Trauma exposure and diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) posttraumatic stress disorder among Danish adults: Implications of narrow and broad operationalizations of criterion A

OBJECTIVE

Posttraumatic stress disorder (PTSD) has long been recognized as a debilitating psychiatric disorder. The definition of Criterion A has been a topic of controversy, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases, 11th version have opted for a narrow and a broad approach to the gatekeeper criterion, respectively. The aim of this study was to test the implications of a narrow (DSM-5) versus broad (including psychologically threatening events) Criterion A for endorsement of a probable PTSD diagnosis and symptom severity.

METHOD

The study was based on a cross-sectional survey conducted in March 2021 among the general population of adult Danish residents in Denmark, ranging in age between 18 and 79 years (n = 1,033).

RESULTS

Psychologically threatening events did not lead to a statistically significant increase in probable PTSD diagnoses, but psychologically threatening events were independently related to probable PTSD risk and severity. Controlling for other potentially traumatizing events and demographic factors, psychologically threatening events were the strongest risk factor for higher symptom severity. We found probable PTSD rates higher but comparable to other Scandinavian countries such as Norway and Sweden.

CONCLUSION

Exposure to psychologically threatening events is an important factor in explaining probable PTSD risk and severity although not independently leading to a significant increase in probable PTSD rates. Probable rates of DSM-5 PTSD are higher than Danish official estimates in a random sample of the Danish adult population (6.8%-6.9% compared to 1%). The generalizability of study findings is limited by nonrepresentativity, the use of self-report measures, and assessment during the COVID-19 lockdown. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees

Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.

Cross-cultural validity of the WHO-5 Well-Being Index and Euthymia Scale: A clinimetric analysis

BACKGROUND

The assessment of psychological well-being and euthymia represents an emerging issue in clinical psychology and psychiatry. Rating scales and indices such as the 5-item version of the World Health Organization Well-Being Index (WHO-5) and the Euthymia Scale (ES) were developed but insufficient attention has been devoted to the evaluation of their cross-cultural validity. This is the first study using Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria to assess cross-cultural validity and sensitivity of five different versions of the WHO-5 and ES.

METHODS

A multicenter cross-sectional study involving a total of 3762 adult participants from different European (i.e., Italy, Poland, Denmark) and non-European (i.e., China, Japan) countries was conducted. Item Response Theory models (Mokken and Rasch analyses) were applied.

RESULTS

Mokken coefficients of scalability were found to range from 0.42 to 0.84. The majority of the versions of the WHO-5 fitted the Rasch model expectations. Paired t-tests revealed that the Italian and Danish WHO-5 versions were unidimensional. Person Separation Reliability indices showed that the Polish, Danish, and Japanese ES versions could reliably discriminate between subjects with different levels of euthymia.

LIMITATIONS

A convenience sampling was used, thus limiting the generalizability of study findings. In addition, no measures of negative mental health were administered.

CONCLUSIONS

WHO-5 can be used in international studies for cross-cultural comparisons since it covers transcultural components of subjective well-being. Findings also suggest that the ES can be used as a cross-cultural screening tool since it entailed the clinimetric property of sensitivity.

Substance-induced psychosis as a risk factor for unipolar depression or anxiety disorders-A nationwide register-based prospective cohort study

BACKGROUND

Substance-induced psychosis has previously been linked to increased incidence of schizophrenia and bipolar disorder. We aimed to investigate if substance-induced psychosis is associated with increased risk of depression or anxiety.

METHODS

We conducted a nationwide prospective register-based cohort study from 1994 to 2017, including all individuals with substance-induced psychosis, and age-and-sex matched controls without substance-induced psychosis. We investigated time to either depression or anxiety, as well as time to depression and time to anxiety, in stratified Cox regression models.

RESULTS

We included 5,557 individuals with substance-induced psychosis and 55,562 controls. Substance-induced psychosis was associated with increased risk of either depression or anxiety (HR=7.05, 95% CI 6.71-7.41), depression (HR=5.40, 95% CI 4.77-6.11), or anxiety (HR=7.05, 95% CI 5.99-8.31). Analyses of individual types of substance-induced psychosis revealed similar hazard ratios across substances. Associations between substance-induced psychosis and depression or anxiety were stronger in people without preceding alcohol or substance use disorders. While strongest shortly after incident substance-induced psychosis, the increased incidence of depression and anxiety remained more than double over the full period of follow-up.

LIMITATIONS

Only psychiatric disorders treated either in psychiatric inpatient or outpatient units, supplemented with information on psychiatric medication, was available. Exact times of onset were similarly unknown, and only dates of first treatment were available.

CONCLUSIONS

Substance-induced psychosis is a strong predictor of later onset of depression or anxiety. Regardless of whether this association is causal, this highlights the need for increased monitoring and possibly improved treatment of patients with substance-induced psychosis.

Level of alexithymia as a measure of personality dysfunction in avoidant personality disorder

BACKGROUND AND OBJECTIVES

Avoidant Personality Disorder (AvPD) is considered a mild to moderate personality disorder. However, few studies have focused on the heterogeneity of AvPD in terms of symptoms and severity. In the current study we set out to replicate and extend earlier findings showing that there is variation among patients with AvPD in terms of alexithymia and, further, that this variation is especially associated with specific facets of personality functioning and is not explained by measures of depression, symptom severity, or co-occurring personality disorder traits.

METHOD

We used intake data from a sample of AvPD patients (n = 56) who had been treated in similar outpatient services. Alexithymia was measured using the Toronto Alexithymia Scale (TAS-20). Patients filled out questionnaires that were analysed using linear regression models.

RESULTS AND CONCLUSIONS

Using well-established cut-off points for low, intermediate and high levels of alexithymia we found an almost equal distribution of alexithymia groups in our sample. Alexithymia was associated with higher personality dysfunction on twelve out of sixteen facets of personality functioning. For eight of these personality facets the alexithymia total score explained significant variance even after controlling for self-reported depression, symptom severity and clinician ratings of personality disorder. Results suggest that AvPD is heterogeneous and that alexithymia may be important as an indicator of severity of specific personality dysfunction.

The PTSD help app in a Danish PTSD population: research protocol of a randomized controlled feasibility trial

BACKGROUND

Due to an increase in PTSD patients seeking help in the Danish mental health sector and the addition of Complex PTSD to the ICD-11, there is a need to increase efficiency of existing treatments for PTSD. mHealth interventions have been shown to reduce PTSD symptoms. Therefore, the implementation of a mHealth intervention designed for psychiatric PTSD patients as a therapy add-on may improve treatment outcome. No study to date has explored the effects of mHealth interventions for PTSD in the Danish mental health sector, the feasibility and effect of this type of intervention needs testing.

METHODS

The study is an investigator-initiated randomized controlled feasibility trial investigating the clinical mHealth tool PTSD help combined with care as usual (CAU) compared to CAU for adults with PTSD. Seventy patients will be recruited and receive either the mHealth intervention combined with CAU or CAU alone. The primary feasibility outcome is the proportion of eligible patients that participate in the study until the end assessment. Secondary outcome data consists of the fraction of compliant patients in the experimental group and exploratory data on PTSD help on PTSD symptom severity, level of psychological distress, sleep quality, dissociation symptoms, therapy readiness, quality of life, disability levels, and recovery.

DISCUSSION

This study may help increase our knowledge of possible benefits of, as well as potential barriers to, the implementation of mHealth tools in the psychiatric sector. It may also provide a cost-efficient means to increase therapy outcomes and decrease the duration of suffering for PTSD patients in the psychiatric sector.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov (ID: NCT03862703) https://clinicaltrials.gov/ct2/show/NCT03862703 on the 27 of February 2019 and has been approved by the Danish Data Protection Agency (journal number: VD-2018-200 ISuite number 6443). Referring to the committee law §2, the National Committee on Health Research Ethics (DNVK) [H-18024180] decided that the study could proceed without approval as the use of PTSD help did not constitute a health science intervention according to Danish health science legislation.

Measuring euthymia within the Neuroticism Scale from the NEO Personality Inventory: A Mokken analysis of the Norwegian general population study for scalability

BACKGROUND

Whereas the Eysenck Neuroticism Scale only contains items covering negative mental health to measure dysthymia, the NEO Personality Inventory (NEO-PI) contains neuroticism items covering both negative mental health and positive mental health (or euthymia). The consequence of wording items both positively and negatively within the NEO-PI has never been psychometrically investigated. The aim of this study was to perform a validation analysis of the NEO-PI neuroticism scale.

METHODS

Using a Norwegian general population study we examined the structure of the negatively and positively formulated items by principal component analysis (PCA). The scalability of the identified two groups of euthymia versus dysthymia items was examined by Mokken analysis.

RESULTS

With a response rate of 90%, 1082 individuals with a completed NEO-PI were available. The PCA identified the neuroticism scale as the most distinct where 14 items had acceptable loadings for the euthymia subscale, another 14 items for the dysthymia subscale. However, the Mokken analysis coefficient of homogeneity only found acceptable scalability for the euthymia subscale.

LIMITATIONS

A comparison with the Eysenck Neuroticism Scale was not performed.

CONCLUSION

The NEO-PI neuroticism scale contains two subscales consisting of items worded in an opposite direction where only the positive euthymia items have an acceptable scalability.

Eysenck's Two Big Personality Factors and Their Relationship to Depression in Patients with Chronic Idiopathic Pain Disorder: A Clinimetric Validation Analysis

Aim. The clinimetric aspects of Eysenck's two big personality factors (neuroticism and extraversion) were originally identified by principal component analysis but have been insufficiently analysed with item response theory models. Their relationship to states of melancholia and anxiety was subsequently analysed. Method. Patients with chronic idiopathic pain disorder were included in the study. The nonparametric item response model (Mokken) was compared to the coefficient alpha to validate the anxiety and depression subscales within the neuroticism scale and the extraversion and introversion subscales within the extraversion scale. When measuring states of depression and anxiety, the Melancholia Scale and the Hamilton Anxiety Scale were used. Results. We identified acceptable subscales of anxiety and depression in the Eysenck factor of neuroticism and extraversion versus introversion subscales within the Eysenck factor of extraversion. Focusing on the item of “Does your mood often go up and down?” we showed a statistically significant association with melancholia and anxiety for patients with a positive score on this item. Conclusion. Within the Eysenck factor of neuroticism it is important to differentiate between the anxiety and depression subscales. The clinimetric analysis of the Eysenck factor of extraversion identified valid subscales.