Increased pituitary and adrenal reactivity in premenopausal women with posttraumatic stress disorder

BACKGROUND

Limited studies of hypothalamic-pituitary-adrenal axis regulation in posttraumatic stress disorder have been performed in premenopausal women. We therefore undertook a study of hypothalamic-pituitary-adrenal axis regulation in this population.

METHODS

Outpatient posttraumatic stress disorder subjects were compared with healthy, age- and weight-matched nontraumatized subjects. Subjects were free from psychotropic medications, alcohol and other illicit substances for at least 4 weeks before study. Menstrual cycle phase was determined by monitoring the LH surge and plasma progesterone levels. Corticotropin releasing factor and adrenocorticotropin stimulation tests, as well as 24-hour urinary-free cortisol measurements were performed.

RESULTS

Corticotropin releasing factor test: Baseline adrenocorticotropic hormone and cortisol levels did not differ between the 12 PTSD and 11 comparison subjects, but the posttraumatic stress disorder group had greater adrenocorticotropic hormone and cortisol responses to corticotropin releasing factor, as well as a later cortisol peak. Adrenocorticotropic hormone test: Baseline cortisol levels did not differ between the 10 posttraumatic stress disorder subjects and seven controls, but the posttraumatic stress disorder group showed greater cortisol responses to adrenocorticotropic hormone. Peak cortisol responses to corticotropin releasing factor and adrenocorticotropic hormone were correlated with each other and with 24-hour urinary-free cortisol excretion.

CONCLUSIONS

Pituitary and adrenal hyperreactivity to exogenous corticotropin releasing factor and adrenocorticotropic hormone is demonstrated in premenopausal women with chronic posttraumatic stress disorder. Cortisol hyperreactivity thus may play a role in the pathophysiology of posttraumatic stress disorder in women.

Gender differences in violence exposure and violence risk among adolescent inpatients

Gender-specific rates of violence exposure and violence perpetration among psychiatrically ill adolescents has received little scientific attention. We examined 130 adolescent inpatients and found no difference between male and female subjects with respect to self-reported violence potential or actual violence perpetration. Female inpatients, however, were significantly more often victims of sexual assault, and male inpatients were significantly more often victims of physical assault. For male inpatients, a history of violence perpetration in one area was closely linked with a history of violence victimization in the same area. Alternatively, patterns of victimization and perpetration among female inpatients were less predictable and had crossover to victimization and perpetration experiences in other areas. Correlational analyses revealed that violence risk was associated with a broad range of internalizing and externalizing psychopathology. Significant associations with hopelessness, suicidality, and childhood trauma differentiated the violence risk of male and female inpatients. We propose a hypothesis for understanding these differences and conclude that although psychiatrically ill adolescent male and female patients may commonly fall victim to differing forms of violence, both genders are at equal risk for actual violence perpetration.

Correlates of community violence exposure in hospitalized adolescents

To examine psychological and behavioral correlates of community violence exposure in psychiatrically hospitalized adolescents, 89 inpatients were administered a battery of psychometrically well-established self-report instruments. Violence exposure was assessed using the Child's Exposure to Violence Checklist (CEVC). Half of the patients reported exposure to multiple incidents violence in their community (52%) and home (53%). Sixty-one percent were victims of physical assault, and 39% were victims of sexual assault. Patients who had witnessed community violence reported significantly more post-traumatic stress disorder (PTSD) symptoms, drug use, and violence potential than patients without a history of witnessing community violence. Patients exposed to community violence were also more likely to be the victim of childhood maltreatment, as well as a perpetrator of violence. In conclusion, traumatization via exposure to community violence may serve as one important determinant in the development of mixed internalizing and externalizing psychopathology in adolescent inpatients, thus necessitating accurate assessment and treatment planning.

Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic

OBJECTIVE

To identify clinical and functional correlates of posttraumatic stress disorder (PTSD) in trauma-exposed urban adolescent girls.

METHOD

Ninety female adolescents aged 12 to 21 years (mean 17.3 years) who presented for routine medical care at an adolescent primary care clinic were assessed with self-report questionnaires and interviews for trauma exposure, posttraumatic stress symptoms, other psychopathology, and psychosocial, family, and school function.

RESULTS

Ninety-two percent (n = 83) endorsed at least one trauma. Witnessing community violence (85.6%) and hearing about a homicide (67.8%) were the most common traumatic events endorsed. Twelve (14.4%) and 10 (11.6%) traumatized girls met DSM-IV symptom criteria for full and partial PTSD, respectively. Compared with traumatized girls without PTSD, girls with PTSD were significantly more depressed, used more cigarettes and marijuana, and were more likely to have failed a school grade, been suspended from school, or been arrested.

CONCLUSIONS

Urban adolescent girls are exposed to multiple types of trauma. Whereas most develop at least one posttraumatic stress symptom, girls who meet full symptom criteria for PTSD show evidence of other psychopathology, increased cigarette and marijuana use, and poorer school performance. Further research is needed to identify and treat inner-city girls with PTSD.

Gender differences in the associations between posttraumatic stress symptoms and problematic substance use in psychiatric inpatient adolescents

This study examined gender differences in the associations between posttraumatic stress symptoms and problematic substance use in psychiatrically hospitalized adolescents. Ninety-five adolescent inpatients (38 boys, 57 girls) were systematically evaluated with a battery of psychometrically well-established self-report measures to assess trauma exposure, posttraumatic stress symptoms, problematic alcohol and drug use, and internalizing and externalizing psychopathology. Twenty-three percent (N = 22) of patients met DSM-IV-based symptom criteria for PTSD, and 37% (N = 35) and 34% (N = 32) of patients endorsed problematic levels of drug and alcohol use, respectively. Posttraumatic stress symptoms were significantly associated with problematic drug and alcohol use in girls but not in boys. There were no significant gender differences in posttraumatic stress symptoms and/or problematic substance use, to account for the gender differences in the association between PTSD and substance use. Our findings suggest that the link between substance abuse and PTSD may be especially salient for female adolescents.

Correlates of suicide risk in adolescent inpatients who report a history of childhood abuse

The study objective was to examine correlates of suicide risk in psychiatrically hospitalized adolescents with a reported history of childhood abuse. Predictors of suicide risk were examined in 74 subjects who reported a history of childhood abuse and 53 depressed subjects who did not report a history of childhood abuse. Subjects completed a battery of psychometrically well-established self-report instruments to assess childhood abuse, suicide risk, and internalizing and externalizing psychopathology. Correlational analyses showed that higher levels of depression, self-criticism, and hopelessness were significantly associated with suicide risk in both study groups and violence was significantly associated with suicide risk in the childhood abuse group. For the childhood abuse group, multiple regression analyses with seven predictor variables accounted for 54% of the variance in suicide risk; depression and alcohol problems made significant independent contributions, while violence and self-criticism were independent predictors at the trend level. For the depressed/nonabused group, multiple regression analyses with the seven predictor variables accounted for 60% of the variance in suicide risk; depression, hopelessness, and self-criticism were independent predictors. Our findings suggest that both internalizing (i.e., depression or self-criticism) and externalizing (i.e., violence or alcohol) factors predict suicide risk in adolescent inpatients who report childhood abuse. This profile appears different from the more internalizing pattern (i.e., depression, self-criticism, and hopelessness) observed for the depressed adolescent inpatients who reported no history of childhood abuse.

Hospitalized adolescents' reports of sexual and physical abuse: a comparison of two self-report measures

This study assesses the consistency of adolescents' reports of sexual and physical abuse via two self-report questionnaires with different measurement approaches and examines demographic and psychopathological characteristics that influence abuse reporting. Seventy adolescent inpatients completed the Childhood Trauma Questionnaire (CTQ) (Likert-type items are summed to form dimensional scales, and cutoff scores determine abuse status), the Traumatic Events Questionnaire--Adolescents (multiple-choice items determine abuse status) and measures of depression, suicidal ideation, and dissociative symptoms. Consistent reports of physical and sexual abuse were given by 86% and 71% of youngsters, respectively. Discrepant reporters of sexual abuse were significantly more likely to be male, whereas consistent reporters were significantly more depressed and suicidal and reported higher levels of sexual abuse and emotional and physical neglect. Adolescents, for the most part, were consistent in their responses about sexual and physical abuse on both a Likert scale and a direct-answer-format questionnaire. The CTQ had a lower threshold for detection of sexual abuse, particularly for boys.

Agreement between hospitalized adolescents' self-reports of maltreatment and witnessed home violence and clinician reports and medical records

Seventy-one consecutive psychiatrically hospitalized adolescents (34 males and 37 females) were systematically asked about their experiences of sexual abuse, physical abuse, and witnessing home violence using a reliable 46-item self-report measure of maltreatment, the Traumatic Events Questionnaire-Adolescent Version (TEQ-A). Subjects' responses were compared with a "best-estimate" source consisting of data from child protective service and police reports, medical records, and clinician interviews. Rates of agreement varied from 88% (kappa value [kappa] = .75) for sexual abuse, to 83% (kappa = .65) for physical abuse, to 75% (kappa = .49) for witnessing home violence. Disclosures of maltreatment were not significantly influenced by the gender, age, educational level, or ethnicity of the adolescent. Disclosures were highest for sexual abuse (86%) and lowest for witnessing home violence (68%). The results show that psychiatrically hospitalized adolescents' self-reports of maltreatment experiences generally concur very well with best-estimate sources.

Posttraumatic stress disorder in hospitalized adolescents: psychiatric comorbidity and clinical correlates

OBJECTIVE

To describe the diagnostic comorbidity and clinical correlates of posttraumatic stress disorder (PTSD) in adolescent psychiatric inpatients.

METHOD

Seventy-four adolescent inpatients were given a structured diagnostic interview, the revised version of the Diagnostic Interview for Children and Adolescents, and a battery of standard self-report measures to assess general trauma exposure, posttraumatic stress symptoms, suicidal behavior, dissociation, and depression.

RESULTS

Ninety-three percent of subjects reported exposure to at least one traumatic event such as being a witness/victim of community violence, witnessing family violence, or being the victim of physical/sexual abuse. Thirty-two percent of subjects met diagnostic criteria for current PTSD, with sexual abuse cited as the most common traumatic stressor in 69% of PTSD cases. Girls were significantly more likely to develop PTSD than boys, although the total number of types of trauma did not differ by gender. Compared with psychiatric controls, male youngsters with PTSD were significantly more likely to have comorbid diagnoses of eating disorders, other anxiety disorders, and somatization disorder. Furthermore, male and female youngsters with PTSD were significantly more likely to have attempted suicide and report greater depressive and dissociative symptoms.

CONCLUSION

In clinical populations of hospitalized adolescents exposed to multiple forms of trauma, PTSD is a common, but highly comorbid disorder. Specific multimodal assessments and treatments targeted to both PTSD and its comorbidity profile are warranted.

Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients

The aim of this study was to assess relative risk of histories of different types of abuse (sexual, physical, and emotional) and neglect (physical and emotional) for suicidal behavior (attempts, ideation, and self-mutilation) in psychiatrically hospitalized adolescents. Seventy-one adolescent inpatients (34 boys, 37 girls) completed self-report measures of abuse and neglect, current suicidal ideation, and lifetime suicide and self-mutilation attempts. The prevalence of sexual and physical abuse was 37.5% and 43.7%, respectively, with 31.3% and 61% of youngsters reporting emotional and physical neglect. Fifty-one percent of youngsters had made suicide attempts, and 39% had self-mutilated. Suicide attempters were significantly more likely to be female, Latino, to report sexual, physical, and emotional abuse, and to endorse emotional neglect. In multivariate analyses, female gender, sexual abuse, and emotional neglect remained significant predictors of self-mutilation and suicidal ideation. Female gender and sexual abuse remained significant predictors of suicide attempts. These findings suggest that emotional neglect is an important and deleterious component of maltreatment experiences and may be a more powerful predictor of suicidal behavior in hospitalized adolescents than physical abuse, emotional abuse, and physical neglect.

Childhood abuse, adult assault, and dissociation

Recent studies have suggested an association between childhood physical and sexual abuse and adult dissociative experiences. The purpose of this study was to determine the relationship of both childhood and adult-onset abuse and their characteristics for adult dissociative symptoms. One hundred forty-four psychiatric outpatients completed self-report questionnaires on measures of dissociation (Dissociative Experience Scale [DES]) and histories of both past and current sexual and physical abuse (Traumatic Events Questionnaire [TEQ]). Of 114 subjects (30 men and 84 women) who completed both forms, 35% and 43% reported childhood physical and sexual abuse, respectively. Dissociative symptoms were significantly related to ethnicity and multiple episodes or combined types of abuse in childhood and adulthood. In terms of the characteristics of childhood abuse, numerous episodes of physical abuse (P = .01) and father-perpetrated sexual abuse (P = .02) were significantly related to the degree of dissociation. These findings emphasize the role of repeated childhood trauma and the combination of both childhood and adult traumatic experiences in the development of dissociative phenomena.

Prevalence and characteristics of physical and sexual abuse among psychiatric outpatients

Eighty-six female and 34 male psychiatric outpatients completed a self-report questionnaire that retrospectively assessed their history of physical and sexual abuse and assault. Seventy percent reported an abusive experience in childhood or adulthood. Female subjects were more likely than male subjects to report childhood sexual abuse and adult physical and sexual assaults. For all subjects, childhood sexual abuse was associated with adult sexual and physical assault. The charts of several patients who reported abuse histories did not include any record of abuse.

Pediatric-onset bipolar disorder: a neglected clinical and public health problem

Bipolar disorder (BPD), probably the most prevalent psychotic disorder in adults, has been relatively neglected or controversial in children and adolescents over the past century. We reviewed the literature on early-onset BPD. Estimates of prevalence, particularly before puberty, are limited by historical biases against pediatric mood disorders and by formidable diagnostic complexity and comorbidity. Although clinical features of pediatric and adult BPD have similarities, pediatric cases probably cannot be defined solely by features characteristic of adult cases. Onset was before age 20 years in at least 25% of reported BPD cases, with some increase in this incidence over the past century. Pediatric BPD is familial more often than is adult-onset BPD, may be associated with a premorbid cyclothymic or hyperthymic temperament, and can be precipitated by antidepressant treatment. Pediatric BPD episodes frequently include irritability, dysphoria, or psychotic symptoms; they are commonly chronic and carry high risks of substance abuse and suicide. BPD is often recognized in adolescents, but the syndrome or its antecedents are almost certainly underrecognized and undertreated in children. Controlled studies of short- and long-term treatment, course, and outcome in this disorder remain strikingly limited, and the syndrome urgently requires increased clinical and scientific interest.

Dissociation and somatization in adolescent inpatients with and without history of abuse

33 adolescents were tested for signs of dissociation and somatization as these processes relate to histories of physical and sexual abuse, a characteristic of over half of patients admitted for acute psychiatric disorder. Analysis suggested that the 19 adolescents having histories of abuse were more likely to score higher on dissociation and somatization.

Suicidal behavior and abuse in psychiatric outpatients

The present study examines the relationship between suicidal behaviors and histories of abuse in psychiatric outpatients. Two hundred fifty-one psychiatric outpatients were evaluated for history of abuse, suicidal behavior, demographics, and clinical characteristics using self-report instruments and a face-to-face interview. Logistic regression analysis indicated that physical abuse (battering) in adulthood and histories of a combination of childhood and adulthood abuse were significant predictors of past suicide attempts and current suicidal ideation. Victims of abuse were more likely than nonvictim controls to have been suicidal at a younger age and to have made multiple suicide attempts. Among patients with a history of abuse, suicide attempters could be distinguished from nonattempters on the basis of higher levels of dissociation, depression, and somatization. Abusive experiences in adulthood appear to play an important role in suicidal behavior among psychiatric outpatients. High levels of specific symptoms (i.e., depression, somatization, and dissociation) among patients with a history of abuse can help to identify outpatients at risk for suicidal behavior.

Correlates of violence risk in hospitalized adolescents

Forty adolescent inpatients with histories of frequent interpersonal violent behavior were compared with 36 hospitalized adolescents without histories of overt violence using self-report questionnaires that measured violence risk, depression, impulsivity, and suicide risk. The two groups did not differ in terms of their demographic characteristics, but the violent patients had a higher prevalence of substance abuse and borderline personality disorder diagnoses. Violent adolescents were more impulsive and at higher suicide risk than nonviolent adolescents. In addition, violent adolescents had more positive histories of suicide attempts and had significantly higher family histories of attempted and completed suicide. In the total sample of adolescents, violence risk was significantly correlated with impulsivity and suicide risk, but not with depression.