The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion A2

OBJECTIVE

Meeting criterion A2 for the diagnosis of posttraumatic stress disorder (PTSD) in DSM-IV requires that an individual have high levels of distress during or after the traumatic event. Because of the paucity of valid and reliable instruments for assessing such responses, the authors developed a 13-item self-report measure, the Peritraumatic Distress Inventory, to obtain a quantitative measure of the level of distress experienced during and immediately after a traumatic event.

METHOD

The cross-sectional study group comprised 702 police officers and 301 matched nonpolice comparison subjects varying in ethnicity and gender who were exposed to a wide range of critical incidents.

RESULTS

The Peritraumatic Distress Inventory was found to be internally consistent, with good test-retest reliability and good convergent and divergent validity. Even after controlling for peritraumatic dissociation and for general psychopathology, the authors found that Peritraumatic Distress Inventory scores correlated with two measures of posttraumatic stress symptoms.

CONCLUSIONS

The Peritraumatic Distress Inventory holds promise as a measure of PTSD criterion A2. Future studies should prospectively examine the ability of the Peritraumatic Distress Inventory to predict PTSD and its associated biological and cognitive correlates in other trauma-exposed groups.

Fluvoxamine and sleep disturbances in posttraumatic stress disorder

This study assesses the efficacy of fluvoxamine treatment on different domains of subjective sleep quality in Vietnam combat veterans with chronic posttraumatic stress disorder (PTSD). Medically healthy male Vietnam theater combat veterans (N = 21) completed a 10-week open label trial. Fluvoxamine treatment led to improvements in PTSD symptoms and all domains of subjective sleep quality. The largest effect was for dreams linked to the traumatic experience in combat. In contrast, generic unpleasant dreams showed only a modest response to treatment. Sleep maintenance insomnia and the item "troubled sleep" showed a large treatment response, whereas sleep onset insomnia improved less substantially. These therapeutic benefits contrast with published reports that have found activating effects of Selective Serotonin Reuptake Inhibitors on the sleep electroencephalogram.

Posttraumatic stress disorder, trauma exposure, and the current health of Canadian bus drivers

OBJECTIVE

Previous studies of veterans have linked posttraumatic stress disorder (PTSD) after combat-related trauma to increased reports of health problems. It is unclear whether this association between PTSD and increased health problems generalizes to civilians who are exposed to a broader array of traumatic events. We also do not know whether trauma exposure is associated with increased health problems in individuals who do not develop PTSD. Using a non-treatment-seeking civilian sample, we examined whether lifetime PTSD or trauma exposure by itself was associated with current health problems.

METHODS

Using a cross-sectional design and self-report measures, we evaluated urban Canadian bus drivers (n = 342) on trauma exposure, lifetime PTSD, and current health problems. Based on their responses, we divided our sample into individuals who had never experienced trauma (n = 91), trauma-exposed individuals who had never developed PTSD (n = 218), and persons who developed PTSD at some point after trauma (n = 33). We compared these groups on health problems, treatment service use, and health assessment measures.

RESULTS

The PTSD group reported increased health complaints, more frequent use of health treatments, and poorer health self-ratings compared with the exposed non-PTSD and nonexposed groups. Trauma-exposed drivers without PTSD did not differ from unexposed drivers on any health measure. Controlling for sex and trauma frequency did not alter our findings.

CONCLUSIONS

Trauma exposure that leads to PTSD is associated with increased health problems, while trauma exposure alone is not. Our results extend previous findings to a broader civilian context and clarify associations between trauma exposure and health.

An overview of the Peritraumatic Distress Scale

Posttraumatic stress disorder (PTSD) occurs when significant intrusion, avoidance, and hyperarousal symptoms are manifest for at least 1 month following exposure to a traumatic event, with at least 1 month following exposure to a traumatic event, with at least 1 month elapsed betwenn the event and the diagnossis (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994 [DSM-IV]).(1) However, such symptoms are not necessarily manifest in the immediate aftermath of the trauman,(2) nor does their intial presence strongly predict who will develop PTSD.(3) One immediate response to trauma which has been convicingly linked to PTSD symptoms is peritraumatic dissociation.(4) In this poster, we briefly introduce a new scale assessing immediate responses distinct from peritraumatic dissociation, and we examine its power to predict PTSD symptoms.

Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel

This study examines the longitudinal course and predictors of stress-specific and general symptomatic distress in emergency services personnel. A three-group quasi-experimental design was used to determine the responses of 322 rescue workers to the Loma Prieta earthquake Interstate 880 Freeway collapse and to unrelated control critical incidents. Self-report questionnaires, including measures of incident exposure, peritraumatic dissociation and emotional distress, and current symptoms, were administered 1.9 years (initial) and 3.5 years (follow-up) after the freeway collapse. Despite modest symptom improvement at follow-up, rescue workers were at risk for chronic symptomatic distress after critical incident exposure. Peritraumatic dissociation accounted for significant increments in current posttraumatic stress disorder symptoms, over and above exposure, adjustment, years of experience, locus of control, social support, and general dissociative tendencies. The results suggest that rescue workers, particularly those with more catastrophic exposure and those prone to dissociate at the time of the critical incident, are at risk for chronic symptomatic distress.

Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans

OBJECTIVE

This study analyzed questionnaire items that address complaints about sleep from the National Vietnam Veterans Readjustment Study, a nationally representative sample of the 3.1 million men and women who served in Vietnam. This study compared the frequency of nightmares and difficulties with sleep onset and sleep maintenance in male Vietnam theater veterans with male Vietnam era veteran and male civilian comparison subjects. It focused on the role of combat exposure, nonsleep posttraumatic stress disorder (PTSD) symptoms, comorbid psychiatric and medical disorder, and substance abuse in accounting for different domains of sleep disturbance.

METHOD

The authors undertook an archival analysis of the National Vietnam Veterans Readjustment Study database using correlations and linear statistical models.

RESULTS

Frequent nightmares were found exclusively in subjects diagnosed with current PTSD at the time of the survey (15.0%). In the sample of veterans who served in Vietnam (N = 1,167), combat exposure was strongly correlated with frequency of nightmares, moderately correlated with sleep onset insomnia, and weakly correlated with disrupted sleep maintenance. A hierarchical multiple regression analysis showed that in Vietnam theater veterans, 57% of the variance in the frequency of nightmares was accounted for by war zone exposure and non-sleep-related PTSD symptoms. Alcohol abuse, chronic medical illnesses, panic disorder, major depression, and mania did not predict the frequency of nightmares after control for nonsleep PTSD symptoms.

CONCLUSIONS

Frequent nightmares appear to be virtually specific for PTSD. The nightmare is the domain of sleep disturbance most related to exposure to war zone traumatic stress.

Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans

OBJECTIVE

Although posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic condition, the relationship between PTSD and functioning and quality of life remains incompletely understood.

METHOD

The authors undertook an archival analysis of data from the National Vietnam Veterans Readjustment Study. The study subjects consisted of the nationally representative sample of male Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. The authors estimated PTSD at the time of the interview with the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. They examined the following outcomes: diminished well-being, physical limitations, bed day in the past 2 weeks, compromised physical health status, currently not working, and perpetration of violence. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions.

RESULTS

The risks of poorer outcome were significantly higher in subjects with PTSD than in subjects without PTSD in five of the six domains. For the outcome domains of physical limitations, not working, compromised physical health, and diminished well-being, these significantly higher risks persisted even in the most conservative logistic models that removed the shared effects of comorbid psychiatric and other medical disorders.

CONCLUSIONS

The suffering associated with combat related-PTSD extends beyond the signs and symptoms of the disorder to broader areas of functional and social morbidity. The significantly higher risk of impaired functioning and diminished quality of life uniquely attributable to PTSD suggests that PTSD may well be the core problem in this group of difficult to treat and multiply afflicted patients.

Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans

OBJECTIVE

This investigation assessed whether current post-traumatic stress disorder (PTSD) was associated with impaired functioning in a nationally representative sample of female Vietnam veterans.

METHODS

Logistic models were used to determine the association between PTSD and outcome while adjusting for demographic characteristics and medical and psychiatric co-morbidities.

RESULTS

PTSD was associated with significantly elevated odds of poorer functioning in five of the six outcome domains; only the association between perpetration of violence in the past year and PTSD did not achieve statistical significance. After adjusting for demographics and medical and psychiatric co-morbidities, PTSD remained associated with significantly elevated odds of bed days, poorer physical health, and currently not working.

CONCLUSIONS

Among female Vietnam veterans PTSD is associated with a broad profile of functional impairment. The significantly increased odds of impaired functioning and diminished quality of life suggest that PTSD may be the core problem of the set of problems afflicting female Vietnam veterans.

The relationship of peritraumatic dissociation and posttraumatic stress: findings in female Vietnam theater veterans

This study examined the relationship of dissociation at the time of trauma, as assessed by the Peritraumatic Dissociation Experiences Questionnaire, Rater Version (PDEQ-RV; C.R. Marmar, D.S. Weiss, & T.J. Metzler, in press), and posttraumatic stress symptoms in a group of 77 female Vietnam theater veterans. PDEQ-RV ratings were found to be associated strongly with posttraumatic stress symptomatology, as measured by the Impact of Event Scale (M.J. Horowitz, N. Wilner, & W. Alvarez, 1979), and also positively associated with level of stress exposure and general dissociative tendencies, measured by the Dissociative Experiences Scale. The PDEQ-RV was unassociated with general psychiatric symptomatology, as assessed by the clinical scales of the Minnesota Multiphasic Personality Inventory-2 (J.N. Butcher, W.G. Dahlstrom, J.R. Graham, A. Tellegen, & B. Kaemmer, 1989). The PDEQ-RV was predictive of posttraumatic stress symptoms beyond the contributions of level of stress exposure and general dissociative tendencies. The findings provide further support for the reliability and validity of the PDEQ-RV as a measure of peritraumatic dissociation.

The relationship of peritraumatic dissociation and posttraumatic stress: findings in female Vietnam theater veterans

This study examined the relationship of dissociation at the time of trauma, as assessed by the Peritraumatic Dissociation Experiences Questionnaire, Rater Version (PDEQ-RV; C.R. Marmar, D.S. Weiss, & T.J. Metzler, in press), and posttraumatic stress symptoms in a group of 77 female Vietnam theater veterans. PDEQ-RV ratings were found to be associated strongly with posttraumatic stress symptomatology, as measured by the Impact of Event Scale (M.J. Horowitz, N. Wilner, & W. Alvarez, 1979), and also positively associated with level of stress exposure and general dissociative tendencies, measured by the Dissociative Experiences Scale. The PDEQ-RV was unassociated with general psychiatric symptomatology, as assessed by the clinical scales of the Minnesota Multiphasic Personality Inventory-2 (J.N. Butcher, W.G. Dahlstrom, J.R. Graham, A. Tellegen, & B. Kaemmer, 1989). The PDEQ-RV was predictive of posttraumatic stress symptoms beyond the contributions of level of stress exposure and general dissociative tendencies. The findings provide further support for the reliability and validity of the PDEQ-RV as a measure of peritraumatic dissociation.

Characteristics of emergency services personnel related to peritraumatic dissociation during critical incident exposure

OBJECTIVE

The aim of this study was to identify characteristics of emergency services personnel related to acute dissociative responses at the time of critical incident exposure, a phenomenon designated "peritraumatic dissociation."

METHOD

The authors studied 157 rescue workers who responded to the Nimitz Freeway collapse during the 1989 Loma Prieta earthquake in the San Francisco Bay Area as well as 201 rescue workers who were not involved in that disaster. Demographics, level of critical incident exposure, perceived threat at the time of exposure, personality attributes (assessed by the Hogan Personality Inventory), coping strategies (assessed by the Ways of Coping Questionnaire), and locus of control were related to subjects' scores on the Peritraumatic Dissociative Experiences Questionnaire.

RESULTS

According to univariate tests, the subjects with clinically meaningful levels of peritraumatic dissociation were younger; reported greater exposure to critical incident stress; felt greater perceived threat; had lower scores on the adjustment, identify, ambition, and prudence scales of the Hogan Personality Inventory; had higher scores on measures of coping by means of escape-avoidance, self-control, and active problem solving; and had greater externality in locus of control. Linear modeling with multiple logistic regression analyses indicated that greater feelings of perceived threat, coping by means of escape-avoidance, and coping by means of self-control were associated with a greater likelihood of being in the peritraumatic dissociation group, above and beyond age and exposure to stress.

CONCLUSIONS

Rescue workers who are shy, inhibited, uncertain about their identity, or reluctant to take leadership roles, who have global cognitive styles, who believe their fate is determined by factors beyond their control, and who cope with critical incident trauma by emotional suppression and wishful thinking are at higher risk for acute dissociative responses to trauma and subsequent posttraumatic stress disorder.

Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents

A three-group quasi-experimental design contrasted the responses of rescue workers to the 1989 Loma Prieta earthquake Interstate 880 freeway collapse (n = 198) with responses to critical incident exposure of Bay Area Controls (n = 140) and San Diego Controls (n = 101). The three groups were strikingly similar with respect to demographics and years of emergency service. The I-880 group reported higher exposure, greater immediate threat appraisal, and more sick days. The three groups did not differ on current symptoms. For the sample as a whole EMT/Paramedics reported higher peritraumatic dissociation compared with Police. EMT/Paramedics and California road workers reported higher symptoms compared with Police and Fire personnel. Nine percent of the sample were characterized as having symptom levels typical of psychiatric outpatients. Compared with lower distress responders, those with greater distress reported greater exposure, greater peritraumatic emotional distress, greater peritraumatic dissociation, greater perceived threat, and less preparation for the critical incident.

Predicting symptomatic distress in emergency services personnel

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors.

Predicting symptomatic distress in emergency services personnel

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors.