Trauma, traumatic stress and depression following an airline catastrophy]

OBJECTIVES: Acute stress responses following a trauma indicate a sensitivity to posttraumatic stress disorder (PTSD), and is often comorbid with depression. Earlier exposure to a traumatic event can be an additional risk factor in PTSD development. METHOD: Eight injured patients hospitalized after a major air disaster were monitored and assessed for a month. The symptoms of acute stress response (ASR), PTSD, and depression were assessed using DSM-IV criteria immediately following the accident, then each week thereafter. The Impact of Event Scale (IES) was completed on the 30th day (D30). RESULTS: Four patients presented with an ASR, and 3 of them had a PTSD at D30. Of those 3 patients with PTSD, 2 presented with an associated depression. These 2 patients had been exposed to a traumatic event before the disaster; and a significant relation was found between the history of the earlier trauma and the PTSD associated with depression. CONCLUSION: The traumatized victims with a history of earlier traumas seem more susceptible to developing a PTSD associated with depression.     

The relationship of gender and trauma characteristics to posttraumatic stress disorder in a community sample of traumatized northern plains American Indian adolescents and young adults

OBJECTIVE: Previous studies have identified a high prevalence (25%-80%) of trauma among American Indian and non-American Indian adolescents and adults. However, only a fraction of traumatized individuals develop posttraumatic stress disorder (PTSD). This article examines the relationships of gender and trauma characteristics to a diagnosis of PTSD among a community sample of traumatized American Indian adolescents and young adults. METHOD: Complete data were collected from 349 American Indians aged 15 to 24 years who participated in a cross-sectional community-based study from July 1997 to December 1999 and reported experiencing at least 1 traumatic event. Traumatic events and PTSD were assessed using a version of the Composite International Diagnostic Interview. Logistic regression determined the relationships of gender, trauma type, age at first trauma, and number of traumas to the development of PTSD. RESULTS: Forty-two participants (12.0% of those who experienced a traumatic event) met criteria for lifetime PTSD. While all 4 of the independent variables noted above demonstrated univariate associations with PTSD, multivariate logistic regression analyses indicated that only experiencing a sexual trauma (odds ratio [OR] = 4.45, 95% confidence interval [CI] = 1.76 to 11.28) and having experienced 6 or more traumas (OR = 2.53, 95% CI = 1.06 to 6.04) were independent predictors of meeting criteria for PTSD. CONCLUSION: American Indian children and adolescents who experience sexual trauma and multiple traumatic experiences may be at particularly high risk for developing PTSD.     

Initial urinary epinephrine and cortisol levels predict acute PTSD symptoms in child trauma victims

BACKGROUND: Previous research examining biological correlates of posttraumatic stress disorder (PTSD) in children has suggested that children with chronic PTSD have altered levels of catecholamines and cortisol compared to similarly traumatized children who do not meet diagnostic criteria. The present study extended these findings by examining whether urinary hormone levels collected soon after a trauma were related to subsequent acute PTSD symptoms in child trauma victims. METHODS: Initial 12-h urine samples were collected from 82 children aged 8-18 admitted to a Level 1 trauma center. Collection was begun immediately upon admission, and samples were assayed for levels of catecholamines and cortisol. PTSD and depressive symptomatology were assessed 6 weeks following the accident. RESULTS: Initial urinary cortisol levels were significantly correlated with subsequent acute PTSD symptoms (r=0.31). After removing the variance associated with demographic variables and depressive symptoms, urinary cortisol and epinephrine levels continued to predict a significant percentage (7-10%) of the variance in 6-week PTSD symptoms. Examination of boys and girls separately suggested that significance was primarily driven by the strength of the relationships between hormone levels and acute PTSD symptoms in boys. CONCLUSIONS: The present findings suggest that high initial urinary cortisol and epinephrine levels immediately following a traumatic event may be associated with increased risk for the development of subsequent acute PTSD symptoms, especially in boys.     

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.     

Identifying Persons at Risk for PTSD After Trauma with TSQ in The Netherlands

In The Netherlands about 80% of the population experience a traumatic event while about 14% develop post traumatic stress disorder (PTSD). Considering this high prevalence the prevention or early treatment of posttraumatic stress is important from a health as well as cost-benefit perspective. The aim of this study was to examine whether we could identify subjects at risk of developing PTSD. We included 100 Dutch victims of different civil traumas that contacted the Victim Support Foundation. The trauma screening questionnaire (TSQ), was used as a screening tool. The results show that a cut-off score of 7 on the TSQ correctly identified most subjects with PTSD. We found a moderate positive correlation between PTSD and the severity of complaints. We also found a significant relationship between the TSQ and depression symptoms. This study indicates that the Dutch version of the TSQ is a useful instrument for identifying future cases of PTSD.     

Trauma repetition and revictimization following physical and sexual abuse

The tendency of victims of physical or sexual childhood abuse to become revictimized in later life has well been documented empirically. Moreover, there is a high stability of violent and abusive relationships. The aim of this paper was to summarize perspectives from psychodynamic theory, attachment theory, and posttraumatic stress research to explain revictimization phenomena. The term repetition compulsion has little explanatory value without additional theoretical assumptions. Within the psychodynamic framework, an ego-psychological view conceives trauma repetition as an attempt to master traumatic experience, while in the object relations perspective, revictimization is explained by the influence of traumatic introjects. Negative cognitions of being worthless, bad and guilty can endorse the conviction that abuse is justified and reduce the capacity of self-care. Negative learning experiences from traumatic helplessness and powerlessness account for low self-efficacy expectations and prevent the establishment of self-boundaries. Trauma repetition can also be understood as an enactment in the service of affect regulation. Research in the field of attachment theory identified attachment styles predisposing to revictimization. Research dealing with posttraumatic stress disorder emphasizes the importance of traumatic affects recurring in daily life and, consequently, the tendency of abuse victims to actively produce dangerous situations in order to cope with these affects, furthermore, the role of dissociation in missing warning signals of impending traumatization. For therapeutically addressing revictimization, a detailed analysis of underlying phenomena is required.     

Posttraumatic stress disorder in victims of sexual assault--related to depression or physical symptoms]

To clarify the clinical characteristics of mental disorders in sexual assault victims, we investigated the victims focusing on PTSD, depression, physical symptoms, and their relationships. SUBJECTS: Participants were 46 treatment-seeking female victims of sexual assault who consulted four hospitals, one clinic and one psychological services center, between February 2000 and April 2001. The mean +/- SD age of the participants was 28.0 +/- 8.9 years, the mean +/- SD period from the traumatic event was 94.5 +/- 88.0 months. PTSD was diagnosed and evaluated using a structured interview (Clinician-Administered PTSD Scale for DSM-IV: CAPS). Depressive symptoms were assessed using Self-rating Depression Scales (SDS). Physical symptoms were assessed using the Physical symptom scale developed by the authors. RESULTS: Thirty-two participants (69.6%) met the criteria for PTSD in their current diagnosis, and 41 (89.1%) had the disorder at some point during their lives. SDS score and Physical symptom scale score of the PTSD group were significantly higher than those scores of the non-PTSD group. The SDS score correlated with the Avoidant-numbing score. The Physical symptoms scale score correlated with the Intrusion score and Hyperarousal score. We think that the PTSD group had the co-existing depression secondary to PTSD. Although previous studies have discussed the relationship between physical symptoms and Hyperarousal symptoms, this study suggested that physical symptoms were related to Intrusion symptoms as much as Hyperarousal symptoms. We found 2 patterns when PTSD patients reported physical symptoms related to Intrusion symptoms. The patterns were caused (1) by physiological reactivity on exposure to internal or external cues that symbolize an aspect of the traumatic event, and caused (2) by somatic reenactment symptoms. CONCLUSION: We discuss the importance for clinicians to distinguish Intrusion symptoms from physical symptoms as well as Avoidant-numbing symptoms from depressive symptoms on PTSD diagnosis. Because sexual assault victims have difficulty in talking about the traumatic experience, clinicians should pay attention to these findings in developing therapeutic plans for the victims.     

Predictors of the co-occurrence of posttraumatic stress disorder and depressive disorder in psychiatric outpatients

IntroductionWe explored the predictors of co-occurring depressive disorder (DD) in individuals with posttraumatic stress disorder (PTSD) in an outpatient psychiatric setting.MethodsParticipants (N = 170; mean age = 40.78, SD = 16.15 years; 58.8% women) included 71 adult patients who met the criteria for a PTSD diagnosis and 99 adult patients who met the criteria for a comorbid PTSD/DD diagnosis. Potential predictors included trauma types (focusing on trauma characteristics), history of previous traumatic experiences (i.e., the number of lifetime traumatic events before current trauma and childhood maltreatment), and post-trauma variables (i.e., elapsed time since the current traumatic event and the severity of PTSD symptoms).ResultsA logistic regression analysis—including demographic variables, trauma types, history of previous traumatic experiences, and post-trauma variables that showed significant differences between the two groups—was conducted. The effects of repeated trauma (OR = 13.18, 95% CI [3.44, 50.48], p < .001), the number of lifetime traumatic events (OR = 1.04, 95% CI [1.01, 1.51], p = .044), and childhood maltreatment (OR = 1.23, 95% CI [1.01, 1.51], p = .004) were associated with a greater likelihood of concurrent PTSD/DD.ConclusionCumulative characteristics such as maltreatment and the number of lifetime traumatic events before the current trauma as well as repetitive properties of the most recent trauma present a key risk factor for co-occurring PTSD/DD.     

Initial symptoms and reactions to trauma-related stimuli and the development of posttraumatic stress disorder

We investigated laboratory and experimental variables as predictors of the development of posttraumatic stress disorder (PTSD). Evoked heart rate response to trauma-related pictures, attentional bias in the dot-probe task, and viewing time were assessed in 35 victims of a traumatic event and again after 3 months. Data was compared to 26 control participants. At first assessment trauma victims showed heart rate (HR) acceleration and controls showed HR deceleration to trauma-related material. The group of trauma victims improved clinically over time. Predictors of the number of PTSD symptoms after 3 months were re-experiencing (33% of the variance) and amplitude of the evoked HR reaction to trauma-related pictures (15%). The two variables were highly correlated. Trauma victims were also more anxious, viewed trauma-related pictures for a longer time, and had a longer reaction time in the dot-probe task (but no distinct attentional bias) than control participants. Results indicate that specific fear responses and re-experiencing contribute to the development of posttraumatic stress disorder.     

Posttraumatic stress disorder in patients with neurogenic amnesia for the traumatic event

The development of symptoms of posttraumatic stress disorder (PTSD) in patients with neurogenic amnesia for the traumatic event is recorded in 2 own patients and in 19 cases from the clinical literature. With a single exception, all patients were accident victims with closed head injuries. Only about three quarters of the patients completely fulfilled DSM-III-R criteria of PTSD. Nineteen patients displayed involuntary conscious memories of aspects of the traumatic event (presenting as recurrent intrusive thoughts, images or dreams) co-existent with a complete or partial lack of voluntary conscious memories of the trauma, suggesting that different memory systems and distinct brain mechanisms subserve these phenomena. The said clinical observations are discussed against the background of current neuropsychological models of multiple memory systems. The recorded cases demonstrate that declarative episodic memory is not necessary for symptoms of PTSD to emerge, whereas preserved functions of non-declarative memory systems represent a sufficient condition for the development of PTSD symptoms.     

Acceptance and commitment therapy in the treatment of posttraumatic stress disorder

The current article describes the application of a behavioral psychotherapy, acceptance and commitment therapy (ACT), to the treatment of post-traumatic stress disorder (PTSD). It is argued that PTSD can be conceptualized as a disorder that is developed and maintained in traumatized individuals as a result of excessive, ineffective attempts to control unwanted thoughts, feelings, and memories, especially those related to the traumatic event(s). As ACT is a therapeutic method designed specifically to reduce experiential avoidance, it may be a treatment that is particularly suited for individuals with PTSD. The application of ACT to PTSD is described, and a case example is used to demonstrate how this therapy can be successfully used with individuals presenting for life problems related to a traumatic event.     

Psychotische Syndrome bei kriegstraumatisierten älteren Patienten

BACKGROUND: Late-onset post-traumatic stress disorder (PTSD) patients with traumatic experiences from World War II often present psychotic features. METHODS: Twelve psychotic elderly PTSD patients were compared with 22 nonpsychotic elderly PTSD patients for age, marital status, age of traumatization, age of onset of psychiatric symptoms, and psychiatric comorbidities. The contents of delusions and hallucinations were registered as well as trauma details. RESULTS: The psychotic PTSD patients were significantly older (80 years vs 74), later traumatized (20 years vs 14), more frequently demented (75% vs 27%), and more frequently widowed (83% vs 50%). The contents of their psychotic features often were related to traumatic experiences in early life. CONCLUSIONS: Psychoses of traumatized elderly patients should be registered regarding psychotic content to discover a possible relation between traumatic experiences and psychosis. The International Classification of Diseases 11th Edition should include the subtype "PTSD with simultaneous psychotic features."     

Glutamate/glutamine concentrations in the dorsal anterior cingulate vary with Post-Traumatic Stress Disorder symptoms

Trauma and stress-related disorders (e.g., Acute Stress Disorder; ASD and Post-Traumatic Stress Disorder; PTSD) that develop following a traumatic event are characterized by cognitive-affective dysfunction. The cognitive and affective functions disrupted by stress disorder are mediated, in part, by glutamatergic neural systems. However, it remains unclear whether neural glutamate concentrations, measured acutely following trauma, vary with ASD symptoms and/or future PTSD symptom expression. Therefore, the current study utilized proton magnetic resonance spectroscopy (¹H-MRS) to investigate glutamate/glutamine (Glx) concentrations within the dorsal anterior cingulate cortex (ACC) of recently (i.e., within one month) traumatized individuals and non-traumatized controls. Although Glx concentrations within dorsal ACC did not differ between recently traumatized and non-traumatized control groups, a positive linear relationship was observed between Glx concentrations and current stress disorder symptoms in traumatized individuals. Further, Glx concentrations showed a positive linear relationship with future stress disorder symptoms (i.e., assessed 3 months post-trauma). The present results suggest glutamate concentrations may play a role in both acute and future post-traumatic stress symptoms following a traumatic experience. The current results expand our understanding of the neurobiology of stress disorder and suggest glutamate within the dorsal ACC plays an important role in cognitive-affective dysfunction following a traumatic experience.     

Pre- and post-disaster negative life events in relation to the incidence and severity of post-traumatic stress disorder.

There is evidence suggesting that stressful life events may precede major psychiatric illness, such as major depression, and that the severity of a traumatic event outside the range of usual human experience may provoke post-traumatic stress disorder (PTSD). The present study was carried out to examine the effects of pre- and post-disaster stressful life events on the incidence rate of PTSD following two man-made traumatic events. An epidemiological study examining 127 victims of a flash fire in a ballroom and 55 motor vehicle accident (MVA) victims was undertaken. PTSD symptoms were assessed by means of the Composite International Diagnostic Interview and the pre- and post-disaster stressful life events by means of the Diagnostic Interview Schedule, Disaster Supplement. Binary logistic and multiple linear regression analyses were employed to examine the relationships between PTSD and pre- and post-disaster life events. There were no significant relationships between stressful life events the year prior to the traumatic event and the incidence or severity of PTSD. There were highly significant relationships between the cumulative number and event severity of post-disaster negative life events and the incidence rate and severity of PTSD. The post-disaster life events were significantly more related to the avoidance-depression dimension than to the anxiety-arousal dimension of PTSD. The most significant life events were: loss of job or income, broken relationships, serious illnesses or injuries in the victims and death or illness in close acquaintances. The results of this study show that the number and severity of additional stressful life events signal a higher risk to develop PTSD and a higher severity of the avoidance-depression dimension of PTSD symptomatology.     

Vicarious trauma and first responders: a case study utilizing eye movement desensitization and reprocessing (EMDR) as the primary treatment modality

Traumatic events can occur and adversely affect people during their lifetime. Natural disasters such as the earthquake in Pakistan in 2005 or the Tsunami in Asia in 2004, terrorist atrocities around the world, or personal events such as physical or sexual assault, can result in psychological difficulties for those people directly affected by these events. The diagnostic term Posttraumatic Stress Disorder (PTSD; Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM IV 1994) is generally used to explain the often-severe psychological sequalae (van der Kolk, 1996; Servan-Schreiber 2004; Shapiro, 1995) that people may exhibit when directly affected by trauma. However, what of those people not directly involved in the trauma, but those who have borne witness to it, either by listening to the stories of survivors, or in the case of the helping professionals (such as police officers, nurses, doctors, psychotherapists, fire-fighters), actively working with survivors in psychological distress? This paper examines the potential psychological consequences for those in helping professions who are working with traumatized clients. This paper then focuses on a specific treatment intervention, EMDR, utilizing a case study by way of explanation.     

Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students

We empirically investigated recent proposed changes to the posttraumatic stress disorder (PTSD) diagnosis for DSM-5 using a non-clinical sample. A web survey was administered to 585 college students using the Stressful Life Events Screening Questionnaire to assess for trauma exposure but with additions for the proposed traumatic stressor changes in DSM-5 PTSD. For the 216 subjects endorsing previous trauma exposure and nominating a worst traumatic event, we administered the original PTSD Symptom Scale based on DSM-IV PTSD symptom criteria and an adapted version for DSM-5 symptoms, and the Center for Epidemiological Studies-Depression Scale. While 67% of participants endorsed at least one traumatic event based on DSM-IV PTSD's trauma classification, 59% of participants would meet DSM-5 PTSD's proposed trauma classification. Estimates of current PTSD prevalence were .4-1.8% points higher for the DSM-5 (vs. the DSM-IV) diagnostic algorithm. The DSM-5 symptom set fit the data very well based on confirmatory factor analysis, and neither symptom set's factors were more correlated with depression.     

Le jeu chez l’enfant victime d’événements traumatiques

The authors work lies within the framework of medicopsychological emergency activities and of specialized consultation the vocation of which is to insure the care of victims of traumatic events that they be of a deliberate (violence, wars) or non-deliberate nature (natural disasters, accidents). Interventions led close to the events with grown-up victims are well organized nowadays whereas the specific coverage of children is still not envisaged in immediate interventions. Nevertheless, children may be affected as much as the adults by the trauma and can present disorders, which must be tracked down, estimated and taken care of. We propose a reflection on a symptom of reviviscence susceptible to be expressed by children victims of traumatic events: The post-traumatic game. We suggest envisaging the post-traumatic game as a clinical entity testifying of a symptom of reviviscence, which can express itself at three levels: The traumatic game, the abreactive game, the re-enactment. - 1 - The traumatic game: Rather than the ’post-traumatic’ expression because in this activity the child is still in the trauma without being able to get free of it. The traumatic game is to be understood as a symptom situated close to reviviscence because the child ’plays’ by repeating the traumatic scene, which was lived through, as a kind of automatic, repetitive and monotonous production that can become a real compulsion, without any decrease of the fear. This expression, to which no pleasure is attached, is due to the complete overwhelming of the mechanisms of defence, to the failure of the psychic devices in metabolising the influx of excitements, in the fixation of the psyche at the moment T of the trauma. The child, in a state of ’emotional petrifaction’, is the prisoner of a deadly activity from which it cannot release itself. The traumatic game is a game in ’white’. - 2 - The abreactive game: This activity marks an evolution with regard to the traumatic game because here, the child is capable of developing it’s scenario until some kind of end without being blocked in a compulsion of rehearsal of the trauma. Each rehearsal staged in the abreactive game is accompanied with feelings, thoughts, sensations and a physical recall of the initial state of distress but here the child succeeds in partially freeing itself of it and sometimes in avoiding suffering. The dimension of auxiliarity of the processes of symbolization is partially restored. The abreactive game has a dimension of emotional discharge, exorcizing the suffering and allowing the restoration of the capacity to support the processes of representation and symbolization. Contrary to the post-traumatic game, which testifies to the failure of any possibility of elaboration, the abreactive game authorizes the reorganization of the psychic contents and restores temporality: the child is not petrified in an instant T of the trauma any more but succeeds in reaching beyond in an ’after traumatic’ mode. The child repeats with the same intensity and in an active mode, via the game, the trauma it experienced passively so as to succeed in mastering it. The abreactive game authorizes the reorganization of what it lived passively on an active mode so as to succeed in mastering it and this reproduction of the experience, by modifying its status, allows its assimilation. The abreactive game then allows the child to resume control over what it underwent and to assimilate its own reactions and feelings: Its mechanisms of defence are not overwhelmed any more: They are restored. - 3 - Re-enactment play such as defined by Terr is characterized by the expression a posteriori of traumatic traces through the game and by the investment of the child. This acting of the traumatism it lived through a posteriori intervenes while the child recovers a certain psychic balance. It is not an automatic rehearsal of the event in its global nature but only a rehearsal of certain aspects of the trauma. The child spends a period of intense stages of psychic suffering through certain activities and by recalling the ancient traumatic memories encrypted in its unconscious. The expression of the re-enactment does not present the rigidity of the traumatic game but is more difficult to track down. We shall then discuss the interest of observing the game for the diagnosis and for the understanding of the child’s psychodynamique traumatic traces. These various modalities of expression show the intensity of ’the after-effect activity of the traumatism’ and the underlying dynamic processes. They are to be understood as symptoms giving evidence of the persisting suffering in the symbolization of these traumatic traces. Distinguishing between the various meaningful activities of the child after a traumatic event offers us the possibility of observing the child to better estimate the impact of the trauma and to perceive if what he/she shows can likely or not play the role of ’psychic prosthesis’ for certain psychic functions having failed due to the event. The distinction between these three post-traumatic expressions is still easy because the child can, on the basis of the same post-traumatic scenario, appeal to these various modalities of expression. This is particularly the case for the children victims of serious and repeated violence (sexual violence, war). We will discuss what it is in the traumatic game, in the abreactive game and in re-enactment, in the process at work in the passage from the passivity in front of the traumatic experience to the activity of the game that aims at cancelling the loss undergone and at retroactively giving meaning to the traumatic scene.     

Longitudinal study of posttraumatic stress disorder, depression, and changes in traumatic memories over time in Bosnian refugees

This longitudinal study examined traumatic memory consistency over a 3-year period among a sample of highly traumatized Bosnian refugees, focusing on demographic factors, types of trauma, and posttraumatic stress disorder (PTSD) and depression. In 1996 and 1999, 376 Bosnian refugees were interviewed about 54 wartime trauma and torture events, and symptoms of PTSD and depression. Reports were compared for both time periods, and changed responses were analyzed for significance. Overall, there was consistency in reporting over time; when change occurred it was in the direction of decreased reports at follow-up. This downward trend was not associated with any particular diagnosis. However, PTSD alone, without comorbid symptoms of depression, was uniquely associated with the group that exhibited an upward trend. This implies that increased reporting is related specifically to the presence of PTSD symptoms, and that PTSD may be distinctly associated with the failed extinction of traumatic memories.