resulting discriminant function accounted for 61% of the between-group variance and correctly classified 92% of participants who were low in posttraumatic stress symptoms and 88% of participants who were high in posttraumatic stress symptoms.

CONCLUSIONS

Chronic pain and posttraumatic stress symptoms in litigating motor vehicle accident victims are associated with increased physical and psychological morbidity.

Empirical limits for the forensic assessment of PTSD litigants

This paper discusses the limits of expert opinion on posttraumatic stress disorder (PTSD) in personal injury claims. The construct of PTSD is hampered by several empirical limitations. Multiple reliable measures of PTSD exist, but have not been evaluated sufficiently within litigating samples and are infrequently used by forensic assessors. Common methods for trauma screening appear insensitive. Opinions about causation of PTSD and disability are complicated by retrospective memory biases, as well as the failure of most anxiety disorders to be detected within primary medical care. PTSD appears to have a steep spontaneous remission curve during the first year, but at least 10% of trauma-exposed people suffer chronic distress. Little is known about the course beyond 1 year. Efficacious psychological treatments have been developed for PTSD, but are not in common use limiting claimants' access to rehabilitative treatments. Research on functional disability associated with PTSD is in its infancy, but it seems likely that PTSD will account for only a part of the variance in work disability. We provide suggestions for improving forensic practice, advising the courts about the limitations of forensic opinions, and necessary research.

Posttraumatic stress disorder in patients with bipolar disorder: a review of prevalence, correlates, and treatment strategies

OBJECTIVES

In this article, we review the evidence for, and implications of, a high rate of comorbid posttraumatic stress disorder (PTSD) in individuals with bipolar disorder.

METHODS

We reviewed studies providing comorbidity data on patients with bipolar disorder, and also examined the PTSD literature for risk factors and empirically supported treatment options for PTSD.

RESULTS

Studies of bipolar patients have documented elevated rates of PTSD. Based on our review, representing 1214 bipolar patients, the mean prevalence of PTSD in bipolar patients is 16.0% (95% CI: 14-18%), a rate that is roughly double the lifetime prevalence for PTSD in the general population. Risk factors for PTSD that are also characteristic of bipolar samples include the presence of multiple axis I disorders, greater trauma exposure, elevated neuroticism and lower extraversion, and lower social support and socio-economic status.

CONCLUSIONS

These findings are discussed in relation to the cost of PTSD symptoms to the course of bipolar disorder. Pharmacological and cognitive-behavioral treatment options are reviewed, with discussion of modifications to current cognitive-behavioral protocols for addressing PTSD in individuals at risk for mood episodes.

Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees

BACKGROUND

Political instability and the civil war in Southern Sudan have resulted in numerous atrocities, mass violence, and forced migration for vast parts of the civilian population in the West Nile region. High exposure to traumatic experiences has been particularly prominent in the Ugandan and Sudanese of the West Nile Region, representing an indication of the psychological strain posed by years of armed conflict.

METHODS

In this study the impact of traumatic events on the prevalence and severity of posttraumatic stress disorder (PTSD) in a random sample of 3.339 Ugandan nationals, Sudanese nationals, and Sudanese refugees (1.831 households) of the West Nile region is assessed.

RESULTS

Results show a positive correlation between the number of traumatic events and the number of endorsed PTSD symptoms. Of the 58 respondents who experienced the greatest number of traumatizing experiences, all reported symptoms which met the DSM-IV criteria for PTSD.

CONCLUSIONS

There is a clear dose-effect relationship between traumatic exposure and PTSD in the studied populations with high levels of traumatic events. In this context, it is probable that any individual could develop PTSD regardless of other risk-factors once the trauma load reaches a certain threshold.

The sense of coherence in early pregnancy and crisis support and posttraumatic stress after pregnancy loss: a prospective study

A. Antonovsky (1987) defined the sense of coherence (SOC) as the ability to perceive a stressor as comprehensible, manageable, and meaningful. In this prospective study of pregnant women, the authors tested the relationships between the SOC in early pregnancy and crisis support and symptom severity of posttraumatic stress disorder (PTSD) and depression after pregnancy loss. A total of 1,372 women completed questionnaires in early pregnancy, including measures for the SOC and depressive symptoms, and were followed for every 2 months thereafter until 1 month after the birth due-date. Of this group, 126 women had a pregnancy loss, and 118 of them completed measures for crisis support, PTSD, and depression about 1 month later. The results showed that a stronger SOC in early pregnancy renders women somewhat resilient to symptoms of PTSD and depression after pregnancy loss, which appears to be due to the mobilization of crisis support.

Traumatic stress in late pregnancy

Traumatic stress has traditionally been studied in the aftermath of traumatic events. In contrast, this study aimed to explore if traumatic stress can occur before an event that is perceived as threatening or feared. Traumatic stress, as related to the forthcoming delivery, was studied in 1224 women. Background data and psychological characteristics were assessed in early pregnancy and traumatic stress and fear of childbirth in late pregnancy. Of all subjects, 2.3% met all DSM-IV criteria for posttraumatic stress disorder (PTSD) and 5.8% fulfilled criteria B, C, and D in late pregnancy. Traumatic stress and fear of childbirth correlated significantly. High trait anxiety, depressive symptomatology, psychological/psychiatric counseling related to childbirth, and self-reported psychological problems, measured in early pregnancy, were risk factors for traumatic stress and fear of childbirth in late pregnancy. Results suggest the occurrence of "pre"traumatic stress (i.e., a threatening forthcoming event provoking symptoms similar to those after a traumatic event).

Progress and controversy in the study of posttraumatic stress disorder

Research on posttraumatic stress disorder (PTSD) has been notable for controversy as well as progress. This article concerns the evidence bearing on the most contentious issues in the field of traumatic stress: broadening of the definition of trauma, problems with the dose-response model of PTSD, distortion in the recollection of trauma, concerns about "phony combat vets," psychologically toxic guilt as a traumatic stressor, risk factors for PTSD, possible brain-damaging effects of stress hormones, recovered memories of childhood sexual abuse, and the politics of trauma.