Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis

A new approach to cultural scripts of trauma sequelae assessment: The sample case of Switzerland

BACKGROUND

The novel concept of cultural scripts of trauma sequelae captures culture-specific expressions of posttraumatic distress (e.g., cognitive, emotional, interpersonal, psychosomatic changes) and their temporal associations. Cultural scripts of trauma sequelae complement pan-cultural (etic) diagnoses, such as posttraumatic stress disorder (PTSD) and Complex PTSD, as well as the cultural syndromes concept.

OBJECTIVE

This study aimed to develop the cultural scripts of trauma inventory (CSTI) for German-speaking Switzerland and to explore temporal associations of script elements.

METHOD

Five semi-structured focus groups were conducted with psychotraumatologists (n = 8) and Swiss trauma survivors (n = 7). The interview schedule included open questions about different domains of potential posttraumatic changes (emotions, cognitions, worldviews, interpersonal relationships, body-related experiences, behavior, and growth). Data were analyzed using qualitative content analysis.

RESULTS

The Swiss CSTI includes 57 emic elements that represent salient trauma sequelae (30 conformed with a theoretically derived item pool, 27 were newly phrased). Temporal script associations were visualized in a network, whereby self-deprecation, the urge to function and overcompensate, and the urge to hide and endure suffering had the highest number of connections.

CONCLUSION

While many posttraumatic changes identified in the present work seem to mirror pan-cultural phenomena represented in the Complex PTSD concept (e.g., self-deprecation), others (e.g., urge to function and perform, urge to hide and endure suffering) may be prominently related to Swiss culture with its value orientations. Knowledge about cultural scripts of trauma sequelae may provide a culture-specific framework that can help to understand individual experiences of distress and enable mental health practitioners to administer culturally sensitive interventions. Pending further validation, the Swiss CSTI bears the potential to advance culture-sensitive assessment of trauma sequelae.

"And Then Cinderella Was Lying in My Bed": Dissociation Displays in Forensic Interviews With Children Following Intrafamilial Child Sexual Abuse

Child sexual abuse (CSA) has been implicated in dissociative peritraumatic and post-traumatic symptoms and disorders. Although explicitly relevant to the legal process following alleged CSA, very little is known about dissociative manifestations in the context of forensic interviews with children following abuse. The current study was designed to uncoverperi- and post-traumatic dissociation of abused children as revealed in forensic interviews. The study examines the display of dissociation in 42 forensic interviews with children (29 girls, aged 4-14) following intra familial child sexual abuse (IFCSA). Thematic analysis was used to identify key expressions of dissociation in all of the forensic interviews. The analyses identified depersonalization and derealization in the children's description of the abuse. This was manifested both in an inability to feel things that happened during the incidents or imagination and fantasies that were reported as part of the abusive incidents. The children's interviews also revealed the potential manifestations of dissociative amnesia, which was evident in the children's attempts to communicate their retrieval difficulties to the forensic interviewers. Finally, it was identified that the forensic interviews were a platform in which dissociative post-traumatic reactions were activated and often displayed in sensory flashbacks. The current findings uncover the importance of acknowledging trauma and dissociation in the context of forensic interviews with abused children and the urgent need to implement unique responses to trauma within practical guidelines.

Effects of Repetitive Transcranial Magnetic Stimulation on Cognitive Function in Patients With Stress-Related Depression: A Randomized Double-Blind fMRI and 1H-MRS Study

Objectives

To reveal the effects of repetitive transcranial magnetic stimulation (rTMS) on the improvement of cognitive function in patients with stress-related depression, and to enrich the neural mechanism(s) underlying rTMS so as to improve cognitive function in patients with stress-related depression.

Methods

We conducted a randomized, double-blind, placebo-controlled study of rTMS in patients with stress-related depression who were 18–40 years of age. Patients were randomly allocated to either a sham or experimental group in a 1:1 ratio. A 10-session rTMS protocol was used with 10-Hz stimulation over the left dorsolateral prefrontal cortex (DLPFC). Clinical assessments (HAMD, HAMA, DASS, MoCA), neuropsychologic (Stroop, WCST), and resting state fMRI and ¹H-MRS assessments were executed at two time points—baseline and after the 10th rTMS session.

Results

rTMS relieved the mental symptoms of patients in both groups. The MoCA score of patients in the experimental group increased; the number of correct answers increased significantly in Stroop testing, and the number of errors and omissions decreased significantly; the number of persistent errors decreased significantly; and the time used to complete the test decreased to an even greater extent in the WCST experimental group. The ReHo value in the lingual gyrus of the right hemisphere and the cuneus of the left and right hemispheres in the experimental group decreased after treatment. The DC value in the left and right hemispheric cuneus and postcentral gyrus of the left hemisphere in the experimental group diminished after treatment. The functional connections of these brain regions also changed as the Cho and NAA/Cr of the left DLPFC changed, with alterations related to the improvement in cognitive function. The level of choline (Cho) in the left DLPFC of the experimental group was significantly lower than that of the control group, and the level of N-acetylaspartate/creatine (NAA/Cr) in the left DLPFC of the control group was significantly higher than that of the experimental group. These changes were related to the overall improvement in cognitive function.

Conclusions

Ten-Hz rTMS over the left DLPFC improved the cognitive function of patients with stress-related depression. The governing mechanism for this phenomenon may be via rTMS effects on multiple visual-related brain regions and their functional connections, and on the somatosensory cortex and its functional connection with visual and auditory cortex, reducing the level of Cho and stabilizing the level of NAA/Cr in the left DLPFC.

An investigation of the incidence of post-traumatic stress disorder, turnover intention and psychological resilience among medical staff in a public hospital in China during the outbreak of the omicron variant in the COVID-19 pandemic in 2022

OBJECTIVE

To investigate the incidence of post-traumatic stress disorder (PTSD), turnover intention and psychological resilience of medical staff during the Outbreak of the Omicron Variant in the COVID-19 pandemic in 2022 and to provide a basis for adopting relevant psychological interventions to reduce medical staff turnover.

METHODS

Using the PTSD Checklist-Civilian Version (PCL-C) and a total score ranging from 17 to 85 points, a total score ≥ 38 indicates significant PTSD symptoms and a diagnosis of PTSD. The Chinese version of the Turnover Intention Scale (TIS) has a total score of 6 to 24 points; the higher the score, the stronger the turnover intention. The Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) has a total score of 0 to 100 points, with higher scores indicating a better level of psychological resilience. A total of 443 front-line medical staff working in Chinese public hospitals and still treating all patients normally during COVID-19 were invited via the internet to complete a survey from 15 May to 30 May 2022 in China.

RESULTS

The incidence of PTSD was 14.4%, the total turnover intention score was 13.38 ± 4.08, and the total psychological resilience score was 87.16 ± 18.42. The prevalence of PTSD was higher among medical staff who were married, had children, and were worried about being infected; in addition, the PTSD group had a higher level of education, higher turnover intention, and lower psychological resilience than the non-PTSD group. The total scores for turnover intention and fear of being infected were risk factors for PTSD, while a high total psychological resilience score and high education level were protective factors for PTSD; the differences were statistically significant (all P < 0.05).

CONCLUSION

Post-traumatic stress disorder among Chinese medical personnel was associated with the marital status, childbirth, education level, turnover intention, and psychological resilience. Among these factors, psychological resilience might be exploited as a protective factor.

From mechanical objectivity to narrative turn: how film has inspired science on trauma

This essay discusses the relationship between film and psychological trauma from the perspective of the history of science. It examines how the psychological sciences were influenced by image technology, primarily after the two world wars. Taking a closer look at the development of film production and mental imagery experiments as cultural and scientific institutions, this essay examines the challenges psychologists began to face when the paradigm of the trauma film was established in the pursuit of positivist evidence informed by mechanical objectivity. Over the past century, psychological trauma have been explained through the lens of psychiatric sciences and literary critics. However, they were not evenly emphasized and experimental psychology became the mainstream institution to manage trauma in clinical settings. This essay argues that explanations of trauma in the past century have been interdisciplinary. The limitations of trauma-related brain sciences could be ameliorated by re-emphasizing narratives explored in films produced for artistic or moral, rather than scientific, purposes.

Traumatic events and posttraumatic stress disorder in individuals with severe mental illness in a non-western setting: Data from rural Ethiopia

Traumatic events and ensuing stress are not widely studied in individuals with severe mental illness (SMI) despite their increased vulnerability to both. Far less is known about traumatic events and posttrauma reactions in people with SMI in low-resourced settings.

OBJECTIVE

To address this gap in knowledge, our study focused on trauma and its effects for individuals with SMI and their caregivers in rural Ethiopia. Study aims were to identify events that were considered traumatic by stakeholders; characterize the mental health effects of such events; and discern events and posttrauma symptoms most relevant for SMI.

METHOD

Qualitative interviews were gathered from 48 participants in Ethiopia who included individuals with SMI, their caregivers, health care providers, and community and religious leaders.

RESULTS

Based on a combined emic and etic approach, major traumatic events included those commonly experienced in rural Ethiopia (e.g., lost property, forced marriage) and endorsed by individuals with SMI (e.g., restraining or chaining, SMI illness in a low-resourced setting). In addition, traumatic events were identified consistent with Western medical criteria (e.g., physical assault, sexual assault). Posttrauma symptoms that were commonly reported included emotions like anger and sadness; thinking too much; crying; and somatic (e.g., burning sensation) and physiological (e.g., shortness of breath) symptoms. As for symptoms consistent with the Diagnostic and Statistical Manual, we found the presence of all four symptom clusters.

CONCLUSIONS

Overall, results point to the common occurrence of traumatic events and trauma-linked symptoms for individuals with SMI and their caregivers, including as a result of SMI. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cultural shift in mental illness: a comparison of stress responses in World War I and the Vietnam War

OBJECTIVES

Post-traumatic stress disorder is an established diagnostic category. In particular, over the past 20 years, there has been an interest in culture as a fundamental factor in post-traumatic stress disorder symptom manifestation. However, only a very limited portion of this literature studies the historical variability of post-traumatic stress within a particular culture.

DESIGN

Therefore, this study examines whether stress responses to violence associated with armed conflicts have been a culturally stable reaction in Western troops.

SETTING

We have compared historical records from World War I to those of the Vietnam War. Reference is also made to observations of combat trauma reactions in pre-World War I conflicts, World War II, the Korean War, the Falklands War, and the First Gulf War.

PARTICIPANTS

The data set consisted of literature that was published during and after these armed conflicts.

MAIN OUTCOME MEASURES

Accounts of World War I Shell Shock that describe symptom presentation, incidence (both acute and delayed), and prognosis were compared to the observations made of Vietnam War post-traumatic stress disorder victims.

RESULTS

Results suggest that the conditions observed in Vietnam veterans were not the same as those which were observed in World War I trauma victims.

CONCLUSIONS

The paper argues that the concept of post-traumatic stress disorder cannot be stretched to cover the typical battle trauma reactions of World War I. It is suggested that relatively subtle changes in culture, over little more than a generation, have had a profound effect on how mental illness forms, manifests itself, and is effectively treated. We add new evidence to the argument that post-traumatic stress disorder in its current conceptualisation does not adequately account, not only for ethnocultural variation but also for historical variation in stress responses within the same culture.

Correlates of posttraumatic stress disorder in adults with congenital heart disease

OBJECTIVE

The aims of this study were to compare the level of posttraumatic stress disorder between adults with and without congenital heart disease, and to examine the correlates of posttraumatic stress disorder (e.g., sociodemographics).

DESIGN

Cross-sectional.

SETTING

Two university-affiliated heart hospitals in Tehran, Iran.

PATIENTS

A sample of 347 adults with congenital heart disease aged 18-64 years (52% women), and 353 adults without congenital heart disease matched by sex and age (±2 years) was recruited.

OUTCOME MEASURES

The PTSD Scale: Self-report version was used to assess the diagnosis and severity of posttraumatic stress disorder. Hierarchical multivariate logistic regression analyses were performed to explore correlates of likely posttraumatic stress disorder diagnosis among each group of participants.

RESULTS

The posttraumatic stress disorder in the patients was comparable to those of the control group, except for increased arousal (P = .027) which was scored higher among the patients. Over 52% of adults with congenital heart disease met the criteria for a likely posttraumatic stress disorder diagnosis compared with 48% of adults without congenital heart disease. The regression analyses among patients revealed that elevated depressive symptoms (OR = 1.27) and a positive history of cardiac surgery (OR = 2.02) were significantly associated with posttraumatic stress disorder. The model could explain 29% of the variance in posttraumatic stress disorder.

CONCLUSIONS

The high and comparable prevalence of posttraumatic stress disorder among patients and nonpatients highlight the significance of the context in which adults with congenital heart disease may face other/additional stressors than disease-related ones, an issue that clinicians need also take into account. Furthermore, the association of posttraumatic stress disorder with elevated depressive symptoms warrant a comprehensive psychological assessment and management of adults with congenital heart disease, in particular among those with a history of invasive procedures.

Differences in Intrusive Memory Experiences in Post-traumatic Stress Disorder after Single, Re- and Prolonged Traumatization

Intrusive memory experiences (IMEs) are a common symptom of post-traumatic stress disorder (PTSD). Sensory perceptions of IMEs in the PTSD context vary substantially. The present research examined 20 patients with a single trauma, 20 re-traumatized patients and 80 Holocaust-traumatized patients who suffered from PTSD. Our results revealed significant differences in IME frequency based on the types of trauma experience. The findings suggest that patients with prolonged (Holocaust) traumata suffered from visual (65%) and combined visual/acoustic intrusive memories (29%), whereas visual memory experiences were most frequent (90%) among single-trauma patients. The trauma experience and the intrusive memory trigger stimulus were interdependent. The type of trauma critically affects the traumatic experience. Future studies should focus on these findings to improve PTSD therapeutic options.

Disrupted resting-state insular subregions functional connectivity in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is suggested to be a structural and functional abnormality in the insula. The insula, which consists of distinct subregions with various patterns of connectivity, displays complex and diverse functions. However, whether these insular subregions have different patterns of connectivity in PTSD remains unclear. Investigating the abnormal functional connectivity of the insular subregions is crucial to reveal its potential effect on diseases specifically PTSD. This study uses a seed-based method to investigate the altered resting-state functional connectivity of insular subregions in PTSD. We found that patients with PTSD showed reduced functional connectivity compared with healthy controls (HCs) between the left ventral anterior insula and the anterior cingulate cortex. The patients with PTSD also exhibited decreased functional connectivity between the right posterior insula and left inferior parietal lobe, and the postcentral gyrus relative to HCs. These results suggest the involvement of altered functional connectivity of insular subregions in the abnormal regulation of emotion and processing of somatosensory information in patients with PTSD. Such impairments in functional connectivity patterns of the insular subregions may advance our understanding of the pathophysiological basis underlying PTSD.

Voices from the past: Mental and physical outcomes described by American Civil War amputees

Studies of trauma commonly concentrate on the psychological and physiological effects of recent violent events. Although today connections are becoming more explicitly drawn, early studies of the aftermath of amputation serve to shed light on modern understanding of the interaction of the physical and emotional. The study of combat amputation, dissociation, and related posttraumatic stress largely began with the work of 19th-century Philadelphia physician Silas Weir Mitchell, who brought attention to the phenomenon of phantom limb pain. Less known, however, are the data he and his son, John K. Mitchell, also collected on the mental outcomes of trauma. Using an archived collection of original surveys of double-amputee patients dating largely from 1893 housed at the Historical Medical Library at the College of Physicians of Philadelphia, an interdisciplinary team explored the historical, anthropological, and psychological background of the study of combat trauma. Almost 30 years following the end of hostilities, the majority of the sample of U.S. Civil War veterans indicated that their general disposition, general health, and sleeping or eating patterns had changed following limb amputation. More telling, possibly, are the written comments on the surveys and letters that indicate frustration with the continuous suffering and the knowledge of their mental and physical changes. These data illustrate the value of historical archives in documenting the development of the study of trauma and modern concepts of combat experiences.

Psychometric Properties of the Child's Reaction to Traumatic Events Scale-Revised in English and Lugandan

Brief and age-appropriate measures of trauma-related symptoms are useful for identifying children in need of clinical services. The current study examines the psychometric properties of the 23-item Child's Reaction to Traumatic Events Scale-Revised (CRTES-R). The CRTES-R includes subscales assessing hyperarousal, avoidance and intrusion. To date, no studies have examined the psychometric properties of this revised measure or cross-cultural differences in its factor structure. Two samples of (a) children (ages 6-21) who had experienced a hurricane in the USA or Grenada (N = 135), and (b) Ugandan children (ages 8-17) who had experienced a variety of traumatic events (N = 339) completed the CRTES-R in English or Lugandan. Confirmatory factor analysis supported an empirically adjusted model with three modified latent factors in both the English (χ²/df = 1.34, CFI = .90, RMSEA = .05) and Lugandan samples (χ²/df = 1.45, CFI = .93, RMSEA = .04). Although the analysis supported separate hyperarousal, avoidance and intrusion subscales, the items that loaded on each factor differed from the original CRTES-R subscales. The English version of the CRTES-R showed good concurrent validity with the Kauai Recovery Index measure of trauma symptoms. Those using the CRTES-R to assess children's experiences of the different symptom types should consider using the empirically-derived subscales described in this paper; however, those who wish to capture a broad spectrum of PTSD symptoms should consider using all the original CRTES-R items and calculating a total score.

Battle for the mind: World War 1 and the birth of military psychiatry

The 100th anniversary of the outbreak of World War 1 could be viewed as a tempting opportunity to acknowledge the origins of military psychiatry and the start of a journey from psychological ignorance to enlightenment. However, the psychiatric legacy of the war is ambiguous. During World War 1, a new disorder (shellshock) and a new treatment (forward psychiatry) were introduced, but the former should not be thought of as the first recognition of what is now called post-traumatic stress disorder and the latter did not offer the solution to the management of psychiatric casualties, as was subsequently claimed. For this Series paper, we researched contemporary publications, classified military reports, and casualty returns to reassess the conventional narrative about the effect of shellshock on psychiatric practice. We conclude that the expression of distress by soldiers was culturally mediated and that patients with postcombat syndromes presented with symptom clusters and causal interpretations that engaged the attention of doctors but also resonated with popular health concerns. Likewise, claims for the efficacy of forward psychiatry were inflated. The vigorous debates that arose in response to controversy about the nature of psychiatric disorders and the discussions about how these disorders should be managed remain relevant to the trauma experienced by military personnel who have served in Iraq and Afghanistan. The psychiatric history of World War 1 should be thought of as an opportunity for commemoration and in terms of its contemporary relevance-not as an opportunity for self-congratulation.

Trauma, post-traumatic stress disorder and psychiatric disorders in a middle-income setting: prevalence and comorbidity

BACKGROUND

Most studies of post-traumatic stress disorder (PTSD) in low- and middle-income countries (LMICs) have focused on 'high-risk' populations defined by exposure to trauma.

AIMS

To estimate the prevalence of post-traumatic stress disorder (PTSD) in a LMIC, the conditional probability of PTSD given a traumatic event and the strength of associations between traumatic events and other psychiatric disorders.

METHOD

Our sample contained a mix of 3995 twins and 2019 non-twins. We asked participants about nine different traumatic exposures, including the category 'other', but excluding sexual trauma.

RESULTS

Traumatic events were reported by 36.3% of participants and lifetime PTSD was present in 2.0%. Prevalence of non-PTSD lifetime diagnosis was 19.1%. Of people who had experienced three or more traumatic events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.

CONCLUSIONS

Despite high rates of exposure to trauma, this population had lower rates of PTSD than high-income populations, although the prevalence might have been slightly affected by the exclusion of sexual trauma. There are high rates of non-PTSD diagnoses associated with trauma exposure that could be considered in interventions for trauma-exposed populations. Our findings suggest that there is no unique relationship between traumatic experiences and the specific symptomatology of PTSD.

First steps in using machine learning on fMRI data to predict intrusive memories of traumatic film footage

After psychological trauma, why do some only some parts of the traumatic event return as intrusive memories while others do not? Intrusive memories are key to cognitive behavioural treatment for post-traumatic stress disorder, and an aetiological understanding is warranted. We present here analyses using multivariate pattern analysis (MVPA) and a machine learning classifier to investigate whether peri-traumatic brain activation was able to predict later intrusive memories (i.e. before they had happened). To provide a methodological basis for understanding the context of the current results, we first show how functional magnetic resonance imaging (fMRI) during an experimental analogue of trauma (a trauma film) via a prospective event-related design was able to capture an individual's later intrusive memories. Results showed widespread increases in brain activation at encoding when viewing a scene in the scanner that would later return as an intrusive memory in the real world. These fMRI results were replicated in a second study. While traditional mass univariate regression analysis highlighted an association between brain processing and symptomatology, this is not the same as prediction. Using MVPA and a machine learning classifier, it was possible to predict later intrusive memories across participants with 68% accuracy, and within a participant with 97% accuracy; i.e. the classifier could identify out of multiple scenes those that would later return as an intrusive memory. We also report here brain networks key in intrusive memory prediction. MVPA opens the possibility of decoding brain activity to reconstruct idiosyncratic cognitive events with relevance to understanding and predicting mental health symptoms.

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Why only some moments within a trauma intrude while others do not is unclear.

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Neuroimaging may provide further clues as to why this is the case.

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Multivariate pattern analysis, a recent neuroimaging analysis tool, was able to predict intrusive memories.

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Those brain networks involved in intrusive memory prediction are presented.

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Multivariate pattern analysis may inform future innovation in mental health.

Differences in prevalence rates of PTSD in various European countries explained by war exposure, other trauma and cultural value orientation

Background

Guided by previous explorations of historical and cultural influences on the occurrence of PTSD, the aim of the present study was to investigate the contributions of war victimisation (in particular, World War II) and other civil trauma on the prevalence of PTSD, as mediated by cultural value orientation. Secondary data analysis was performed for 12 European countries using data, including PTSD prevalence and number of war victims, crime victims, and natural disaster victims, from different sources. Ten single value orientations, as well as value aggregates for traditional and modern factors, were investigated.

Results

Whilst differences in PTSD prevalence were strongly associated with war victim rates, associations, albeit weaker, were also found between crime victims and PTSD. When cultural value orientations, such as stimulation and conformity as representatives of modern and traditional values, were included in the multivariate predictions of PTSD prevalence, an average of approximately 80% of PTSD variance could be explained by the model, independent of the type of trauma exposure.

Conclusion

The results suggest that the aftermath of war contributes to current PTSD prevalence, which may be explained by the high proportion of the older population who directly or indirectly experienced traumatic war experiences. Additional findings for other types of civil trauma point towards an interaction between value orientation and country-specific trauma rates. Particularly, being personally oriented towards stimulation appears to interact with differences in trauma prevalence. Thus, cultural value orientation might be viewed not only as an individual intrinsic process but also as a compensatory strategy after trauma exposure.

Low emotional response to traumatic footage is associated with an absence of analogue flashbacks: an individual participant data meta-analysis of 16 trauma film paradigm experiments

Most people will experience or witness a traumatic event. A common occurrence after trauma is the experience of involuntary emotional memories of the traumatic event, herewith “flashbacks”. Some individuals, however, report no flashbacks. Prospective work investigating psychological factors associated with an absence of flashbacks is lacking. We performed an individual participant data meta-analysis on 16 experiments (n = 458) using the trauma film paradigm to investigate the association of emotional response to traumatic film footage and commonly collected baseline characteristics (trait anxiety, current depression, trauma history) with an absence of analogue flashbacks. An absence of analogue flashbacks was associated with low emotional response to the traumatic film footage and, to a lesser extent, low trait anxiety and low current depression levels. Trauma history and recognition memory for the film were not significantly associated with an absence of analogue flashbacks. Understanding why some individuals report an absence of flashbacks may aid preventative treatments against flashback development.

Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.

Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress disorder

Apparent psychotic symptoms are often associated with posttraumatic stress disorder (PTSD), but these symptoms are poorly understood. In a sample of 30 male Vietnam combat veterans with severe and chronic PTSD, we conducted detailed assessments of psychotic symptom endorsement, insight, symptom severity, neurocognitive function, and feigning. Two thirds of the subjects endorsed a psychotic item but did not believe that the experiences were real. Those endorsing psychotic items were higher in PTSD severity, general psychopathology, and dissociation but not depression, functional health, cognitive function, or feigned effort. Severity of psychotic symptoms correlated with dissociation, combat exposure, and attention but not PTSD, depression, or functional health. Those endorsing psychotic items scored higher on a screen but not on a detailed structured interview for malingering. Endorsement of psychotic experiences by combat veterans with PTSD do not seem to reflect psychotic symptoms or outright malingering.

The neural basis of flashback formation: the impact of viewing trauma

BACKGROUND

Psychological traumatic events, such as war or road traffic accidents, are widespread. A small but significant proportion of survivors develop post-traumatic stress disorder (PTSD). Distressing, sensory-based involuntary memories of trauma (henceforth 'flashbacks') are the hallmark symptom of PTSD. Understanding the development of flashbacks may aid their prevention. This work is the first to combine the trauma film paradigm (as an experimental analogue for flashback development) with neuroimaging to investigate the neural basis of flashback aetiology. We investigated the hypothesis that involuntary recall of trauma (flashback) is determined during the original event encoding. Method A total of 22 healthy volunteers viewed a traumatic film whilst undergoing functional magnetic resonance imaging (fMRI). They kept a 1-week diary to record flashbacks to specific film scenes. Using a novel prospective fMRI design, we compared brain activation for those film scenes that subsequently induced flashbacks with both non-traumatic control scenes and scenes with traumatic content that did not elicit flashbacks ('potentials').

RESULTS

Encoding of scenes that later caused flashbacks was associated with widespread increases in activation, including in the amygdala, striatum, rostral anterior cingulate cortex, thalamus and ventral occipital cortex. The left inferior frontal gyrus and bilateral middle temporal gyrus also exhibited increased activation but only relative to 'potentials'. Thus, these latter regions appeared to distinguish between traumatic content that subsequently flashed back and comparable content that did not.

CONCLUSIONS

Results provide the first prospective evidence that the brain behaves differently whilst experiencing emotional events that will subsequently become involuntary memories - flashbacks. Understanding the neural basis of analogue flashback memory formation may aid the development of treatment interventions for this PTSD feature.

Psychiatric disorder and suicide in the military, then and now: commentary on Frueh and Smith

Consulting archival medical data from the American Civil War, Frueh and Smith found little evidence of mental disorders, no evidence of reexperiencing symptoms suggestive of posttraumatic stress disorder, but a notable rate of suicide. In this commentary, I suggest reasons why the archives contain so few traces of combat-related disorders despite the massive trauma experienced by soldiers in the Civil War, and I draw implications for military personnel returning from the wars in Iraq and Afghanistan.

Suicide, alcoholism, and psychiatric illness among union forces during the U.S. Civil War

Little is known about post-combat psychological reactions of warriors prior to the Twentieth Century. We estimated rates of suicide, alcohol abuse, and probable psychiatric illness among Union Forces during the U.S. Civil War via examination of data compiled by the Union Army. White active-duty military personnel suicide rates ranged from 8.74 to 14.54 per 100,000 during the war, and surged to 30.4 the year after the war. For blacks, rates ranged from 17.7 in the first year of their entry into the war (1863), to 0 in their second year, and 1.8 in the year after the war. Rates for most other relevant domains, including chronic alcoholism, "nostalgia," and insanity, were extremely low (<1.0%) by modern day standards. Data provide contextual information on suicide and psychiatric variables for combatants during the U.S. Civil War, a brutal modern war with vastly higher casualty rates than recent wars in Iraq and Afghanistan.

Psychotherapy and neuroscience: towards closer integration

The original aim of psychology was to study and understand the spirit-from the Latin spiritus, literally "breath." The limitations of scientific methods in the past favoured psychology's aloofness in terms of studying the "intangible," while medicine developed methods of examining the body (Latin corpus: essential part). Until 20 years ago, knowledge of the localization of brain functions was limited to inferences from clinical observation of brain-lesioned patients or parallel studies of primate brains. Current neuroscience, with its integrative approach, is bringing together research from molecular through cognitive levels, and psychotherapy has benefited from these findings. Functional neuroimaging studies may make specific and more far-reaching contributions in this respect, since cerebral dynamics may be observed in vivo and in controlled situations. Methods such as single photon emission tomography, positron emission tomography, and functional magnetic resonance imaging have been able to evaluate the neural correlates involved in psychotherapy for individuals with obsessive-compulsive disorder, major depression, social phobia, specific phobia, and post-traumatic disorder. Researchers have found that psychotherapy has the potential to modify dysfunctional neural circuits associated with these disorders. However, precautions are required in constructing feasible designs for neurofunctional investigations. This article reviews the 21 studies that have been published on the subject, and sets out the main advantages and limitations of the technologies used most frequently in protocols involving psychotherapies, and prerequisites for experimental designs. We also pose ways in which the findings from neuroimaging may produce knowledge to guide psychotherapeutic interventions by specifying what should be stimulated in these individuals in order to normalize deficient neural activities.

Anthropological discourses on the globalization of posttraumatic stress disorder (PTSD) in post-conflict societies

Posttraumatic stress disorder (PTSD) is a construct that has moved far beyond its origins in Veterans Administration hospitals after the Vietnam War. It is now commonly used in post-conflict societies by humanitarian agencies and researchers. This article looks at the ever-growing expansion of PTSD and reviews medical anthropologists' critiques of this cross-cultural dissemination of Western psychiatric knowledge. The article also reviews post-conflict ethnographies and their results, which often highlight a mismatch between local priorities and the psycho-social services being provided by outside agencies. Finally, the author highlights interventions that are currently being undertaken by humanitarian agencies in an attempt to bridge psychiatric expertise and local forms of healing. Although PTSD is a useful construct for conceptualizing the experience of those who have suffered traumatic events, it does not lend itself to universal cross-cultural application and should be cautiously applied in post-conflict societies.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5

BACKGROUND

There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5.

RESULTS

Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity.

CONCLUSIONS

The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

Scientific Method and the Regulation of Health and Nutritional Claims by the European Food Safety Authority

The protection of European consumers from the false or misleading scientific and nutritional claims of food manufacturers took a step forward with the recent opinions of the European Food Safety Authority (EFSA). As a risk assessment agency, the EFSA recently assessed and rejected a vast number of food claim forcing the withdrawal of many claims from leading manufacturers. Focusing on the functional food sector, consumer protection issues, and market impacts, this article looks into the role of the EFSA and examines the rejection of claims based on bad and misleading science and outlines how the EFSA map claims and distinguishes between the good and bad scientific methods.

Development and psychometric evaluation of a measure to assess distress in partners of Australian combat veterans

OBJECTIVE

The aim of the present study was to develop and evaluate a multidimensional measure of distress experienced by partners of Australian combat veterans.

METHOD

The Partners of Veterans Distress Scale (POV-DS) was developed using factor analysis on a sample of 665 female members of Partners of Veterans Association of Australia. Content validity for the scale was established by using focus groups and expert feedback during item development phase. In addition, two self-report inventories were administered to assess physical/mental health, and satisfaction with life.

RESULTS

Following principal-axis factoring, 45 items were retained, loading on seven distinct but correlated factors: Sleep problems, Hyper-vigilance, Social isolation, Financial problems, Intimacy problems, Exhaustion, and Negative affect. The factor structure was cross-validated using confirmatory factor analysis on a hold-out sample. The distress subscales all exhibited excellent internal consistency (alphas ranged from 0.84 to 0.95). Validation analyses revealed subscales derived from the seven-factor model explained 31% to 45% of the variance in partners' physical health, mental health, and satisfaction with life.

CONCLUSIONS

The study found that the POV-DS is a reliable and valid tool for assessing distress in partners of Australian combat veterans.

Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics

BACKGROUND

Only limited empirical data support the existence of delayed-onset post-traumatic stress disorder (PTSD).

AIMS

To expand our understanding of delayed-onset PTSD prevalence and phenomenology.

METHOD

A cross-sectional, epidemiological design (n = 747) incorporating structured interviews to obtain relevant information for analyses in a multisite study of military veterans.

RESULTS

A small percentage of veterans with identified current PTSD (8.3%, 7/84), current subthreshold PTSD (6.9%, 2/29), and lifetime PTSD only (5.4%, 2/37) met criteria for delayed onset with PTSD symptoms initiating more than 6 months after the index trauma. Altogether only 0.4% (3/747) of the entire sample had current PTSD with delayed-onset symptoms developing more than 1 year after trauma exposure, and no PTSD symptom onset was reported more than 6 years post-trauma.

CONCLUSIONS

Retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure.

PTSD prevalence, associated exposures, and functional health outcomes in a large, population-based military cohort

OBJECTIVES

Posttraumatic stress disorder (PTSD) results from experiencing or witnessing traumatic, life-threatening events including combat-related experiences. The purpose of this study was to investigate the prevalence of PTSD symptoms and diagnosis, self-reported exposures, and functional health in a large cross-section of the U.S. military.

METHODS

This study used baseline Millennium Cohort data (July 2001 to June 2003) of 75,156 U.S. military members to assess the population-based prevalence of PTSD symptoms, self-reported exposures, and functional health as measured by the Medical Outcomes Study Short Form 36-Item Health Survey for Veterans (SF-36V).

RESULTS

PTSD diagnosis without current symptoms was reported by 953 respondents (1.2%, weighted), 1,490 respondents (2.1%, weighted) reported no diagnosis but reported PTSD symptoms, and 287 respondents (0.4%, weighted) reported diagnosis and current symptoms. Self-reported exposure to chemical or biological warfare agents, protective countermeasures, or hearing alarms were associated with PTSD symptoms independent of other combat-like exposures. Physical health was similar among those with PTSD diagnosis and current PTSD symptoms. However, compared with the overall cohort, lower mental health summary means for those reporting current PTSD symptoms (mean = 27.8), current symptoms and diagnosis (mean = 24.6), and diagnosis without current symptoms (mean = 47.5) were found.

CONCLUSIONS

Results suggest a 2.0% prevalence of PTSD symptoms without diagnosis and that self-reported threatening exposures were significantly associated with PTSD symptoms. Mental and physical health scores of those with current PTSD symptoms appear diminished, but suggest a return to cohort levels with resolution of PTSD symptoms.

The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war

The aims of this study were to assess: (1) the relationship between PTSD and impairment, (2) whether there is a threshold in the association of PTSD score and impairment, and (3) whether any of the PTSD criteria are more strongly associated with impairment. We studied 10,069 service personnel from a representative sample of the British Armed Forces to assess the effects of the Iraq war. Participants completed the PTSD checklist (PCL), the general health questionnaire-12 (GHQ-12), the alcohol use disorder identification test (AUDIT) and five questions to assess impairment. 78% of those with a PCL-score of 50 or more endorsed at least one impairment item in comparison to 27% of those with a score below 50. The odds ratio (OR) of impairment in the PCL group with a score of 50 or more was 16.7 (95% CI 12.9-21.6). There was an increasing risk of impairment with an increasing category of PCL-score without a noticeable threshold. For each PTSD subscale: intrusiveness, avoidance/numbing and hyper-arousal, divided into four score categories, there was an increased association with impairment, but the association of avoidance/numbing with impairment was the greatest and independent of the other two criteria (OR 7.2 (95% CI 4.8-10.9). Having a good relationship with a partner had minimal effect on the level of association between PTSD and impairment. Functional impairment is a serious problem for those with PTSD. The impairment is not confined to those with the highest PCL-score. Avoidance/numbing is the criterion which makes the greatest independent contribution to impairment.

"Hotspots" in trauma memories in the treatment of post-traumatic stress disorder: a replication

"Hotspots" refer to memories of detailed moments of peak emotional distress during a traumatic event. This study investigates hotspot frequency, and the emotions and cognitions contained in hotspots of memory for trauma, to replicate a previous study in this area (Holmes, Grey, & Young, 2005). Participants were patients receiving treatment for post-traumatic stress disorder (PTSD) at a specialist outpatient clinic after experiencing a range of traumatic events. The main finding was that, after fear, the most common emotions reported were anger and sadness. Cognitions related to psychological threat to the self were more common than those related to physical threat.

Panic and posttraumatic stress disorder: implications for culture, risk, and treatment

The articles in this special series reflect productive cross-fertilization between the fields of panic disorder and posttraumatic stress disorder. The purpose of this commentary is to elucidate the implications of this research for the broader themes of culture, risk factors, and treatment.

Flashbacks in social anxiety disorder: Psychopathology of a case

Social anxiety disorder is characterized by overwhelming anxiety in everyday situations which are frequently avoided due to a fear of being watched and scrutinized by others or acting in an embarrassing way. Flashbacks are typical symptoms of post-traumatic stress disorder, and their main features are intrusive and vivid images that occur in a waking state. We present a case study of a man diagnosed with social anxiety disorder who had reexperiencing symptoms similar to flashbacks of what he considered "shameful situations". The differential aspects between flashbacks and obsessional imagery are discussed. Reexperiencing symptoms and imagery of social phobia as well as the sociocultural influence over the symptomatology of psychiatric disorders are then highlighted.

Traumatic memories: bridging the gap between functional neuroimaging and psychotherapy

OBJECTIVE

Neuroimaging studies have highlighted important issues related to structural and functional brain changes found in sufferers of psychological trauma that may influence their ability to synthesize, categorize, and integrate traumatic memories.

METHODS

Literature review and critical analysis and synthesis.

RESULTS

Traumatic memories are diagnostic symptoms of post-traumatic stress disorder (PTSD), and the dual representation theory posits separate memory systems subserving vivid re-experiencing (non-hippocampally dependent) versus declarative autobiographical memories of trauma (hippocampally dependent). But the psychopathological signs of trauma are not static over time, nor is the expression of traumatic memories. Multiple memory systems are activated simultaneously and in parallel on various occasions. Neural circuitry interaction is a crucial aspect in the development of a psychotherapeutic approach that may favour an integrative translation of the sensory fragments of the traumatic memory into a declarative memory system.

CONCLUSION

The relationship between neuroimaging findings and psychological approaches is discussed for greater efficacy in the treatment of psychologically traumatized patients.

Gulf war syndrome: a reaction to psychiatry's invasion of the military?

Following the 1991 Gulf War, a number of soldiers who fought there began to complain of various symptoms and disorders, the collection of which came to be known as Gulf War syndrome (GWS). A debate has raged about the nature and cause of this illness, with many suggesting that it is a psychiatric condition. GWS continues to be a contested illness, yet there is no disputing that many Gulf veterans are ill. This article considers the way in which GWS sufferers understand their illness to be physical in nature and the way in which they negotiate and resist psychological theories of their illness. Based on 14 months of ethnographic fieldwork in the United Kingdom, data for this article were collected mainly by in-depth, semistructured interviews with GWS sufferers, their family members, doctors, and scientists, as well as healthy Gulf veterans. A total of 93 informants were interviewed, including 67 UK Gulf veterans, most of whom were ill. The paper argues that despite the increasing presence of psychiatry in military discourse, GWS reveals the way that people are able to transform, negotiate and even negate its power and assumptions.

New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study

OBJECTIVE

To describe new onset and persistence of self reported post-traumatic stress disorder symptoms in a large population based military cohort, many of whom were deployed in support of the wars in Iraq and Afghanistan.

DESIGN

Prospective cohort analysis.

SETTING AND PARTICIPANTS

Survey enrolment data from the millennium cohort (July 2001 to June 2003) obtained before the wars in Iraq and Afghanistan. Follow-up (June 2004 to February 2006) data on health outcomes collected from 50 184 participants.

MAIN OUTCOME MEASURES

Self reported post-traumatic stress disorder as measured by the posttraumatic stress disorder checklist-civilian version using Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria.

RESULTS

More than 40% of the cohort were deployed between 2001 and 2006; between baseline and follow-up, 24% deployed for the first time in support of the wars in Iraq and Afghanistan. New incidence rates of 10-13 cases of post-traumatic stress disorder per 1000 person years occurred in the millennium cohort. New onset self reported post-traumatic stress disorder symptoms or diagnosis were identified in 7.6-8.7% of deployers who reported combat exposures, 1.4-2.1% of deployers who did not report combat exposures, and 2.3-3.0% of non-deployers. Among those with self reported symptoms of post-traumatic stress disorder at baseline, deployment did not affect persistence of symptoms.

CONCLUSIONS

After adjustment for baseline characteristics, these prospective data indicate a threefold increase in new onset self reported post-traumatic stress disorder symptoms or diagnosis among deployed military personnel who reported combat exposures. The findings define the importance of post-traumatic stress disorder in this population and emphasise that specific combat exposures, rather than deployment itself, significantly affect the onset of symptoms of post-traumatic stress disorder after deployment.

Post-traumatic stress disorder symptoms in the files of Australian servicemen hospitalized in 1942-1952

OBJECTIVE

To investigate post-traumatic stress disorder (PTSD) symptomatology in servicemen hospitalized 1942-1952.

METHOD

Hospital files of servicemen (n = 590) were studied and PTSD symptoms in groups, based on service experience, were compared.

RESULTS

Based on their hospital files, 19% of servicemen were classified as having partial PTSD. No full cases of PTSD were identified, due primarily to the small number of recorded avoidance symptoms and the limited information in relation to the stressor criterion. Prisoners of war had the highest reported avoidance and lowest intrusive symptoms compared with other combatants.

CONCLUSIONS

PTSD symptoms may have been common during and after World War II. At that time avoidance was not considered a symptom of disorder. Intrusive and arousal symptoms may be the core symptoms of PTSD and avoidance symptoms need to be reconsidered.

Follow up of post-traumatic stress disorder symptoms in Australian servicemen hospitalized in 1942-1952

OBJECTIVE

To follow up survivors of Australian services hospitalized in 1942-1952 and compare their reported symptoms of post-traumatic stress disorder (PTSD) with symptoms in their hospital files.

METHOD

Twelve survivors were interviewed and combatants completed the revised Impact of Event Scale.

RESULTS

Eight survivors had symptoms satisfying a diagnosis of PTSD at the time of the study. There was underreporting of most relevant symptoms in their hospital files.

CONCLUSIONS

PTSD symptoms were probably common during and after World War II. The findings have implications for the management of PTSD generally and the treatment of ageing WWII veterans in particular.

From intrusive to oscillating thoughts

This paper focused on the possibility that intrusive thoughts (ITs) are a form of an evolutionary, adaptive, and complex strategy to prepare for and resolve stressful life events through schema formation. Intrusive thoughts have been studied in relation to individual conditions, such as traumatic stress disorder and obsessive-compulsive disorder. They have also been documented in the average person experiencing everyday stress. In many descriptions of thought intrusion, it is accompanied by thought suppression. Several theories have been put forth to describe ITs, although none provides a satisfactory explanation as to whether ITs are a normal process, a normal process gone astray, or a sign of pathology. There is also no consistent view of the role that thought suppression plays in the process. I propose that thought intrusion and thought suppression may be better understood by examining them together as a complex and adaptive mechanism capable of escalating in times of need. The ability of a biological mechanism to scale up in times of need is one hallmark of a complex and adaptive system. Other hallmarks of complexity, including self-similarity across scales, sensitivity to initial conditions, presence of feedback loops, and system oscillation, are also discussed in this article. Finally, I propose that thought intrusion and thought suppression are better described together as an oscillatory cycle.

Post-traumatic stress disorder: medicine and politics

Regrettably, exposure to trauma is common worldwide, and can have serious adverse psychological results. The introduction of the notion of post-traumatic stress disorder has led to increasing medicalisation of the problem. This awareness has helped popular acceptance of the reality of post-traumatic psychiatric sequelae, which has boosted research into the pathogenesis of the disorder, leading to improved pharmacological and psychological management. The subjective experience of trauma and subsequent expression of symptoms vary considerably over space and time, and we emphasise that not all psychological distress or psychiatric disorders after trauma should be termed post-traumatic stress disorder. There are limits to the medicalisation of distress and there is value in focusing on adaptive coping during and after traumas. Striking a balance between a focus on heroism and resilience versus victimhood and pathological change is a crucial and constant issue after trauma for both clinicians and society. In this Review we discuss the advantages and disadvantages of medicalising trauma response, using examples from South Africa, the Armed Services, and post-disaster, to draw attention to our argument.

Malingering of PTSD: forensic and diagnostic considerations, characteristics of malingerers and clinical presentations

OBJECTIVE

This paper aims to study the detection of individuals malingering posttraumatic stress disorder (PTSD) in criminal and civil situations.

METHOD

A brief history of PTSD and its rise to prominence in legal circles are discussed. The characteristics of individuals who malinger and particularly those who fake PTSD are discussed. Diagnostic dilemmas inherent to the condition, such as the definition of a traumatic exposure, what constitutes a PTSD flashback and the potential for normal symptom exaggeration, are explored.

RESULTS

The typical presentation of malingered symptoms is presented to help clinicians detect commonly seen malingering patterns. Suggestions for interview techniques, Minnesota Multiphasic Personality Inventory test values and sources of collateral information to help detect malingering are reviewed.

CONCLUSION

The paper concludes with a review of the typical presentations of malingered PTSD symptoms and a reminder that physicians need to distinguish legitimate symptoms from faked or embellished presentations.

Reconciling disparate prevalence rates of PTSD in large samples of US male Vietnam veterans and their controls

BACKGROUND

Two large independent studies funded by the US government have assessed the impact of the Vietnam War on the prevalence of PTSD in US veterans. The National Vietnam Veterans Readjustment Study (NVVRS) estimated the current PTSD prevalence to be 15.2% while the Vietnam Experience Study (VES) estimated the prevalence to be 2.2%. We compared alternative criteria for estimating the prevalence of PTSD using the NVVRS and VES public use data sets collected more than 10 years after the United States withdrew troops from Vietnam.

METHODS

We applied uniform diagnostic procedures to the male veterans from the NVVRS and VES to estimate PTSD prevalences based on varying criteria including one-month and lifetime prevalence estimates, combat and non-combat prevalence estimates, and prevalence estimates using both single and multiple indicator models.

RESULTS

Using a narrow and specific set of criteria, we derived current prevalence estimates for combat-related PTSD of 2.5% and 2.9% for the VES and the NVVRS, respectively. Using a more broad and sensitive set of criteria, we derived current prevalence estimates for combat-related PTSD of 12.2% and 15.8% for the VES and NVVRS, respectively.

CONCLUSION

When comparable methods were applied to available data we reconciled disparate results and estimated similar current prevalences for both narrow and broad definitions of combat-related diagnoses of PTSD.

Historical approaches to post-combat disorders

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.

Traumatic memories of war veterans: not so special after all

Several authors have argued that traumatic experiences are processed and remembered in a qualitatively different way from neutral events. To investigate this issue, we interviewed 121 Croatian war veterans diagnosed with posttraumatic stress disorder (PTSD) about amnesia, intrusions (i.e., flashbacks and nightmares), and the sensory qualities of their most horrific war memories. Additionally, they completed a self-report scale measuring dissociative experiences. In contrast to what one would expect on the basis of theories emphasizing the special status of traumatic memories, amnesia, and high frequency intrusions were not particularly typical for our sample of traumatized individuals. Moreover, traumatic memories were not qualitatively different from neutral memories with respect to their stability and sensory qualities. The severity of PTSD symptoms was not significantly correlated with dissociative experiences. Our findings do not support the existence of special memory mechanisms that are unique to experiencing traumatic events.

Post-traumatic stress disorder revisited: Deconstructing the A-criterion

Since its introduction in 1980, post-traumatic stress disorder (PTSD) has become an indispensable diagnosis in clinical practice and in research. The usefulness and great heuristic value of this newly created diagnosis are undisputed today. In spite of its obvious qualities, there have always been conceptual difficulties with the diagnosis, mainly concerning the crucial A-criterion. The A-criterion of PTSD (i.e. the trauma criterion according to the Diagnostic and Statistical Manual of Mental Disorders) represents the conceptual core of the diagnosis. It is much owed to social and political stances of its original authors and stipulates a monocausal etiology of the disorder. This is in fact inadequate and misleading. Furthermore, the A-criterion is tautologic and therefore dispensable. It may be more appropriate to define PTSD strictly on the basis of descriptive, phenomenological terms and to omit the A-criterion, in order to avoid useless confusions about causal attribution.

Psychological dynamics affecting traumatic memories: implications in psychotherapy

The search to understand response to trauma has turned to the contribution of personality factors. The way people process the stressor event is critical in determining whether a trauma will be configured or not. Neuroscience shows that the brain does not store memories, but traces of information that are later used to create memories, which do not always express a completely factual picture of the past experience. Whenever an event is retrieved, it may undergo a cognitive and emotional change. Psychological dynamics--emotional interpretative tendency that affects the internal dialogue related to a meaningful event--may influence the development of positive or negative outcomes after stressor events. We postulate that therapists must see beyond the traumatic event itself and work with the internal dialogues that maintain the pathological relationship with the past episode. Thus, they may better treat traumatized patients by therapeutically rebuilding the memory. A brief clinical case is presented to show how exposure-based and cognitive restructuring therapy may help trauma victims experience psychological growth from their negative experiences, by fostering healthy psychological dynamics.