Traumatic life events and PTSD among women with substance use disorders and schizophrenia

OBJECTIVE: The authors assessed the prevalence of traumatic life events and posttraumatic stress disorder (PTSD) among women with schizophrenia or schizoaffective disorder and co-occurring substance abuse or dependence. The association between PTSD and specific traumatic life events was also examined. METHODS: Fifty-four drug-addicted women with schizophrenia or schizoaffective disorder participated in the study. All women were psychiatric outpatients and completed a large battery of structured clinical assessments. RESULTS: High rates of trauma, particularly physical abuse (81 percent), and revictimization--being abused both as a child and as an adult--were reported. The average number of traumatic life events reported was eight, and almost three-quarters of the sample reported revictimization. Rates of current PTSD were considerably higher than those documented in previous study samples of persons with serious mental illness and of drug-addicted women in the general community. PTSD was significantly associated with childhood sexual abuse and revictimization. CONCLUSIONS: The high levels of trauma and revictimization observed in the study highlight the need for the development of evidence-based interventions to treat trauma and its aftermath among women with schizophrenia or schizoaffective disorder. Given the overlap in symptoms between PTSD and schizophrenia, a better understanding is needed of how PTSD is expressed among people with schizophrenia. Recommendations and standards for the assessment of PTSD among this population need to be articulated. Finally, the comparatively high rates of PTSD suggest that the combination of schizophrenia or schizoaffective disorder and substance use disorder makes these women particularly vulnerable to adverse outcomes.     

Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates

Seclusion and restraint represent adverse experiences that cause negative attitudes against psychiatric treatment and psychopathologic sequels such as posttraumatic stress disorder. We examined 117 consecutive admissions with schizophrenia, with an average of 8.7 previous admissions. Positive and Negative Syndrome Scale and Global Assessment of Functioning were obtained at admission and discharge, and traumatic events in the biography were recorded using the Posttraumatic Diagnostic Scale. Twenty-four men (42.9%) and 18 women (29.0%) had experienced seclusion or restraint in their psychiatric history. Seclusion or restraint during the present admission was best predicted in a logistic regression model by physical aggressive behavior [odds ratio (OR), 11.5] and the Positive and Negative Syndrome Scale hostility item at admission (OR, 23.6). Seclusion or restraint ever in the psychiatric history, however, was mostly associated with lifetime exposure to life-threatening traumatic events (OR, 7.2). We conclude that exposure to traumatic events in the biography severely enhances the risk of revictimization and retraumatization during inpatient treatment.     

Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder

OBJECTIVE: This review integrates recent advances in attachment theory, affective neuroscience, developmental stress research, and infant psychiatry in order to delineate the developmental precursors of posttraumatic stress disorder. METHOD: Existing attachment, stress physiology, trauma, and neuroscience literatures were collected using Index Medicus/Medline and Psychological Abstracts. This converging interdisciplinary data was used as a theoretical base for modelling the effects of early relational trauma on the developing central and autonomic nervous system activities that drive attachment functions. RESULTS: Current trends that integrate neuropsychiatry, infant psychiatry, and clinical psychiatry are generating more powerful models of the early genesis of a predisposition to psychiatric disorders, including PTSD. Data are presented which suggest that traumatic attachments, expressed in episodes of hyperarousal and dissociation, are imprinted into the developing limbic and autonomic nervous systems of the early maturing right brain. These enduring structural changes lead to the inefficient stress coping mechanisms that lie at the core of infant, child, and adult posttraumatic stress disorders. CONCLUSIONS: Disorganised-disoriented insecure attachment, a pattern common in infants abused in the first 2 years of life, is psychologically manifest as an inability to generate a coherent strategy for coping with relational stress. Early abuse negatively impacts the developmental trajectory of the right brain, dominant for attachment, affect regulation, and stress modulation, thereby setting a template for the coping deficits of both mind and body that characterise PTSD symptomatology. These data suggest that early intervention programs can significantly alter the intergenerational transmission of posttraumatic stress disorders.     

Changes in women's sexual behavior following sexual assault

The present study examines changes in women's sexual activity and behavior following sexual assault and the relationship between alcohol abuse and postassault promiscuity. Although many researchers have focused on avoidance of sexual activity following an assault, some have suggested that women may exhibit an increase in sexual activity postassault. Such outcomes are not mutually exclusive possibilities but may instead reflect subtypes of sexual assault victims. A significant percentage of assault survivors did report increases in sexual activity following trauma. Assault survivors also reported increases in posttraumatic alcohol consumption relative to a comparison sample of motor vehicle accident survivors. In both groups, increases in posttraumatic alcohol usage predicted increases in posttraumatic sexual activity, suggesting that use of alcohol as a coping strategy may result in an increased likelihood of engaging in risky sexual behavior. If true, this maladaptive coping mechanism could help to account for some instances of revictimization.     

Response of traumatized patients with depersonalization --from the perspective of attachment theory]

We recognized that several traumatized individuals re-lived the danger associated with trauma on recollecting the original traumatic event; moreover, some of them experienced a similar traumatic event. In this article, we report these cases and show that this tendency is exhibited more frequently in victims of sexual abuse. Van der Kolk, who treated veteran soldiers who served in Vietnam, became aware of the compulsion of patients to repeat their trauma through treatment. He expressed this repetition compulsion as re-enactment or re-victimization of past traumatic experiences, showing how the trauma was repeated at a behavioral level in his article. After their treatment, he published his research on traumatized people as Post-Traumatic Stress Disorder in the 1980's. Nowadays, generally, this repetition compulsion behavior is not included as a symptom of PTSD in Japan. Van der Kolk insisted that these repetition compulsions caused further suffering for victims and their relations. We also thought that these repetition compulsions can disturb rehabilitation. In our article, we expressed the condition as active compulsion repetition. We considered that it should be distinguished from passive conditions including instructive symptoms such as repetitive nightmare and flashback. We also represented how active compulsion was repeated in our cases, which was not consistent with the concept of PTSD on DSM-IV. When the active repetition compulsion was acted, we noticed that patients showed depersonalization. We thought that an understanding of the depersonalization following reenactment and re-vicitimization was important in order to comprehend the mechanism of PTSD.     

Traumatic entrapment, appeasement and complex post-traumatic stress disorder: evolutionary perspectives of hostage reactions, domestic abuse and the Stockholm syndrome

Evolutionary theory and cross-species comparisons are explored to shed new insights into behavioural responses to traumatic entrapment, examining their relationships to the Stockholm syndrome (a specific response to traumatic entrapment) and complex post-traumatic stress disorder (PTSD). A selective literature review is undertaken examining responses to traumatic entrapment (including hostage, domestic abuse and similar situations) and the Stockholm syndrome, before examining mammalian, reptilian and other defensive responses to relevant threats. Chimpanzees, the closest relatives of humans, are closely examined from this perspective and commonalities in behavioural responses are highlighted. The neurobiological basis of defensive behaviours underlying PTSD is explored with reference to the triune brain model. Victims of protracted traumatic entrapment under certain circumstances may display the Stockholm syndrome, which involves paradoxically positive relationships with their oppressors that may persist beyond release. Similar responses are observed in many mammalian species, especially primates. Ethological concepts including dominance hierarchies, reverted escape, de-escalation and conditional reconciliation appear relevant and are illustrated. These phenomena are commonly encountered in victims of severe abuse and understanding these concepts may assist clinical management. Appeasement is the mammalian defence most relevant to the survival challenge presented by traumatic entrapment and appears to be the foundation of complex PTSD. Evolutionary perspectives have considerable potential to bridge and integrate neurobiology and the social sciences with respect to traumatic stress responses.     

Revictimization and information processing in women survivors of childhood sexual abuse

This study examined the effect of sexual revictimization on information processing of trauma-related stimuli in a sample of child sexual abuse (CSA) survivors diagnosed with posttraumatic stress disorder (PTSD). Fifty-one treatment-seeking women participated in this study. Participants completed the Sexual Experiences Survey regarding sexual revictimization in the last 6 months and performed a modified emotional Stroop task in which they named the colors of neutral words (e.g., apple), general threat words (e.g., malignant and death), and sexual/victimization words (e.g., penis and abuser). As predicted, the revictimized participants (n = 16) took significantly longer to color-name sexual/victimization words than did the nonrevictimized participants. These results suggest that revictimization serves to prime preexisting "trauma" memory networks, thereby amplifying the impact of childhood sexual trauma on selective attention toward trauma-related stimuli.     

The use of imagery in the treatment of posttraumatic stress disorder

The role of visual imagery in the symptomatology of posttraumatic stress disorder (PTSD) has not been fully appreciated. The occurrence of intrusive recollections of a traumatic event in the form of flashbacks is very common and may suggest a possible approach to treatment for many individuals with PTSD. A case is presented in which a combat veteran in psychodynamic psychotherapy for PTSD was successfully treated by capitalizing on his tendency to have flashbacks. In this instance, abreaction and subsequent working through of affective reactions to the abreaction resolved his disorder. Technical considerations and patient selection are discussed, and it is suggested that further study of the efficacy of this approach is warranted.     

Psychopathology of sexual abuse in young people with intellectual disability

The present study addressed two issues using a sample of child and adolescent victims and perpetrators of sexual abuse: (1) the extent of post‐traumatic stress disorder (PTSD) in the sample; and (2) the possible distinction between perpetrators whose motivations were sexually impulsive, and those who were controlling and abuse‐reactive. Retrospective case material from 43 cases (21 victims only, and 22 perpetrators, of whom 16 were also victims) provided the data. Post‐traumatic symptomatology was not common. Only one case of PTSD was found. Perpetrators could be distinguished by whether they had suffered sexual abuse alone, sexual and physical abuse, or neither. The proposed distinction between perpetrators received support. Sexual abuse directed at younger victims was associated with earlier experience of multiple forms of abuse. The present data does not support the view that post‐traumatic symptoms following victimization are a mediator of sexual abuse perpetration. It is argued that an elaboration of the Williams & New developmental model of perpetration better fits the data.     

Incidence of post-traumatic stress disorder in adolescents: results of the Bremen Adolescent Study

The frequency and comorbidity of posttraumatic stress disorders (PTSD) were assessed together with the resultant psychosocial impairment in 1035 adolescents between the ages of 12 and 17 years. Posttraumatic stress disorder and other psychiatric disorders were coded on the basis of the DSM-IV criteria using the computerized personal interview of the Munich version of the Composite International Diagnostic Interview (CIDI). A total of 17 (1.6%) adolescents met the DSM-IV criteria for PTSD at some point in their life. Slightly more girls than boys met the criteria for the disorder, whose frequency increased with age. The lifetime prevalence of traumatic events is much higher still: 233 (22.5%) adolescents reported one or more traumatic events in their life. The types of traumatic events experienced by the greatest number of adolescents were: physical attack, injury, and serious accident. Boys experienced significantly more traumatic events than did girls. The occurrence of a traumatic event was mostly associated with hypervigilance and recurrent and intrusive psychological distress upon exposure to cues which symbolized the event itself or resembled an aspect thereof. PTSD occurred in highly frequent comorbidity with depressive disorders, somatoform disorders, and substance abuse. Over 90% of those with posttraumatic stress disorder were severely impaired in their daily life and activities. Despite the high-grade psychosocial impairment, only a small number sought professional help.     

Does stress damage the brain?

Studies in animals showed that stress results in damage to the hippocampus, a brain area involved in learning and memory, with associated memory deficits. The mechanism involves glucocorticoids and possibly serotonin acting through excitatory amino acids to mediate hippocampal atrophy. Patients with posttraumatic stress disorder (PTSD) from Vietnam combat and childhood abuse had deficits on neuropsychological measures that have been validated as probes of hippocampal function. In addition, magnetic resonance imaging (MRI) showed reduction in volume of the hippocampus in both combat veterans and victims of childhood abuse. In combat veterans, hippocampal volume reduction was correlated with deficits in verbal memory on neuropsychological testing. These studies introduce the possibility that experiences in the form of traumatic stressors can have long-term effects on the structure and function of the brain.     

Is there a common pathway to developing ASD and PTSD symptoms?

Numerous studies have identified risk factors for acute and long-term posttraumatic stress symptoms following traumatic exposure. However, little is known about whether there are common pathways to the development of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Research suggests that a common path to ASD and PTSD may lie in peritraumatic responses and cognitions. The results of structural equation modeling in a national sample of Danish bank robbery victims (N = 450) show that peritraumatic panic, anxiety sensitivity, and negative cognitions about self were significant common risk factors for both ASD severity and PTSD severity when controlled for the effect of the other risk factors. The strongest common risk factor was negative cognitions about self. Future research should focus on replicating these results as they point to possible areas of preventive and treatment actions against the development of traumatic stress symptoms.     

Injury severity,prior trauma history,urinary cortisol levels,and acute PTSD in motor vehicle accident victims

This study examined the relationship between prior history of traumatic events, life threat, and injury severity experienced during a motor vehicle accident (MVA), and posttraumatic stress disorder (PTSD) assessed 1 month after the accident. In addition, initial urinary cortisol levels after the accident were examined as a possible mediator of this relationship. Fifteen-hour urinary cortisol samples were collected from MVA victims upon admission to the trauma unit. In the hospital, subjective life threat was measured and objective Injury Severity Scores (ISSs) were computed. One month after the accident, participants were assessed for prior history of traumatic experiences, presence of acute PTSD, and levels of intrusive and avoidant thoughts and behaviors. Victims, who met PTSD diagnostic criteria, reported more prior traumatic events, and significantly greater life threat despite receiving significantly lower ISSs than victims who did not develop PTSD. The relationships between ISSs and PTSD symptoms and prior trauma history and PTSD symptoms were mediated by cortisol levels. Results suggest that cortisol levels in the acute aftermath of a traumatic event may serve as a mechanism through which various factors may increase risk for PTSD.     

Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD.

BACKGROUND: Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms. METHODS: Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome. RESULTS: Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome. CONCLUSIONS: In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.     

The Io Syndrome: Symptom Formation in Victims of Sexual Abuse

The sexual abuse of women today is analyzed alongside the mythology of Ovid's Metamorphoses. Two thousand years ago, Ovid unfolded a world view of human beliefs and practices that make up today's symptom formation and psychodynamic in victims of sexual abuse. Herewith the mythology of Io. Her rape and subsequent symptom formation is understood as a clinical account of rape-trauma syndrome and post-traumatic stress disorder.     

The Io syndrome: symptom formation in victims of sexual abuse

The sexual abuse of women today is analyzed alongside the mythology of Ovid's Metamorphoses. Two thousand years ago, Ovid unfolded a world view of human beliefs and practices that make up today's symptom formation and psychodynamic in victims of sexual abuse. Herewith the mythology of Io. Her rape and subsequent symptom formation is understood as a clinical account of rape-trauma syndrome and post-traumatic stress disorder.     

Early life stress and PTSD symptoms in patients with comorbid schizophrenia and substance abuse

OBJECTIVE: The comorbidity of schizophrenia and substance abuse is well documented and is remarkable for its prevalence and poor prognosis. While the etiology for this association is unknown, one possible mechanism relates to traumatic early life experiences, which have been shown to predispose individuals to both psychosis and substance abuse. METHODS: Participants (N=122) who were outpatients in an inner city public mental health clinic and who were diagnosed with schizophrenia, were administered a battery of structured clinical assessments including the Childhood Traumatic Events Scale (CTES), Davidson PTSD rating scale, Hamilton Depression Rating Scale (HDRS), Positive and Negative Symptom Scale (PANSS), and assessments of medication satisfaction and side effects. Patients with schizophrenia and a history of substance abuse (N=70) were compared to patients with schizophrenia who did not have a history of substance abuse (N=52). RESULTS: Patients with schizophrenia and a history of substance abuse had significantly higher frequency and severity of childhood traumatic events, greater PTSD symptomatology, significantly higher depression scores, and higher scores on the general subscale of the PANSS. DISCUSSION: Our findings lend support to the notion that sensitization to stress from early life experiences may be a factor contributing to the high rate of substance abuse comorbidity in patients with schizophrenia.     

Brain morphometry in female victims of intimate partner violence with and without posttraumatic stress disorder.

BACKGROUND: To examine neuroanatomical morphometry in adult female victims of intimate partner violence with and without posttraumatic stress disorder. METHODS: Seventeen nonvictimized comparison subjects and 22 victims of intimate partner violence, 11 with and 11 without posttraumatic stress disorder, were studied. Using quantitative magnetic resonance imaging, three mesial temporal lobe areas were measured: hippocampus, amygdala, and parahippocampal gyrus. Additionally, whole brain morphometry provided fluid, gray, and white matter volumes of the cortex and cerebellum for exploratory analyses. Relationships of morphometric measures to symptoms, abuse history, and neuropsychological function were examined. RESULTS: Intimate partner violence subjects with posttraumatic stress disorder did not demonstrate significantly smaller hippocampal or other mesial temporal lobe volumes. Overall, intimate partner violence subjects had smaller supratentorial cranial vaults and smaller frontal and occipital gray matter volumes relative to nonvictimized comparison subjects. Supratentorial cranial vault volume was negatively correlated with severity of childhood physical abuse, but not with intimate partner violence or posttraumatic stress disorder severity. Trails B performance was negatively correlated with frontal gray matter volume. CONCLUSIONS: These findings are inconsistent with prior reports of smaller hippocampal volumes in patients with posttraumatic stress disorder. Rather, the findings point to cerebral abnormalities that may reflect the influence of early trauma on neurodevelopmental processes or denote brain morphometric characteristics of persons at increased risk for serious psychosocial adversity.     

Initial posttraumatic urinary cortisol levels predict subsequent PTSD symptoms in motor vehicle accident victims.

BACKGROUND: This study was designed to examine the relationship between urinary hormone levels collected upon admission to the trauma unit following a motor vehicle accident and posttraumatic stress disorder symptomatology 1 month later. METHODS: Fifteen-hour urine samples were collected from 63 male and 36 female motor vehicle accident victims and were used to assess levels of catecholamines and cortisol reflecting peritraumatic and acute-phase posttraumatic levels. Presence of posttraumatic stress disorder symptomatology was assessed 1 month after the accident. RESULTS: Motor vehicle accident victims subsequently diagnosed with acute posttraumatic stress disorder excreted significantly lower levels of cortisol in 15-hour urines collected upon admission to the hospital. In addition, urinary levels of cortisol predicted a significant percentage of the variance in intrusive and avoidant thoughts 1 month after the accident. CONCLUSIONS: The results of our study suggest that initial cortisol levels in the immediate aftermath of a traumatic event contribute, in part, to subsequent symptoms of posttraumatic stress disorder.     

Maltraitances sexuelles infantiles et répétition victimaire dans les relations conjugales à l’âge adulte

AimsIn this article, we show the consequences of childhood sexual abuse on psychic development and its implication in victimary repetition in adulthood.MethodThe case study presented in this article is from a doctoral research project in psychology about the impact of early relationships on the experience of intimate partner violence in adulthood. This case appears emblematic of the rest of our population. The elements mentioned are anonymized and analyzed from a psychoanalytic perspective.ResultsThe results show the conscious and unconscious consequences of childhood sexual abuse on the victims’ psychological development. Indeed, the psychic intrusion following early sexual abuse hinders the construction of the self and prevents the psychic instances from functioning properly. This intrusion also leads to repetition in violent intimate relationships. Oscillating between primary and secondary processes, the person can cut her/himself off from a part of her/his emotional life to avoid psychic and/or somatic disorganization.DiscussionAfter experiencing early sexual trauma, even if the psychic apparatus is temporarily able to keep the traumatic elements far from the conscious mind, these elements still act in the unconscious. The work of shame and guilt, which are constitutive elements of moral masochism, lock the subject into a deadly repetition compulsion that can promote the experience of repetitive intimate partner violence (physical, psychological, sexual) in adulthood.ConclusionTo prevent, detect, and care for women victims of childhood sexual abuse, it is necessary to consider their modalities of psychic functioning, the formation of their Self, and their ability to psychically transform the trauma they suffered.