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Levin Y, Ben-Ezra M, Hamama-Raz Y. Heal the aftermath of intergenerational trauma and grief. Nature 2023; 624:522. [PMID: 38114674 DOI: 10.1038/d41586-023-04059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
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Hien DA, Fitzpatrick S, Saavedra LM, Ebrahimi CT, Norman SB, Tripp J, Ruglass LM, Lopez-Castro T, Killeen TK, Back SE, Morgan-López AA. What's in a name? A data-driven method to identify optimal psychotherapy classifications to advance treatment research on co-occurring PTSD and substance use disorders. Eur J Psychotraumatol 2021; 13:2001191. [PMID: 34992759 PMCID: PMC8725709 DOI: 10.1080/20008198.2021.2001191] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/05/2022] Open
Abstract
Background/Objective The present study leveraged the expertise of an international group of posttraumatic stress and substance use disorder (PTSD+SUD) intervention researchers to identify which methods of categorizing interventions which target SUD, PTSD, or PTSD+SUD for populations with both PTSD+SUD may be optimal for advancing future systematic reviews, meta-analyses, and comparative effectiveness studies which strive to compare effects across a broad variety of psychotherapy types. Method A two-step process was used to evaluate the categorization terminology. First, we searched the literature for pre-existing categories of PTSD+SUD interventions from PTSD+SUD clinical trials, systematic and literature reviews. Then, we surveyed international trauma and substance use subject matter experts about their opinions on pre-existing intervention categorization and ideal categorization nomenclature. Results Mixed method analyses revealed that a proliferation of PTSD+SUD treatment research over the last twenty years brought with it an abundance of ways to characterize the treatments that have been evaluated. Results from our survey of experts (N = 27) revealed that interventions for PTSD+SUD can be classified in many ways that appear to overlap highly with one another. Many experts (11/27; 41%) selected the categories of 'trauma-focused and non-trauma focused' as an optimal way to distinguish treatment types. Although several experts reinforced this point during the subsequent meeting, it became clear that no method of categorizing treatments is without flaws. Conclusion One possible categorization (trauma-focused/non-trauma focused) was identified. Revised language and nomenclature for classification of PTSD+SUD treatments are needed in order to accommodate the needs of this advancing field.
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Affiliation(s)
- Denise A. Hien
- Center of Alcohol & Substance Use Studies, Rutgers University–New Brunswick, Piscataway, NJ, USA
| | | | | | - Chantel T. Ebrahimi
- Center of Alcohol & Substance Use Studies, Rutgers University–New Brunswick, Piscataway, NJ, USA
- Department of Psychology, The New School for Social Research, New York, NY, USA
| | - Sonya B. Norman
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Jessica Tripp
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Lesia M. Ruglass
- Center of Alcohol & Substance Use Studies, Rutgers University–New Brunswick, Piscataway, NJ, USA
- Department of Psychology, City College of New York, New York, NY, USA
| | | | - Therese K. Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Brenner LA, Betthauser LM, Penzenik M, Germain A, Li JJ, Chattopadhyay I, Frank E, Kupfer DJ, Gibbons RD. Development and Validation of Computerized Adaptive Assessment Tools for the Measurement of Posttraumatic Stress Disorder Among US Military Veterans. JAMA Netw Open 2021; 4:e2115707. [PMID: 34236411 PMCID: PMC8267606 DOI: 10.1001/jamanetworkopen.2021.15707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Veterans from recent and past conflicts have high rates of posttraumatic stress disorder (PTSD). Adaptive testing strategies can increase accuracy of diagnostic screening and symptom severity measurement while decreasing patient and clinician burden. OBJECTIVE To develop and validate a computerized adaptive diagnostic (CAD) screener and computerized adaptive test (CAT) for PTSD symptom severity. DESIGN, SETTING, AND PARTICIPANTS A diagnostic study of measure development and validation was conducted at a Veterans Health Administration facility. A total of 713 US military veterans were included. The study was conducted from April 25, 2017, to November 10, 2019. MAIN OUTCOMES AND MEASURES The participants completed a PTSD-symptom questionnaire from the item bank and provided responses on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5). A subsample of 304 participants were interviewed using the Clinician-Administered Scale for PTSD for DSM-5. RESULTS Of the 713 participants, 585 were men; mean (SD) age was 52.8 (15.0) years. The CAD-PTSD reproduced the Clinician-Administered Scale for PTSD for DSM-5 PTSD diagnosis with high sensitivity and specificity as evidenced by an area under the curve of 0.91 (95% CI, 0.87-0.95). The CAT-PTSD demonstrated convergent validity with the PCL-5 (r = 0.88) and also tracked PTSD diagnosis (area under the curve = 0.85; 95% CI, 0.79-0.89). The CAT-PTSD reproduced the final 203-item bank score with a correlation of r = 0.95 with a mean of only 10 adaptively administered items, a 95% reduction in patient burden. CONCLUSIONS AND RELEVANCE Using a maximum of only 6 items, the CAD-PTSD developed in this study was shown to have excellent diagnostic screening accuracy. Similarly, using a mean of 10 items, the CAT-PTSD provided valid severity ratings with excellent convergent validity with an extant scale containing twice the number of items. The 10-item CAT-PTSD also outperformed the 20-item PCL-5 in terms of diagnostic accuracy. The results suggest that scalable, valid, and rapid PTSD diagnostic screening and severity measurement are possible.
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Affiliation(s)
- Lisa A. Brenner
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora
- Department of Physical Medicine & Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Psychiatry & Neurology, University of Colorado, Anschutz Medical Campus, Aurora
| | - Lisa M. Betthauser
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora
- Department of Physical Medicine & Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora
| | - Molly Penzenik
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora
| | - Anne Germain
- Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jin Jun Li
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Computer Science, University of Chicago, Chicago, Illinois
| | - Ishanu Chattopadhyay
- Department of Medicine, University of Chicago, Chicago, Illinois
- Committee on Quantitative Methods, University of Chicago, Chicago, Illinois
- Committee on Genetics, Genomics & Systems Biology, University of Chicago, Chicago, Illinois
| | - Ellen Frank
- Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Robert D. Gibbons
- Department of Medicine, University of Chicago, Chicago, Illinois
- Committee on Quantitative Methods, University of Chicago, Chicago, Illinois
- Center for Health Statistics, University of Chicago, Chicago, Illinois
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Abstract
BACKGROUND In the nearly a quarter of a century since the addition of the clinically significant distress/impairment criterion to the definition of PTSD in DSM-IV, little research has been done to examine the association of this criterion with symptom group criteria and with the numbing subgroup specifically. This study was conducted to examine these relationships in a large database of disaster survivors consistently studied across 12 different incidents of the full range of disaster typology. METHODS Analysis was conducted on a merged database representing 1187 trauma-exposed survivors of 12 different disasters studied systematically. DSM-IV-TR criteria for disaster-related PTSD were assessed with the Diagnostic Interview Schedule. RESULTS PTSD Group C (avoidance/numbing) and numbing specifically were less common and more associated than other symptom groups with criterion F (distress/impairment). Consistently in multivariable models, group C and numbing were independently associated with criterion F. Group D (hyperarousal) was less strongly associated with criterion F. Neither group B (intrusion) nor avoidance were associated with criterion F. CONCLUSIONS In this and other studies, group C and numbing specifically have been shown to be associated with criterion F, which is consistent with the demonstration that group C and the numbing component specifically are central to the psychopathology of PTSD. The addition of the distress/impairment requirement broadly across the psychiatric diagnoses in DSM-IV added little value to PTSD symptom criteria. Future revisions of diagnostic criteria may benefit by carefully considering these findings to possibly re-include a prominent numbing symptom section.
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Affiliation(s)
- Carol S North
- The Altshuler Center for Education & Research at Metrocare Services and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erin Van Enkevort
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Barry A Hong
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Alina M Surís
- VA North Texas Health Care System and The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Forte G, Favieri F, Tambelli R, Casagrande M. COVID-19 Pandemic in the Italian Population: Validation of a Post-Traumatic Stress Disorder Questionnaire and Prevalence of PTSD Symptomatology. Int J Environ Res Public Health 2020; 17:E4151. [PMID: 32532077 PMCID: PMC7312976 DOI: 10.3390/ijerph17114151] [Citation(s) in RCA: 209] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/06/2020] [Accepted: 06/08/2020] [Indexed: 12/19/2022]
Abstract
Since December 2019, the COVID-19 pandemic has attracted worldwide attention for its rapid and exponential diffusion. The long-term psychological impact, of both the spread of the virus and the restrictive policies adopted to counteract it, remains uncertain. However, recent studies reported a high level of psychological distress and Post-Traumatic Stress Disorder (PTSD) symptoms. The purpose of this study is to assess the psychometric properties of a new questionnaire, to evaluate PTSD risk related to the COVID-19 emergency. A total of Italian people completed a web-based cross-sectional survey broadcasted through different social-media. Demographic data and some psychological dimensions, such as general distress and sleep disturbance, were collected. A new self-report questionnaire (COVID-19-PTSD), consisting of 19 items, was developed starting from the PTSD Check List for DSM-5 (PCL-5) questionnaire, and it was administered in order to analyze its psychometric properties. The results highlighted the adequate psychometric properties of the COVID-19-PTSD questionnaire. The confirmatory factor analysis indicated that a seven-factor model (Intrusion, Avoidance, Negative Affect, Anhedonia, Dysphoric arousal, Anxious arousal and Externalizing behavior) best fits the data. Significant correlations were found among COVID-19-PTSD scores, general distress and sleep disturbance. A high percentage of PTSD symptomatology (29.5%) was found in the Italian population. COVID-19-PTSD appears to be effective in evaluating the specific stress symptoms related to the COVID-19 pandemic in the Italian population. These results are relevant from a clinical point of view because they suggest that the COVID-19 pandemic could be considered as a traumatic event. Psychological interventions to counteract short- and long-term psychopathological effects, consequent to the COVID-19 pandemic, appear to be necessary.
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Affiliation(s)
- Giuseppe Forte
- Department of Psychology, Sapienza University of Rome, Via dei Marsi 78, 00185 Rome, Italy;
| | - Francesca Favieri
- Department of Psychology, Sapienza University of Rome, Via dei Marsi 78, 00185 Rome, Italy;
| | - Renata Tambelli
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185 Rome, Italy;
| | - Maria Casagrande
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185 Rome, Italy;
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Knefel M, Lueger‐Schuster B, Bisson J, Karatzias T, Kazlauskas E, Roberts NP. A Cross-Cultural Comparison of ICD-11 Complex Posttraumatic Stress Disorder Symptom Networks in Austria, the United Kingdom, and Lithuania. J Trauma Stress 2020; 33:41-51. [PMID: 30688371 PMCID: PMC7155025 DOI: 10.1002/jts.22361] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/24/2018] [Accepted: 05/02/2018] [Indexed: 11/30/2022]
Abstract
The 11th revision of the World Health Organization's International Classification of Diseases (ICD-11) includes a new disorder, complex posttraumatic stress disorder (CPTSD). The network approach to psychopathology enables investigation of the structure of disorders at the symptom level, which allows for analysis of direct symptom interactions. The network structure of ICD-11 CPTSD has not yet been studied, and it remains unclear whether similar networks replicate across different samples. We investigated the network models of four different trauma samples that included a total of 879 participants (M age = 47.17 years, SD = 11.92; 59.04% women) drawn from Austria, Lithuania, and Scotland and Wales in the United Kingdom. The International Trauma Questionnaire was used to assess symptoms of ICD-11 CPTSD in all samples. The prevalence of PTSD and CPTSD ranged from 23.7% to 37.3% and from 9.3% to 53.1%, respectively. Regularized partial correlation networks were estimated and the resulting networks compared. Despite several differences in the symptom presentation and cultural background, the networks across the four samples were considerably similar, with high correlations between symptom profiles (ρs = .48-.87), network structures (ρs = .69-.75), and centrality estimates (ρs = .59-.82). These results support the replicability of CPTSD network models across different samples and provide further evidence about the robust structure of CPTSD. The most central symptom in all four sample-specific networks and the overall network was "feelings of worthlessness." Implications of the network approach in research and practice are discussed.
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Affiliation(s)
| | | | | | - Thanos Karatzias
- School of Health & Social CareEdinburgh Napier UniversityEdinburghUK
- Rivers Centre for Traumatic StressNHS LothianEdinburghEdinburghUK
| | - Evaldas Kazlauskas
- Department of Clinical and Organizational PsychologyVilnius UniversityVilniusLithuania
| | - Neil P. Roberts
- School of MedicineCardiff UniversityCardiffUK
- Cardiff & Vale University Health BoardCardiffUK
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Pencea I, Munoz AP, Maples-Keller JL, Fiorillo D, Schultebraucks K, Galatzer-Levy I, Rothbaum BO, Ressler KJ, Stevens JS, Michopoulos V, Powers A. Emotion dysregulation is associated with increased prospective risk for chronic PTSD development. J Psychiatr Res 2020; 121:222-228. [PMID: 31865212 PMCID: PMC6957226 DOI: 10.1016/j.jpsychires.2019.12.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
Abstract
While emotion dysregulation is associated with many psychological disorders, including posttraumatic stress disorder (PTSD), it remains uncertain whether pre-existing emotion dysregulation increases individual risk for prospectively developing PTSD in the aftermath of trauma exposure. Thus, the objective of the current study was to determine whether emotion dysregulation could prospectively predict the development of chronic PTSD symptoms following a traumatic event above and beyond other known associated factors, including depressive symptoms, baseline PTSD symptoms, total traumas experienced, and exposure to interpersonal trauma. Participants (N = 135) were recruited from the emergency department (ED) at Grady Memorial Hospital in Atlanta and follow-up assessments were conducted at 1-, 3-, 6-, and 12-months following trauma exposure. Latent Growth Mixture Modeling was used to identify PTSD symptom trajectories based on symptoms assessed at 1, 3, 6, and 12 months; three trajectories emerged: "chronic", "recovery", and "resilient". For the present study, probability of chronic PTSD symptoms was used as the outcome variable of interest. Linear regression modeling showed that emotion dysregulation was significantly associated with probability of developing chronic PTSD symptoms (p = 0.001) and accounted for an additional 7% of unique predictive variance when controlling for trauma exposure, baseline PTSD, and depressive symptoms. Our findings suggest that emotion dysregulation can be used as both a predictor of chronic PTSD and as a treatment target. Thus, identifying individuals with high levels of emotion dysregulation at the time of trauma and implementing treatments designed to improve emotion regulation could aid in decreasing the development of chronic PTSD among these at-risk individuals.
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Affiliation(s)
- Ioana Pencea
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Adam P Munoz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Jessica L Maples-Keller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Devika Fiorillo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | | | - Isaac Galatzer-Levy
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Kerry J Ressler
- Mclean Hospital, Harvard Medical School, Belmont, MA, USA; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Jennifer S Stevens
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA
| | - Vasiliki Michopoulos
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA; Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, New York, USA.
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Abstract
Although many studies have assessed gender differences in posttraumatic stress disorder (PTSD) prevalence, few examine individual PTSD symptoms (PTSSs). Hypothesizing that trauma differences explain many gender differences in symptomatology, this is the first known study to adjust PTSSs for trauma type, and to compare gender differences in those with sexual traumas. Using a cross-sectional survey methodology in a sample of adult outpatients (n = 775), we examined gender, trauma type, PTSSs, suicide, alcohol, and tobacco. Among those with trauma (n = 483), women generally had more severe symptoms than men, but after adjusting for trauma type, only physical reactivity (p = .0002), excessive startle (p = .0005), external avoidance (p = .0007), internal avoidance (p = .0008), psychological reactivity (p = .0009), and suicide attempts (p = .001) remained significantly worse among women, whereas men more commonly reported alcohol problems (p = .007). Among those with PTSD (n = 164), there were no significant PTSS gender differences. Those with sexual trauma had worse symptoms (particularly amnesia) compared with non-sexual trauma (p < .0001 for PTSD diagnosis and total severity), including within each gender. Among those with sexual trauma (n = 157), men had worse recklessness (p = .004) and more commonly reported tobacco (p = .02), whereas women more commonly attempted suicide (p = .02) and had worse avoidance (p = .04). However, when isolating the effects of sexual trauma beyond other traumas, there were no significant symptom difference-in-differences between genders. Our findings suggest that, while women have higher PTSD rates, men with PTSD present similarly. In addition, while women have higher sexual trauma rates, men may have similarly severe responses. Most gender differences in PTSD presentation appear to be explained by trauma type, particularly women having higher rates of sexual trauma. We discuss potential biopsychosocial explanations.
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Affiliation(s)
- Jeffrey Guina
- Wright-Patterson Air Force Base, OH, USA
- Wright State University, Dayton, OH, USA
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Rusch HL, Robinson J, Yun S, Osier ND, Martin C, Brewin CR, Gill JM. Gene expression differences in PTSD are uniquely related to the intrusion symptom cluster: A transcriptome-wide analysis in military service members. Brain Behav Immun 2019; 80:904-908. [PMID: 31039430 PMCID: PMC6752960 DOI: 10.1016/j.bbi.2019.04.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/18/2019] [Accepted: 04/26/2019] [Indexed: 11/19/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is associated with wide-spread immune dysregulation; however, little is known about the gene expression differences attributed to each PTSD symptom cluster. This is an important consideration when identifying diagnostic and treatment response markers in highly comorbid populations with mental and physical health conditions that share symptoms. To this aim, we utilized a transcriptome-wide analysis of differential gene expression in peripheral blood by comparing military service members: (1) with vs. without PTSD, (2) with high vs. low PTSD cluster symptom severity, and (3) with improved vs. not improved PTSD symptoms following 4-8 weeks of evidenced-based sleep treatment. Data were analyzed at a ±2.0-fold change magnitude with subsequent gene ontology-based pathway analysis. In participants with PTSD (n = 39), 89 differentially expressed genes were identified, and 94% were upregulated. In participants with high intrusion symptoms (n = 22), 1040 differentially expressed genes were identified, and 98% were upregulated. No differentially expressed genes were identified for the remaining two PTSD symptom clusters. Ten genes (C5orf24, RBAK, CREBZF, CD69, PMAIP1, AGL, ZNF644, ANKRD13C, ESCO1, and ZCCHC10) were upregulated in participants with PTSD and high intrusion symptoms at baseline and downregulated in participants with improved PTSD symptoms following treatment. Pathway analysis identified upregulated immune response systems and metabolic networks with a NF-kB hub, which were downregulated with symptom reduction. Molecular biomarkers implicated in intrusion symptoms and PTSD symptom improvement may inform the development of therapeutic targets for precise treatment of PTSD.
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Affiliation(s)
- Heather L Rusch
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, United States.
| | - Jeffrey Robinson
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, United States
| | - Sijung Yun
- Yotta Biomed, LLC, Bethesda, MD 20817, United States
| | - Nicole D Osier
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, United States
| | - Christiana Martin
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, United States
| | - Chris R Brewin
- University College London, London WC1E 6BT, United Kingdom
| | - Jessica M Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, United States
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Affiliation(s)
- Ruth Spence
- Centre for Abuse and Trauma Studies,Psychology Department,Middlesex University,London,UK
| | - Lisa Kagan
- Centre for Abuse and Trauma Studies,Psychology Department,Middlesex University,London,UK
| | - Antonia Bifulco
- Centre for Abuse and Trauma Studies,Psychology Department,Middlesex University,London,UK
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Affiliation(s)
- Richard A A Kanaan
- Department of Psychiatry, Austin Health,University of Melbourne,Heidelberg, VIC 3084,Australia
| | - Thomas K J Craig
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College,London,UK
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Harrington KM, Quaden R, Stein MB, Honerlaw JP, Cissell S, Pietrzak RH, Zhao H, Radhakrishnan K, Aslan M, Gaziano JM, Concato J, Gagnon DR, Gelernter J, Cho K. Validation of an Electronic Medical Record-Based Algorithm for Identifying Posttraumatic Stress Disorder in U.S. Veterans. J Trauma Stress 2019; 32:226-237. [PMID: 31009556 PMCID: PMC6699164 DOI: 10.1002/jts.22399] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 12/28/2022]
Abstract
We developed an algorithm for identifying U.S. veterans with a history of posttraumatic stress disorder (PTSD), using the Department of Veterans Affairs (VA) electronic medical record (EMR) system. This work was motivated by the need to create a valid EMR-based phenotype to identify thousands of cases and controls for a genome-wide association study of PTSD in veterans. We used manual chart review (n = 500) as the gold standard. For both the algorithm and chart review, three classifications were possible: likely PTSD, possible PTSD, and likely not PTSD. We used Lasso regression with cross-validation to select statistically significant predictors of PTSD from the EMR and then generate a predicted probability score of being a PTSD case for every participant in the study population (range: 0-1.00). Comparing the performance of our probabilistic approach (Lasso algorithm) to a rule-based approach (International Classification of Diseases [ICD] algorithm), the Lasso algorithm showed modestly higher overall percent agreement with chart review than the ICD algorithm (80% vs. 75%), higher sensitivity (0.95 vs. 0.84), and higher accuracy (AUC = 0.95 vs. 0.90). We applied a 0.7 probability cut-point to the Lasso results to determine final PTSD case-control status for the VA population. The final algorithm had a 0.99 sensitivity, 0.99 specificity, 0.95 positive predictive value, and 1.00 negative predictive value for PTSD classification (grouping possible PTSD and likely not PTSD) as determined by chart review. This algorithm may be useful for other research and quality improvement endeavors within the VA.
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Affiliation(s)
- Kelly M. Harrington
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rachel Quaden
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Murray B. Stein
- Psychiatry Service, VA San Diego Healthcare System, San Diego, California, USA
- Departments of Psychiatry and Family Medicine & Public Health, University of California San Diego, La Jolla, California, USA
| | - Jacqueline P. Honerlaw
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Shadha Cissell
- Psychiatry Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Robert H. Pietrzak
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hongyu Zhao
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Krishnan Radhakrishnan
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Mihaela Aslan
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Concato
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David R. Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joel Gelernter
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Departments of Genetics and Neuroscience, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Barbano AC, van der Mei WF, Bryant RA, Delahanty DL, deRoon-Cassini TA, Matsuoka YJ, Olff M, Qi W, Ratanatharathorn A, Schnyder U, Seedat S, Kessler RC, Koenen KC, Shalev AY. Clinical implications of the proposed ICD-11 PTSD diagnostic criteria. Psychol Med 2019; 49:483-490. [PMID: 29754591 PMCID: PMC6331687 DOI: 10.1017/s0033291718001101] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/13/2018] [Accepted: 04/05/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND Projected changes to post-traumatic stress disorder (PTSD) diagnostic criteria in the upcoming International Classification of Diseases (ICD)-11 may affect the prevalence and severity of identified cases. This study examined differences in rates, severity, and overlap of diagnoses using ICD-10 and ICD-11 PTSD diagnostic criteria during consecutive assessments of recent survivors of traumatic events. METHODS The study sample comprised 3863 survivors of traumatic events, evaluated in 11 longitudinal studies of PTSD. ICD-10 and ICD-11 diagnostic rules were applied to the Clinician-Administered PTSD Scale (CAPS) to derive ICD-10 and ICD-11 diagnoses at different time intervals between trauma occurrence and 15 months. RESULTS The ICD-11 criteria identified fewer cases than the ICD-10 across assessment intervals (range -47.09% to -57.14%). Over 97% of ICD-11 PTSD cases met concurrent ICD-10 PTSD criteria. PTSD symptom severity of individuals identified by the ICD-11 criteria (CAPS total scores) was 31.38-36.49% higher than those identified by ICD-10 criteria alone. The latter, however, had CAPS scores indicative of moderate PTSD. ICD-11 was associated with similar or higher rates of comorbid mood and anxiety disorders. Individuals identified by either ICD-10 or ICD-11 shortly after traumatic events had similar longitudinal course. CONCLUSIONS This study indicates that significantly fewer individuals would be diagnosed with PTSD using the proposed ICD-11 criteria. Though ICD-11 criteria identify more severe cases, those meeting ICD-10 but not ICD-11 criteria remain in the moderate range of PTSD symptoms. Use of ICD-11 criteria will have critical implications for case identification in clinical practice, national reporting, and research.
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Affiliation(s)
- Anna C. Barbano
- Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY 10016, USA
| | - Willem F. van der Mei
- Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY 10016, USA
| | - Richard A. Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Douglas L. Delahanty
- Department of Psychological Sciences, Kent State University, 144 Kent Hall, Kent, OH 44242, USA
| | - Terri A. deRoon-Cassini
- Department of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Yutaka J. Matsuoka
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, 5-1-1 Tsukiji, Chou-ku, Tokyo 104-0045, Japan
| | - Miranda Olff
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Arq Psychotrauma Expert Group, Postbus 240, 1110 AE, Diemen, The Netherlands
| | - Wei Qi
- Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY 10016, USA
| | - Andrew Ratanatharathorn
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY 10032, USA
| | - Ulrich Schnyder
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, PO Box 1931, Lenggstrasse 31, 8032, Zürich/Switzerland
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Private Bag X1, Matieland, 7602, Stellenbosch, South Africa
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA
| | - Karestan C. Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Kresge 505, 677 Huntington Avenue, Kresge Building, Boston, MA 02115, USA
| | - Arieh Y. Shalev
- Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY 10016, USA
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Hecker T, Huber S, Maier T, Maercker A. Differential Associations Among PTSD and Complex PTSD Symptoms and Traumatic Experiences and Postmigration Difficulties in a Culturally Diverse Refugee Sample. J Trauma Stress 2018; 31:795-804. [PMID: 30431683 DOI: 10.1002/jts.22342] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 07/15/2018] [Accepted: 07/17/2018] [Indexed: 11/07/2022]
Abstract
Forced migration is one of the major challenges currently facing the international community. Many refugees have been affected by traumatic experiences at home and during their flight, putting them at a heightened risk of developing trauma-related disorders. The new version of the International Classification of Diseases (ICD-11) introduced two sibling disorders, posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). So far, little is known about risk and protective factors in refugees that are specifically associated with the disturbances in self-organization (DSO) characteristic of CPTSD. In this study, we aimed to investigate the association between PTSD and DSO symptoms and traumatic experiences, postmigration difficulties, and social support in a culturally diverse sample of refugees who resettled in Switzerland. A total of 94 refugees (85.1% male; M age = 31.60 years, SD = 10.14, range: 18-61 years) participated in this study. Trained assessors performed either guided questionnaire assessments or structured interviews. In our advice- and help-seeking sample, 32.9% of individuals suffered from PTSD and 21.3% from CPTSD. After controlling for potential gender differences, we found positive associations between PTSD symptoms and trauma exposure, β = .22, as well as between DSO symptoms and postmigration living difficulties, β = .42, and lack of social support, β = .22. Our findings support the notion that it is highly important to consider differential associations among PTSD and DSO symptoms and risk and protective factors to gain a deeper understanding of the trauma-related problems refugees face.
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Affiliation(s)
- Tobias Hecker
- Department of Psychology, University of Zurich, Zurich, Switzerland
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Stephanie Huber
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Thomas Maier
- Psychiatric Services of the Canton of St. Gallen-North, Wil, Switzerland
| | - Andreas Maercker
- Department of Psychology, University of Zurich, Zurich, Switzerland
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15
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Moshier SJ, Bovin MJ, Gay NG, Wisco BE, Mitchell KS, Lee DJ, Sloan DM, Weathers FW, Schnurr PP, Keane TM, Marx BP. Examination of posttraumatic stress disorder symptom networks using clinician-rated and patient-rated data. J Abnorm Psychol 2018; 127:541-547. [PMID: 30102064 PMCID: PMC7059999 DOI: 10.1037/abn0000368] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Network theory, which conceptualizes psychiatric disorders as networks of interacting symptoms, may provide a useful framework for understanding psychopathology. However, questions have arisen regarding the stability and generalizability of network analytic methods, with some researchers arguing that symptom networks have limited replicability. The aim of this study was to evaluate assessment modality as one possible source of instability in the estimation of posttraumatic stress disorder (PTSD) symptom networks. We estimated two cross-sectional DSM-5 PTSD symptom networks in 378 U.S. veterans: one using data from a clinician-rated assessment instrument (Clinician-Administered PTSD Scale for DSM-5; CAPS-5) and one using data from a self-rated questionnaire (the PTSD Checklist for DSM-5; PCL-5). We calculated centrality indices, conducted community structure analyses, and compared the strength and structure of the networks. The CAPS-5 and PCL-5 symptom networks were highly similar, challenging the notion that network methods produce unreliable results due to estimations consisting primarily of measurement error. Furthermore, each network contained distinct symptom communities that only partially overlapped with the DSM-5 PTSD symptom clusters. These findings may provide guidance for future revisions of the DSM, suggest hypotheses about how PTSD symptoms interact, and inform recent debate about replicability of psychopathology symptom networks. (PsycINFO Database Record
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Affiliation(s)
| | - Michelle J Bovin
- Behavioral Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
| | - Natalie G Gay
- Department of Psychology, University of North Carolina at Greensboro
| | - Blair E Wisco
- Department of Psychology, University of North Carolina at Greensboro
| | - Karen S Mitchell
- Women's Health Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
| | - Daniel J Lee
- Behavioral Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
| | - Denise M Sloan
- Behavioral Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
| | | | | | - Terence M Keane
- Behavioral Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
| | - Brian P Marx
- Behavioral Sciences Division, Department of Veterans Affairs Boston National Center for Posttraumatic Stress Disorder
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16
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Choi KR, Seng JS, Briggs EC, Munro-Kramer ML, Graham-Bermann SA, Lee RC, Ford JD. The Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) Among Adolescents: Co-Occurring PTSD, Depersonalization/Derealization, and Other Dissociation Symptoms. J Am Acad Child Adolesc Psychiatry 2017; 56:1062-1072. [PMID: 29173740 PMCID: PMC5726572 DOI: 10.1016/j.jaac.2017.09.425] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 09/08/2017] [Accepted: 09/26/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the co-occurrence of posttraumatic stress disorder (PTSD) and dissociation in a clinical sample of trauma-exposed adolescents by evaluating evidence for the depersonalization/derealization dissociative subtype of PTSD as defined by the DSM-5 and then examining a broader set of dissociation symptoms. METHOD A sample of treatment-seeking, trauma-exposed adolescents 12 to 16 years old (N = 3,081) from the National Child Traumatic Stress Network Core Data Set was used to meet the study objectives. Two models of PTSD/dissociation co-occurrence were estimated using latent class analysis, one with 2 dissociation symptoms and the other with 10 dissociation symptoms. After model selection, groups within each model were compared on demographics, trauma characteristics, and psychopathology. RESULTS Model A, the depersonalization/derealization model, had 5 classes: dissociative subtype/high PTSD; high PTSD; anxious arousal; dysphoric arousal; and a low symptom/reference class. Model B, the expanded dissociation model, identified an additional class characterized by dissociative amnesia and detached arousal. CONCLUSION These 2 models provide new information about the specific ways PTSD and dissociation co-occur and illuminate some differences between adult and adolescent trauma symptom expression. A dissociative subtype of PTSD can be distinguished from PTSD alone in adolescents, but assessing a wider range of dissociative symptoms is needed to fully characterize adolescent traumatic stress responses.
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17
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Buhmann CB, Andersen HS. [Diagnosing and treating post-traumatic stress disorder]. Ugeskr Laeger 2017; 179:V12160914. [PMID: 28606295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The post-traumatic stress disorder (PTSD) diagnosis has undergone large developments. With the changes in DSM-5 and the proposed changes in ICD-11, the two systems move in different directions. Treatment for PTSD is developing, but the evidence for the effect is lacking behind. Trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing remain first choice. Pharmacotherapy is secondary. There is evidence for the effect of paroxetine, venlafaxine and fluoxetine and less so for sertraline.
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Scheeringa MS, Lilly ME, Staiger AB, Heller ML, Jones EG, Weems CF. Do Children and Adolescents Have Different Types of Trauma Narratives and Does It Matter? Reliability and Face Validation for a Narrative Taxonomy. J Trauma Stress 2017; 30:323-327. [PMID: 28569390 PMCID: PMC5485839 DOI: 10.1002/jts.22190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/12/2022]
Abstract
The construction of trauma narratives is a major component of several psychotherapy approaches for trauma-related problems, but questions remain as to whether fully expressive narratives are necessary and whether it is detrimental to ask avoidant youths to tell their narratives repeatedly. Characteristics of trauma narratives during psychotherapy have not been examined in youths and this represents a salient gap in knowledge. This study aimed to begin filling this gap by identifying categories of trauma narratives and empirically validating them. Youths (N = 47) aged 7 to 18 years, who were involved in a randomized controlled trial, received cognitive behavioral therapy. Transcripts of all narrative exposure therapy sessions for each youth were rated. Four categories were identified and were named expressive, avoidant, fabricated, and undemonstrative. Interrater reliability for identifying these categories was good, and face validation of the categories was supported by statistically significant differences between categories on the number of data elements of the trauma events, negative emotion words, and positive emotion words. These promising findings indicate that different types of narrative styles can be reliably identified. There was strong evidence for reduction of posttraumatic stress symptoms in each of the categories (Cohen's d = 0.9 to 2.5). Favorable treatment outcomes for all categories suggest that more remembering is not always better and clients appeared to effectively deal with memories in different ways.
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Affiliation(s)
- Michael S Scheeringa
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Megan E Lilly
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Allison B Staiger
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Maren L Heller
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Edward G Jones
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Carl F Weems
- Department of Human Development and Family Studies, Iowa State University, Ames, Iowa, USA
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19
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Hansen M, Ross J, Armour C. Evidence of the dissociative PTSD subtype: A systematic literature review of latent class and profile analytic studies of PTSD. J Affect Disord 2017; 213:59-69. [PMID: 28192736 DOI: 10.1016/j.jad.2017.02.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/30/2017] [Accepted: 02/05/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The dissociative PTSD (D-PTSD) subtype was first introduced into the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. Prior to this, studies using latent profile analysis (LPA) or latent class analysis (LCA), began to provide support for the D-PTSD construct and associated risk factors. This research is important, because dissociative symptoms in the context of PTSD may potentially interfere with treatment course or outcome. The aims of the present study were twofold: to systematically review the LCA and LPA studies investigating support for the D-PTSD construct; and to review the associated research on the risk factors or covariates of D-PTSD in the identified studies. METHOD Six databases (PubMed, Web of Science, Scopus, PILOTS, PsychInfo, and Embase) were systematically searched for relevant papers. RESULTS Eleven studies were included in the present review. The majority of the studies were supportive of the D-PTSD subtype; primarily characterized by depersonalization and derealization. Several covariates of the D-PTSD subtype have been investigated with mixed results. LIMITATIONS Many limitations relate to the state of the current literature, including a small number of studies, the use of self-report measurements of PTSD, and heterogeneity across the samples in investigated covariates. CONCLUSION The results were overall supportive of the D-PTSD construct. Future research on D-PTSD and associated risk factors is needed to shed light on the possibilities of facilitating preventive actions, screening, and implications on treatment effects.
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Affiliation(s)
- Maj Hansen
- Department of Psychology, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
| | - Jana Ross
- Psychology Research Institute, Psychotraumatology, Mental Health & Suicidal Behavior Research Group, Ulster University, Cromore Road, Coleraine BT52 1SA, Northern Ireland
| | - Cherie Armour
- Psychology Research Institute, Psychotraumatology, Mental Health & Suicidal Behavior Research Group, Ulster University, Cromore Road, Coleraine BT52 1SA, Northern Ireland
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Abstract
The Infrequency-Posttraumatic Stress Disorder scale (Fptsd), recently created for the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), has demonstrated incremental validity over other MMPI-2 scales in malingered posttraumatic stress disorder (PTSD) detection. Fptsd was developed with combat-exposed PTSD patients, potentially limiting its use with PTSD patients in general. The current study evaluated the MMPI-2’s F, Infrequency-Psychopathology scale (Fp), and Fptsd scales in discriminating genuine civilian PTSD among 41 adult victims of child sexual abuse from a group of 39 students instructed to simulate PTSD. Analyses demonstrated Fptsd’s incremental validity over F but not over Fp. Based on the two studies examining Fptsd, Fptsd may be more appropriate for combat trauma victims, and Fp may be more appropriate for civilian trauma victims.
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Affiliation(s)
- Jon D Elhai
- Disaster Mental Health Institute, University of South Dakota, Vermillion 57069-2390, USA.
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21
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Roley ME, Contractor AA, Weiss NH, Armour C, Elhai JD. Impulsivity facets' predictive relations with DSM-5 PTSD symptom clusters. Psychol Trauma 2016; 9:76-79. [PMID: 27243571 DOI: 10.1037/tra0000146] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) has a well-established theoretical and empirical relation with impulsivity. Prior research has not used a multidimensional approach for measuring both PTSD and impulsivity constructs when assessing their relationship. METHOD The current study assessed the unique relationship of impulsivity facets on PTSD symptom clusters among a nonclinical sample of 412 trauma-exposed adults. RESULTS Linear regression analyses revealed that impulsivity facets best accounted for PTSD's arousal symptoms. The negative urgency facet of impulsivity was most predictive, because it was associated with all of PTSD's symptom clusters. Sensation seeking did not predict PTSD's intrusion symptoms, but did predict the other symptom clusters of PTSD. Lack of perseverance only predicted intrusion symptoms, while lack of premeditation only predicted PTSD's mood/cognition symptoms. CONCLUSIONS Results extend theoretical and empirical research on the impulsivity-PTSD relationship, suggesting that impulsivity facets may serve as both risk and protective factors for PTSD symptoms. (PsycINFO Database Record
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Affiliation(s)
| | | | - Nicole H Weiss
- Department of Psychiatry, Yale University School of Medicine
| | | | - Jon D Elhai
- Department of Psychology, University of Toledo
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22
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Levy Yeyati E. [Translating Hysteria: PTSD dissociative subtype]. Vertex 2016; XXVII:103-108. [PMID: 28199426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
To address the symptoms of depersonalization and derealization a specific dissociative subtype of posttraumatic stress disorder has been included in DSM-5. Depersonalization and derealization have been defined as acute and chronic symptoms of dissociative disorders since DSM-III. Dissociative disorders with chronic features are often diagnosed in North America, Canada and other European countries, but this is not the case in Argentina. Dissociative disorders have clinical and historical features that are strongly connected with hysteria. The latter is included in ICD-10 within the guidelines for diagnoses of dissociative disorders. This would be one of the reasons for not using dissociative disorders with chronic presentations of symptoms like depersonalization and derealization in countries other than North America or Canada: instead hysteria keeps on been used. The relation between trauma, dissociation and hysteria has been explained in different ways depending on the underlying theory (i.e. Janet's or Freud's). Janet's conceptualizations have had decisive influence in DSM formulations in chronic forms of dissociative disorders. Janet's and Freud's theories lead to different consequences on psychotherapy: hypnosis or psychoanalysis. The aim of this article is to show that the authors of PTSD dissociative subtype are in search of a cross-cultural validity of the construct which might be able to exert a more global influence.
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Magruder KM, Goldberg J, Forsberg CW, Friedman MJ, Litz BT, Vaccarino V, Heagerty PJ, Gleason TC, Huang GD, Smith NL. Long-Term Trajectories of PTSD in Vietnam-Era Veterans: The Course and Consequences of PTSD in Twins. J Trauma Stress 2016; 29:5-16. [PMID: 26764215 PMCID: PMC5884065 DOI: 10.1002/jts.22075] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We estimated the temporal course of posttraumatic stress disorder (PTSD) in Vietnam-era veterans using a national sample of male twins with a 20-year follow-up. The complete sample included those twins with a PTSD diagnostic assessment in 1992 and who completed a DSM-IV PTSD diagnostic assessment and a self-report PTSD checklist in 2012 (n = 4,138). Using PTSD diagnostic data, we classified veterans into 5 mutually exclusive groups, including those who never had PTSD, and 4 PTSD trajectory groups: (a) early recovery, (b) late recovery, (c) late onset, and (d) chronic. The majority of veterans remained unaffected by PTSD throughout their lives (79.05% of those with theater service, 90.85% of those with nontheater service); however, an important minority (10.50% of theater veterans, 4.45% of nontheater veterans) in 2012 had current PTSD that was either late onset (6.55% theater, 3.29% nontheater) or chronic (3.95% theater, 1.16% nontheater). The distribution of trajectories was significantly different by theater service (p < .001). PTSD remains a prominent issue for many Vietnam-era veterans, especially for those who served in Vietnam.
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Affiliation(s)
- Kathryn M. Magruder
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jack Goldberg
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Christopher W. Forsberg
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Matthew J. Friedman
- National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs, White River Junction, Vermont, USA
- Departments of Psychiatry and Pharmacology & Toxicology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Brett T. Litz
- Massachusetts Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Viola Vaccarino
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Theresa C. Gleason
- Cooperative Studies Program, Clinical Science Research and Development, VA Office of Research and Development, Washington, DC, USA
| | - Grant D. Huang
- Cooperative Studies Program, Clinical Science Research and Development, VA Office of Research and Development, Washington, DC, USA
| | - Nicholas L. Smith
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Hecker J. [Letter to W. Gronau, A. Meyer-Lindenberg, H. Dressing: Assessment of trauma disorders in Insurance Medicine 67 (2015) Issue 1, page 19th]. Versicherungsmedizin 2015; 67:203. [PMID: 26775312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Dressing H. [ Closing remarks]. Versicherungsmedizin 2015; 67:203. [PMID: 26775313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Nicholson AA, Densmore M, Frewen PA, Théberge J, Neufeld RWJ, McKinnon MC, Lanius RA. The Dissociative Subtype of Posttraumatic Stress Disorder: Unique Resting-State Functional Connectivity of Basolateral and Centromedial Amygdala Complexes. Neuropsychopharmacology 2015; 40:2317-26. [PMID: 25790021 PMCID: PMC4538346 DOI: 10.1038/npp.2015.79] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 11/09/2022]
Abstract
Previous studies point towards differential connectivity patterns among basolateral (BLA) and centromedial (CMA) amygdala regions in patients with posttraumatic stress disorder (PTSD) as compared with controls. Here we describe the first study to compare directly connectivity patterns of the BLA and CMA complexes between PTSD patients with and without the dissociative subtype (PTSD+DS and PTSD-DS, respectively). Amygdala connectivity to regulatory prefrontal regions and parietal regions involved in consciousness and proprioception were expected to differ between these two groups based on differential limbic regulation and behavioral symptoms. PTSD patients (n=49) with (n=13) and without (n=36) the dissociative subtype and age-matched healthy controls (n=40) underwent resting-state fMRI. Bilateral BLA and CMA connectivity patterns were compared using a seed-based approach via SPM Anatomy Toolbox. Among patients with PTSD, the PTSD+DS group exhibited greater amygdala functional connectivity to prefrontal regions involved in emotion regulation (bilateral BLA and left CMA to the middle frontal gyrus and bilateral CMA to the medial frontal gyrus) as compared with the PTSD-DS group. In addition, the PTSD+DS group showed greater amygdala connectivity to regions involved in consciousness, awareness, and proprioception-implicated in depersonalization and derealization (left BLA to superior parietal lobe and cerebellar culmen; left CMA to dorsal posterior cingulate and precuneus). Differences in amygdala complex connectivity to specific brain regions parallel the unique symptom profiles of the PTSD subgroups and point towards unique biological markers of the dissociative subtype of PTSD.
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Affiliation(s)
- Andrew A Nicholson
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Maria Densmore
- Lawson Health Research Institute, London, Ontario, Canada
| | - Paul A Frewen
- Lawson Health Research Institute, Western University, London, Ontario, Canada
| | - Jean Théberge
- Department of Diagnostic Imaging, St Joseph's Health Care London, Departments of Medical Imaging, Medical Biophysics and Psychiatry, Western University, London, Ontario, Canada
| | - Richard WJ Neufeld
- Departments of Psychology and Psychiatry, Neuroscience Program, Western University, London, Ontario, Canada
| | - Margaret C McKinnon
- McMaster University, St Joseph's Healthcare Hamilton, Homewood Research Institute, Hamilton, Ontario, Canada
| | - Ruth A Lanius
- Lawson Health Research Institute, Western University, London, Ontario, Canada
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Bae JD, Jeong JH, Lee JJ, Chung US. The Study of Reliability and Validity of the Korean Version of the Trauma Symptom Checklist for Young Children. J Korean Med Sci 2015; 30:1340-6. [PMID: 26339177 PMCID: PMC4553684 DOI: 10.3346/jkms.2015.30.9.1340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/20/2015] [Indexed: 11/28/2022] Open
Abstract
The present study aimed to evaluate the psychometric properties of the Korean version of the Trauma Symptom Checklist for Young Children (TSCYC) including reliability and validity. The TSCYC is an instrument to identify trauma symptoms in children from age 3 to 12 yr by their caretakers. The Korean version of the TSCYC was administered to the caretakers of a normative group of 299 children (137 boys and 162 girls) aged 3 to 12 yr and a traumatized group of 73 sexually abused children (22 boys and 51 girls) aged 3 to 12 yr and their caretakers rated the TSCYC and the Child Behavior Checklist and the Child Sexual Behavior Inventory. Among normative group, 88 performed a re-test after 4 weeks. The internal consistency, Cronbach's alpha of total scale of the TSCYC was 0.92 (normative group) and 0.96 (traumatized group). For the nine clinical scales in the TSCYC, it ranged between 0.46-0.92 and 0.77-0.96, respectively. Test-retest correlation of the TSCYC was good (Pearson r score ranging 0.52-0.96). Correlations between the TSCYC and other measures of corresponding constructs were satisfactory. Regarding discriminant validity, the mean total score of the TSCYC was significantly higher in the traumatized children than in the normative group. This study demonstrated that Korean version of the TSCYC is a reliable measure with excellent internal consistency and good stability over 4-week test-retest interval. It can be recommended for clinicians to screen for trauma symptoms after child sexual abuse in Korean young children between the ages 3 and 12.
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Affiliation(s)
| | - Jae Hoon Jeong
- Department of Psychiatry, Kyungpook National University Hospital, Daegu, Korea
| | - Jung Jae Lee
- Department of Psychiatry, College of Medicine, Dankook University, Cheonan, Korea
| | - Un-Sun Chung
- Department of Psychiatry, Kyungpook National University Hospital, Daegu, Korea
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Gronau W, Meyer-Lindenberg A, Dreßing H. [Difficulties in the assessment of trauma-related disorders]. Versicherungsmedizin 2015; 67:19-24. [PMID: 25971145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Assessment of trauma disorders is becoming increasingly important. A major problem here is that trauma disorders are extremely heterogeneous. Moreover, they are often associated with comorbid disorders, such as borderline personality disorder. The valid diagnostic systems ICD-10 and DSM-5 poorly represent trauma disorders. The so-called complex post-traumatic stress disorder or DESNOS (disorders of extreme stress not otherwise specified) are listed .in either of the ICD-10 or DSM-5. The distinctiveness is not generally scientifically accepted. In addition, the assessment of trauma disorders is complicated because there are often multiple traumas of varying degrees of severity.
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Abstract
In February 2010, the American Psychiatric Association (APA) launched their DSM-5 website with details about the development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The APA invited "the general public" to review the draft diagnostic criteria and provide written comments and suggestions. This revision marks the first time the APA has solicited public review of their diagnostic manual. This article analyzes reported speech on the DSM-5 draft diagnostic criteria for the classification Posttraumatic Stress Disorder. It demonstrates how textual standardization facilitates the cultural portability of the DSM-5 diagnostic criteria such that a community of speakers beyond the borders of the APA come to be seen as exemplary speakers, writers, and revisers of the professional style. Furthermore, analysis shows how co-authoring practices recontextualize the "voice" and persona of putative patient reported speech on Criterion D2. As a consequence of textual standardization, spoken discourse becomes recontextualized as the product of scientific inquiry and the organization of psychiatric knowledge.
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Affiliation(s)
- Patty A Kelly
- Department of English, Simon Fraser University, Academic Quadrangle 6129, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada,
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30
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Stevens A, Fabra M. [The assessment of posttraumatic stress disorder in the transformation of DSM-IV-TR DSM-5: what remains, what will change? (II)]. Versicherungsmedizin 2014; 66:12-22. [PMID: 24683892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Levy Yeyati E. [Posttraumatic stress disorder: meaningful changes in DSM-5]. Vertex 2014; 25:68-72. [PMID: 24887373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
UNLABELLED The fact that posttraumatic stress disorder is a very important construct in public health and opinion, especially in the United States of America, has veiled it dubious specificity and problematic universality. HYPOTHESIS the abandon of Freudian theory since 1980 was correlative of a permanent revision of criteria to define "traumatic" in DSM versions, as well as of revaluation of ancient theory of dissociation. METHOD most meaningful changes introduced in PTSD criteria are critically reviewed from DSM-IV to DSM-5. "Traumatic", symptoms and dissociative estates, and a new preschool children subtype are revised. CONCLUSION "Traumatic" yet being an artificial criterion is steel needed in order to keep the construct as a whole. Dissociative estates occupy an important place for the American authors and have turned more visible in DSM-5 than in previous DSM. New chapter "Trauma and stressor disorders" and new descriptions about PTSD support an enlarged clinical view of "traumatic". Inconsistencies found between reviews considered for PTSD in DSM-5 show that different work groups contribute to the construction of the disorder with fragmentary and divorced parts from one another.
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32
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Piven' BN. [A new essence or just new names?]. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:104-107. [PMID: 24988967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Some new terms and meanings in modern psychiatry ("emotional burnout syndrome", "chronic fatigue syndrome", "panic attacks", etc.) were analyzed, due to save clinic psychiatry traditions and succession of different generations of psychiatrists. Comparison of their content and well-known science concepts proves absence of any unknown phenomenon. These terms do not introduce some new items of classic determination of psychopathology catastasis, they just rename it. The reasons of this tendency were investigated.
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33
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Levin AP, Kleinman SB, Adler JS. DSM-5 and posttraumatic stress disorder. J Am Acad Psychiatry Law 2014; 42:146-158. [PMID: 24986341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The latest iteration of the posttraumatic stress disorder (PTSD) criteria presented in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes specific elaborations of the gatekeeper criteria, a new category of stressor, an expansion in the number of symptoms, addition of a new subtype of PTSD, and an enlarged text discussion that breaks new ground in defining the criteria. We first trace the rationale underlying these changes and their impact on the prevalence of PTSD diagnoses in clinical studies and then present potential implications of the new criteria for forensic assessment methodology and the detection of malingering, interpretations of criminal responsibility and mitigation, evaluation of the reliability of witnesses, the scope of claims in civil and employment cases, and eligibility for disability.
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Affiliation(s)
- Andrew P Levin
- Dr. Levin is Medical Director, Westchester Jewish Community Services, Hartsdale, NY, and Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY. Dr. Kleinman is Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Adjunct Professor of Law, Brooklyn Law School, Brooklyn, NY. Mr. Adler is a shareholder with Littler Mendelson, PC, in its San Diego, CA office.
| | - Stuart B Kleinman
- Dr. Levin is Medical Director, Westchester Jewish Community Services, Hartsdale, NY, and Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY. Dr. Kleinman is Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Adjunct Professor of Law, Brooklyn Law School, Brooklyn, NY. Mr. Adler is a shareholder with Littler Mendelson, PC, in its San Diego, CA office
| | - John S Adler
- Dr. Levin is Medical Director, Westchester Jewish Community Services, Hartsdale, NY, and Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY. Dr. Kleinman is Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, and Adjunct Professor of Law, Brooklyn Law School, Brooklyn, NY. Mr. Adler is a shareholder with Littler Mendelson, PC, in its San Diego, CA office
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34
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Bucci P. Plans for the chapter on mental disorders of ICD-11: a synopsis for WPA constituencies. Psychiatr Hung 2014; 29:124-130. [PMID: 25041742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Paola Bucci
- Department of Psychiatry, University of Naples SUN, Naples, Italy, E-mail:
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35
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Stevens A, Fabra M. [Forensic assessment of DSM-5 posttraumatic stress disorder: a commentary on the transition from DSM-IV-TR (I)]. Versicherungsmedizin 2013; 65:191-196. [PMID: 24400398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In May 2013 the American Psychiatric Association (APA) has released the latest and fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5). Like its predecessor, the DSM-IV-TR, it will have considerable impact on the science of Psychiatry. The DSM-5 describes - actually available in English - the present medical knowledge about mental disorders. In the short run, German medical science and scientific medicolegal expertises will continue to rely on the German version of the DSM-IV-TR, however, they will be difficult to defend without bearing in mind the changes that DSM-5 brings about. This report discusses the transition from DSM-IV-TR to DSM-5 with regard to posttraumatic stress disorder (PTSD) and provides suggestions, how the criteria might be evaluated.
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Affiliation(s)
- A Stevens
- Medizinischen Begutachtungsinstitut Tübingen
| | - M Fabra
- Medizinischen Gutachteninstitut Hamburg-Rostock-Berlin
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36
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Zerach G, Solomon Z. The relations between posttraumatic stress disorder symptoms and disorder of extreme stress (not otherwise specified) symptoms following war captivity. Isr J Psychiatry Relat Sci 2013; 50:148-155. [PMID: 24622473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE War captivity is a recognized pathogenic agent for both posttraumatic stress disorder (PTSD) symptoms and disorder of extreme stress not otherwise specified (DESNOS) symptoms, also known as Complex PTSD. However, the relationship between the two disorders remains unclear. While some scholars assume that the two diagnoses are overlapping and share the same predictors, others believe that the two diagnoses are relatively independent and differ in phenomenology and functional impairment. This study aims to assess both PTSD and DESNOS symptoms and their inter-relations among ex-prisoners of war (ex-POWs) and matched controls, 35 years after the end of the war. METHOD The sample included two groups of male Israeli veterans from the 1973 Yom Kippur War: ex-POWs (n = 176) and comparable veterans who had not been held captive (n = 118). PTSD and DESNOS symptoms, battlefield and captivity stressors, and ways of coping in captivity were assessed using self-report questionnaires in 2008. RESULTS Ex-POWs reported a higher number of PTSD symptoms and higher rates of PTSD symptoms that fill criteria for the diagnosis of PTSD than controls. Furthermore, ex-POWs reported a higher number of DESNOS symptom clusters and higher rates of DESNOS symptoms that fill criteria for the diagnosis of DESNOS. Moreover, we found positive relationships between PTSD symptom clusters and DESNOS symptom clusters. Finally, weight loss and mental suffering in captivity, loss of emotional control and total number of DESNOS symptoms predicted total number of PTSD symptoms. However, only the total number of PTSD symptoms predicted the total number of DESNOS symptoms. CONCLUSIONS This study demonstrated the heavy and extensive toll of war captivity, three decades after the ex-POWs' release from captivity. Importantly, approaching the publication of DSM-5, this study depicts both the high number of DESNOS symptom clusters alongside PTSD symptoms and highlights the complex relationship between the two diagnostic entities. Thus, DESNOS characteristics might be viewed as associated features of PTSD but also that the symptoms of PTSD are the core foundations of DESNOS.
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Affiliation(s)
- Gadi Zerach
- Department of Behavioral Sciences, Ariel University Israel
| | - Zahava Solomon
- School of Social Work, Tel Aviv University, Ramat Aviv, Israel
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37
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Bensimon M, Solomon Z, Horesh D. The utility of Criterion A under chronic national terror. Isr J Psychiatry Relat Sci 2013; 50:81-83. [PMID: 24225434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
According to DSM-IV-TR, both an objective and a subjective exposure component (A1 and A2 criteria, respectively) are required in order to qualify for a Posttraumatic stress Disorder (PTSD) diagnosis. one proposed DSM-5 change is that Criterion A be more explicitly defined and made purely objective. the DSM and the ICD appear to be largely products of the north american and european societies and, therefore, may be culturally-biased. Compared with other societies, the latter are not exposed to chronic national traumatic stress. therefore, the current structure of Criterion A may be especially relevant to single traumatic incidents, rather than to chronic national scale. the current review raises the question of whether the proposed DSM-5 changes to Criterion A are congruent with the reality of nations where exposure to terror is persistent, constant and of national proportions.
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Affiliation(s)
- Moshe Bensimon
- The Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
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Bensimon M, Levine SZ, Zerach G, Stein E, Svetlicky V, Solomon Z. Elaboration on posttraumatic stress disorder diagnostic criteria: a factor analytic study of PTSD exposure to war or terror. Isr J Psychiatry Relat Sci 2013; 50:84-90. [PMID: 24225435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND In societies facing prolonged exposure to war and terror, empirical research provides mixed support for the posttraumatic stress disorder (PTSD) symptom clusters groupings identified by the Diagnostic and Statistical Manual (DSM-IV-TR) as re-experiencing the event, avoidance and emotional numbing, and hyperarousal. METHOD This study examines the validity of the PTSD symptom clusters in elements of Israeli society exposed to man-made trauma. Survivors (N=2,198) of seven different war and terror-related traumas were assessed using a DSM-IV-TR based PTSD inventory. Four confirmatory factor analytic models were compared. RESULTS/CONCLUSIONS The most acceptable model was a correlated model consisting of four factors of re-experiencing, avoidance, emotional numbing, and hyperarousal. DSM-IV-TR avoidance empirically split into active avoidance and emotional numbing. These results corroborate knowledge and suggest that in Israel, where stressors are ongoing, the PTSD symptom clusters may be reformulated in DSM-5 to consist of re-experiencing, active avoidance, emotional numbing and hyperarousal.
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Affiliation(s)
- Moshe Bensimon
- The Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
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Calhoun PS, Hertzberg JS, Kirby AC, Dennis MF, Hair LP, Dedert EA, Beckham JC. The effect of draft DSM-V criteria on posttraumatic stress disorder prevalence. Depress Anxiety 2012; 29:1032-42. [PMID: 23109002 PMCID: PMC3514586 DOI: 10.1002/da.22012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 08/23/2012] [Accepted: 09/20/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study was designed to examine the concordance of proposed DSM-V posttraumatic stress disorder (PTSD) criteria with DSM-IV classification rules and examine the impact of the proposed DSM-V PTSD criteria on prevalence. METHOD The sample (N = 185) included participants who were recruited for studies focused on trauma and health conducted at an academic medical center and VA medical center in the southeastern United States. The prevalence and concordance between DSM-IV and the proposed DSM-V classifications were calculated based on results from structured clinical interviews. Prevalence rates and diagnostic efficiency indices including sensitivity, specificity, area under the curve (AUC), and Kappa were calculated for each of the possible ways to define DSM-V PTSD. RESULTS Ninety-five percent of the sample reported an event that met both DSM-IV PTSD Criterion A1 and A2, but only 89% reported a trauma that met Criterion A on DSM-V. Results examining concordance between DSM-IV and DSM-V algorithms indicated that several of the algorithms had AUCs above 0.90. The requirement of two symptoms from both Clusters D and E provided strong concordance to DSM-IV (AUC = 0.93; Kappa = 0.86) and a greater balance between sensitivity and specificity than requiring three symptoms in both Clusters D and E. CONCLUSIONS Despite several significant changes to the diagnostic criteria for PTSD for DSM-V, several possible classification rules provided good concordance with DSM-IV. The magnitude of the impact of DSM-V decision rules on prevalence will be largely affected by the DSM-IV PTSD base rate in the population of interest.
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Affiliation(s)
- Patrick S Calhoun
- VISN-6 Mental Illness Research & Education Center, Durham, NC 27705, USA.
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40
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Babić D. Posttraumatic stress disorder: paradigm for new psychiatry. Psychiatr Danub 2012; 24 Suppl 3:S373-S376. [PMID: 23114819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Although the description of the PTSD clinical picture dates from history, our professional community has known for about two decades. PTSD is clearly defined in the 10th International Classification of Diseases, World Health Organization and IV Diagnostic Statistical Manual of Mental Disorders. Together with panic disorder, agoraphobia, specific and social phobias, obsessive-compulsive disorder and generalized anxiety disorder is one of the large groups of anxiety disorders. A superficial approach, we could conclude that in the relation with PTSD is all clear. It was also found that PTSD is often associated with depression, anxiety disorders, and excessive drinking, substance abuse, and personality disorder, dissociative and other disorders. It is true that our knowledge of PTSD from year to year is larger and larger. However, regarding PTSD, there are many uncertainties, doubts and controversies. Is PTSD a disorder, illness, rent or a passing phase in the development of various diseases? In recent years, there are many studies that are trying to illuminate different aspects of PTSD. Numerous clinical, neurobiological, psycho physiological and MR volumetric studies indicate many uncertainties related to PTSD. About psychotic PTSD is more frequently discussed and written. Whether PTSD is or its symptoms or complications during periods of decompensation may have the character of the psychosis and the psychosis within PTSD or a co-morbid diagnosis? It is certain that about PTSD there are many uncertainties and doubts, that the investigation should continue and that PTSD is a paradigm for new psychiatry.
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Affiliation(s)
- Dragan Babić
- Psychiatric Clinic, University Clinical Hospital Mostar, Department of Psychiatry, School of Medicine, University of Mostar, 88000 Mostar, Bosnia and Herzegovina.
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Abstract
This article reviews the current classification of posttraumatic stress disorder and its limitations when applied to youth. Distinctions are made between single-event and multiple-event traumas. Diagnosis, neurobiology, treatment development, and treatment outcomes are presented. A summary of current empirical interventions is provided. The authors present implications for future research and for clinical practice.
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Affiliation(s)
- Victor G Carrion
- Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford School of Medicine, Stanford University, 401 Quarry Road, Stanford, CA 94305, USA.
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Wolf EJ, Miller MW, Reardon AF, Ryabchenko KA, Castillo D, Freund R. A latent class analysis of dissociation and posttraumatic stress disorder: evidence for a dissociative subtype. Arch Gen Psychiatry 2012; 69:698-705. [PMID: 22752235 PMCID: PMC3390764 DOI: 10.1001/archgenpsychiatry.2011.1574] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The nature of the relationship of dissociation to posttraumatic stress disorder (PTSD) is controversial and of considerable clinical and nosologic importance. OBJECTIVES To examine evidence for a dissociative subtype of PTSD and to examine its association with different types of trauma. DESIGN A latent profile analysis of cross-sectional data from structured clinical interviews indexing DSM-IV symptoms of current PTSD and dissociation. SETTINGS The VA Boston Healthcare System and the New Mexico VA Health Care System. PARTICIPANTS A total of 492 veterans and their intimate partners, all of whom had a history of trauma. Participants reported exposure to a variety of traumatic events, including combat, childhood physical and sexual abuse, partner abuse, motor vehicle accidents, and natural disasters, with most participants reporting exposure to multiple types of traumatic events. Forty-two percent of the sample met the criteria for a current diagnosis of PTSD. MAIN OUTCOME MEASURES Item-level scores on the Clinician-Administered PTSD Scale. RESULTS A latent profile analysis suggested a 3-class solution: a low PTSD severity subgroup, a high PTSD severity subgroup characterized by elevations across the 17 core symptoms of the disorder, and a small but distinctly dissociative subgroup that composed 12% of individuals with a current diagnosis of PTSD. The latter group was characterized by severe PTSD symptoms combined with marked elevations on items assessing flashbacks, derealization, and depersonalization. Individuals in this subgroup also endorsed greater exposure to childhood and adult sexual trauma compared with the other 2 groups, suggesting a possible etiologic link with the experience of repeated sexual trauma. CONCLUSIONS These results support the subtype hypothesis of the association between PTSD and dissociation and suggest that dissociation is a highly salient facet of posttraumatic psychopathology in a subset of individuals with the disorder.
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Affiliation(s)
- Erika J Wolf
- National Center for PTSD, VA Boston Healthcare System, Massachusetts, USA
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Zerach G, Greene T, Ein-Dor T, Solomon Z. The relationship between posttraumatic stress disorder symptoms and paternal parenting of adult children among ex-prisoners of war: a longitudinal study. J Fam Psychol 2012; 26:274-84. [PMID: 22309816 DOI: 10.1037/a0027159] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The aversive impact of combat and combat-induced posttraumatic stress disorder (PTSD) on parenting of young children has been examined in a few studies. Nevertheless, the toll of war captivity on parenting and the long-term relations between posttraumatic symptoms and paternal parenting of adult children remains unknown. This longitudinal study examined paternal parenting of adult children among war veterans, some of whom were held in captivity. Furthermore, we examined the mediating role of PTSD symptoms in the association between captivity and parenting. The sample included two groups of male Israeli veterans from the 1973 Yom Kippur War: ex-prisoners of war (ex-POWs) and comparable veterans who had not been held captive. Both groups were assessed via self-report measures of PTSD at three time points: Time 1 (18 after the war), Time 2 (30 after the war), and Time 3 (35 after the war) years after the war. Results shows that ex-POWs reported lower levels of positive parenting compared to comparison group veterans at Time 3. Furthermore, PTSD symptoms at Time 1, Time 2, and Time 3 mediated the association between captivity experience and parenting at Time 3. In addition, it was found that increases in the levels of PTSD symptom clusters over time were associated with lower levels of positive parenting at Time 3.
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Affiliation(s)
- Gadi Zerach
- Department of Behavioral Sciences, Ariel University Center of Samaria, Ariel, Israel.
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Luther S, Berndt D, Finch D, Richardson M, Hickling E, Hickam D. Using statistical text mining to supplement the development of an ontology. J Biomed Inform 2011; 44 Suppl 1:S86-S93. [PMID: 22101126 DOI: 10.1016/j.jbi.2011.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 10/31/2011] [Accepted: 11/06/2011] [Indexed: 11/19/2022]
Abstract
Statistical text mining was used to supplement efforts to develop a clinical vocabulary for post-traumatic stress disorder (PTSD) in the VA. A set of outpatient progress notes was collected for a cohort of 405 unique veterans with PTSD and a comparison group of 392 with other psychological conditions at one VA hospital. Two methods were employed: (1) "multi-model term scoring" used stepwise logistic regression to develop 21 separate models by varying three frequency weight and seven term weight options and (2) "iterative term refinement" which used a standard stop list followed by clinical review to eliminate non-clinical terms and terms not related to PTSD. Combined results of the two methods were reviewed by two clinicians resulting in 226 unique PTSD related terms. Results of the statistical text mining methods were compared with ongoing efforts to identify terms based on literature review, focus groups with clinicians treating PTSD and review of an existing vocabulary, lending support to the contributions of the STM analyses.
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Affiliation(s)
- Stephen Luther
- Consortium for Healthcare Informatics Research (CHIR); VA HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes, Tampa, FL, United States.
| | - Donald Berndt
- Consortium for Healthcare Informatics Research (CHIR); College of Business, University of South Florida, Tampa, FL, United States.
| | - Dezon Finch
- Consortium for Healthcare Informatics Research (CHIR); VA HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes, Tampa, FL, United States.
| | - Matthew Richardson
- Consortium for Healthcare Informatics Research (CHIR); VA HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes, Tampa, FL, United States.
| | - Edward Hickling
- Consortium for Healthcare Informatics Research (CHIR); VA HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes, Tampa, FL, United States.
| | - David Hickam
- Consortium for Healthcare Informatics Research (CHIR); HSR&D Research Enhancement Program, Portland VA Medical Center, Portland, OR, United States; Department of Medicine, Oregon Health and Science University, Portland, OR, United States.
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Scheeringa MS, Zeanah CH, Cohen JA. PTSD in children and adolescents: toward an empirically based algorithma. Depress Anxiety 2011; 28:770-82. [PMID: 20734362 PMCID: PMC6101653 DOI: 10.1002/da.20736] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/24/2010] [Accepted: 06/25/2010] [Indexed: 12/23/2022] Open
Abstract
In considering potential revisions for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), describing developmental influences on symptomatic expression is a high priority. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Research conducted in the past 15 years is reviewed that pertains to expressions of posttraumatic stress disorder (PTSD) symptoms in preschool and school age children and in adolescents. This research has attempted to determine the usefulness of the DSM-IV criteria for PTSD in children and adolescents. Based on the studies of preschool children, evidence supports two sets of suggestions: first, we suggest that developmental manifestations are warranted in A-D criteria of PTSD; and second, we suggest that a developmental preschool PTSD subtype is warranted that lowers the C threshold from three to one symptom. For school-age children and young adolescents, the evidence is more limited. Nevertheless, there is also evidence suggesting that modifications in PTSD criteria A-D, including fewer Cluster C symptoms, may facilitate accurate diagnosis in this age group.
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Affiliation(s)
- Michael S Scheeringa
- Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, Louisiana, USA.
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Kwako LE, Glass N, Campbell J, Melvin KC, Barr T, Gill JM. Traumatic brain injury in intimate partner violence: a critical review of outcomes and mechanisms. Trauma Violence Abuse 2011; 12:115-126. [PMID: 21511686 DOI: 10.1177/1524838011404251] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The prevalence of intimate partner violence (IPV) is striking, as are its consequences to the lives of women. The IPV often includes physical assault, which can include injuries to the head and attempted strangulation injuries. Both types of injuries can result in traumatic brain injury (TBI). The TBI sustained during IPV often occurs over time, which can increase the risk for health declines and postconcussive syndrome (PCS). Current studies have identified sequelae of cognitive dysfunction, posttraumatic stress disorder, and depression in women experiencing IPV, yet, most fail to determine the role of TBI in the onset and propagation of these disorders. Although imaging studies indicate functional differences in neuronal activation in IPV, they also have not considered the possibility of TBI contributing to these outcomes. This review highlights the significant gaps in current findings related to neuropsychological complications and medical and psychosocial symptoms that likely result in greater morbidity, as well as the societal costs of failing to acknowledge the association of IPV and TBI in women.
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Affiliation(s)
- Laura E Kwako
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA.
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Asberg M, Grape T, Krakau I, Nygren A, Rohde M, Wahlberg A, Währborg P. [Stress as the cause of mental illness]. Lakartidningen 2010; 107:1307-1310. [PMID: 20556983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
MESH Headings
- Fatigue Syndrome, Chronic/classification
- Fatigue Syndrome, Chronic/diagnosis
- Fatigue Syndrome, Chronic/etiology
- Health Care Costs
- Humans
- Life Change Events
- Mental Disorders/classification
- Mental Disorders/diagnosis
- Mental Disorders/etiology
- Risk Factors
- Sick Leave/economics
- Stress Disorders, Post-Traumatic/classification
- Stress Disorders, Post-Traumatic/diagnosis
- Stress Disorders, Post-Traumatic/etiology
- Stress Disorders, Traumatic/classification
- Stress Disorders, Traumatic/diagnosis
- Stress Disorders, Traumatic/etiology
- Stress, Physiological
- Stress, Psychological/complications
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Affiliation(s)
- Marie Asberg
- Karolinska Institutet/Danderyds Sjukhus, Stockholm.
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49
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Flood AM, Boyle SH, Calhoun PS, Dennis MF, Barefoot JC, Moore SD, Beckham JC. Prospective study of externalizing and internalizing subtypes of posttraumatic stress disorder and their relationship to mortality among Vietnam veterans. Compr Psychiatry 2010; 51:236-42. [PMID: 20399332 PMCID: PMC2858053 DOI: 10.1016/j.comppsych.2009.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/31/2009] [Accepted: 08/05/2009] [Indexed: 11/18/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) can be a complex disorder, and some studies have found that samples of individuals with PTSD contain subtypes that may relate to health outcomes. The goals were to replicate previously identified PTSD subtypes and examine how subtype membership relates to mortality. Data from the Vietnam Experience Study and a clinical sample of Vietnam veterans were combined (n = 5248) to address these research questions. Consistent with previous studies, 3 PTSD subtypes emerged: externalizers (n = 317), internalizers (n = 579), and low pathology (n = 280). Posttraumatic stress disorder diagnosis was associated with increased risk of all-cause and behavioral-cause (eg, homicide, suicide) mortality. Both externalizing and internalizing subtypes had higher mortality and were more likely to die from cardiovascular causes than those without PTSD. Externalizers were more likely to die from substance-related causes than those without PTSD. The value of considering possible PTSD subtypes is significant in that it may contribute to identifying more specific targets for treatment and rehabilitation in veterans with PTSD.
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Affiliation(s)
| | - Stephen H. Boyle
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Patrick S. Calhoun
- Durham Veterans Affairs Medical Center, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
- VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC
| | - Michelle F. Dennis
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - John C. Barefoot
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Scott D. Moore
- Durham Veterans Affairs Medical Center, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
- VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC
| | - Jean C. Beckham
- Durham Veterans Affairs Medical Center, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
- VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC
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50
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Sukiasian SG, Tadevosian MI. [The relationship of posttraumatic stress and exogenous-organic disorders]. Zh Nevrol Psikhiatr Im S S Korsakova 2010; 110:63-70. [PMID: 21329017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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