Traumatic events and posttraumatic stress in childhood

CONTEXT: Traumatic events are common and are related to psychiatric impairment in childhood. Little is known about the risk for posttraumatic stress disorder (PTSD) across different types of trauma exposure in children. OBJECTIVE: To examine the developmental epidemiology of potential trauma and posttraumatic stress (PTS) in a longitudinal community sample of children. METHODS: A representative population sample of 1420 children aged 9, 11, and 13 years at intake were followed up annually through 16 years of age. Main Outcome Measure Traumatic events and PTS were assessed from child and parent reports annually to 16 years of age. Risk factors and DSM-IV disorders were also assessed. RESULTS: More than two thirds of children reported at least 1 traumatic event by 16 years of age, with 13.4% of those children developing some PTS symptoms. Few PTS symptoms or psychiatric disorders were observed for individuals experiencing their first event, and any effects were short-lived. Less than 0.5% of children met the criteria for full-blown DSM-IV PTSD. Violent or sexual trauma were associated with the highest rates of symptoms. The PTS symptoms were predicted by previous exposure to multiple traumas, anxiety disorders, and family adversity. Lifetime co-occurrence of other psychiatric disorders with traumatic events and PTS symptoms was high, with the highest rates for anxiety and depressive disorders. CONCLUSIONS: In the general population of children, potentially traumatic events are fairly common and do not often result in PTS symptoms, except after multiple traumas or a history of anxiety. The prognosis after the first lifetime trauma exposure was generally favorable. Apart from PTSD, traumatic events are related to many forms of psychopathology, with the strongest links being with anxiety and depressive disorders.     

Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity.

OBJECTIVE: Despite progress in epidemiologic research on posttraumatic stress disorder (PTSD), little is known about factors that distinguish chronic from nonchronic PTSD. In a previous report, the authors identified a set of personal predispositions associated with PTSD following traumatic events in a general population sample of young adults. The purpose of this analysis was to identify characteristics of chronic PTSD and examine whether any of the suspected risk factors for PTSD was associated specifically with chronic PTSD. METHOD: A random sample of 1,007 21- to 30-year-old members of a large health maintenance organization in the Detroit area was interviewed, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS), revised for DSM-III-R. The analysis was performed on data from 394 respondents who reported traumatic events, of whom 93 met criteria for PTSD. Chronic PTSD was defined as duration of symptoms for 1 year or more. RESULTS: Persons with chronic PTSD (N = 53) had, on the average, a significantly higher total number of PTSD symptoms and higher rates of overreactivity to stimuli that symbolized the stressor and interpersonal numbing than persons with nonchronic PTSD. The rates of one or more additional anxiety or affective disorders and a variety of medical conditions were higher in persons with chronic than nonchronic PTSD. Family history of antisocial behavior and female sex were associated specifically with chronic PTSD. CONCLUSIONS: The findings suggest that chronic PTSD may be associated with specific risk factors and clinical features. Longitudinal data on the course of PTSD are needed to determine whether the distinct features and the medical and psychiatric histories of persons with chronic PTSD are complications attendant on a chronic course or coexisting disturbances that inhibit recovery.     

Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults

OBJECTIVE: Few studies have focused on the natural course of posttraumatic stress disorder (PTSD) and its determinants in samples of the general population. The authors examined determinants of remission and chronicity of PTSD and associations with other disorders in a prospective community sample. METHOD: The data were drawn from a prospective, longitudinal epidemiological study of adolescents and young adults (age 14-24 years) in Munich, Germany (N=2,548). The course of PTSD from baseline to follow-up 34-50 months later was studied in 125 respondents with DSM-IV PTSD or subthreshold PTSD at baseline. RESULTS: Although 52% of the PTSD cases remitted during the follow-up period, 48% showed no significant remission of PTSD symptoms. Respondents with a chronic course were more likely to experience new traumatic event(s) during follow-up (odds ratio=5.21, 95% confidence interval [CI]=1.95-13.92), to have higher rates of avoidant symptoms at baseline (odds ratio=10.16, 95% CI=1.73-59.51), and to report more help seeking (odds ratio=5.50, 95% CI=1.04-29.05), compared to respondents with remission. Rates of incident somatoform disorder (odds ratio=4.24, 95% CI=1.60-11.19) and other anxiety disorders (odds ratio=4.07, 95% CI=1.15-14.37) were also significantly associated with a chronic course. CONCLUSIONS: PTSD is often a persistent and chronic disorder. Specific symptom clusters--especially avoidant symptoms--might be associated with the course of PTSD. In addition, the occurrence of new traumatic events differentiates PTSD cases with a chronic course from those with remission.     

Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population

IntroductionConditional risk for PTSD is the risk of developing PTSD after exposure to traumatic events. This epidemiological study of the general urban population from the two largest cities in Brazil reports exposure to traumatic events; conditional risk for PTSD; and proportion/estimated number of PTSD cases secondary to each type of traumatic event.MethodCross-sectional study of general population (15–75 y.o.) from Rio de Janeiro and São Paulo. PTSD was assessed through Composite International Diagnostic Interview 2.1.ResultsOur main findings, from 3744 participants, were: 1) high prevalence of traumatic events (86%), urban violence being the most common; 2) conditional risk for PTSD was 11.1%; 3) women (15.9%) have overall conditional risk 3 times higher than men (5.1%); 4) war-related trauma (67.8%), childhood sexual abuse (49.1%) and adult sexual violence (44.1%) had the highest conditional risks; 5) 35% of PTSD cases (estimated 435,970 individuals) were secondary to sudden/unexpected death of a close person, and 40% secondary to interpersonal violence.ConclusionsBrazilian urban population is highly exposed to urban violence, and overall conditional risk for PTSD was 11.1%. Violence prevention and enhancement of resilience should be part of public policies, and mental health sequelae of trauma should be better recognized and treated.     

Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review

Although video-EEG monitoring has revolutionized the diagnosis of psychogenic nonepileptic seizure (PNES), the etiology of this condition remains poorly understood. This article is a critical review of studies on the prevalence of traumatic events, abuse, and/or posttraumatic stress disorder (PTSD) in patients with PNES. Searches carried out on MEDLINE (1966-2004) and Web of Science (1945-2004) identified 17 relevant studies. PNES samples showed very high rates of trauma (44-100%) and abuse (23-77%), which were 15-40% higher than those found in control groups. This suggests that traumatic experiences may be a potential risk factor for PNES. PNES samples also showed a higher prevalence of PTSD than control groups, raising the possibility that PNES may arise as a clinical expression of a hypothetical PTSD subtype the core symptoms of which are dissociative. Methodological limitations do not permit the confirmation of these hypotheses. Stronger research designs are needed, such as prospective and case-control studies in both hospital and community settings.     

Symptoms of posttraumatic stress disorder among urban residents

Previous studies indicate a high risk of Posttraumatic Stress Disorder (PTSD) among women and low-income, urban-residing African-Americans. This study examined PTSD symptoms among urban-residing, socioeconomically diverse, working-age African-Americans and whites. The participants completed the PTSD Checklist-Civilian Version. Of the 2104 participants, 268 (12.7%) were screened positive for PTSD symptoms. Women (13.8%) were more likely than men (11.3%), white participants (13.8%) were more likely than African-Americans (11.9%), and younger participants (16.1%) were more likely than older participants (10.2%) to screen positive for PTSD symptoms. A significant interaction (p = 0.05) revealed that white women living below the 125% poverty level were most likely to report PTSD symptoms. These findings highlight the importance of PTSD screening in low-income urban neighborhoods.     

Cumulative adversity and posttraumatic stress disorder: evidence from a diverse community sample of young adults

The authors hypothesized that a history of adversities, whether they were objectively traumatic or not, predicts risk for 1st onset of PTSD. Survival analysis in a community sample of 1,803 young adults revealed that risk is associated with retrospectively reported adverse experiences that occurred in years prior to the focal traumatic event. Analyses control for clustering of events proximal to onset. Implications for etiology and preventive intervention are noted.     

The emotional impact of national music on young and older adults differing in posttraumatic stress disorder symptoms

In spite of previous evidence regarding the function of national songs as a contextual stimulus, their effect on the emotional state of older adults living with different levels of posttraumatic stress disorder (PTSD) symptoms has not be been examined. Following the 2014 Israel–Gaza conflict, we examined the emotional effects of listening to happy national songs (songs of Independence Day) and sad national songs (Memorial Day songs) on young (N = 144, mean age = 29.4) and older adults (N = 132, mean age = 68.5). Respondents were exposed to happy or sad national songs, and completed measures of exposure to missile attacks, related PTSD symptoms, and positive and negative emotions. Sad national songs were related to higher negative affect among young adults who were lower on PTSD symptoms, but not among their older counterparts. In contrast, sad national songs were related to higher negative affect among older adults who were higher on PTSD symptoms, but not among their young counterparts. These findings support the strength and vulnerability model, as they demonstrate that relative to young adults, older adults are generally more capable to withstand negative stimuli, yet are more sensitive to negative stimuli when they suffer from chronic vulnerability, as in the case of higher level of PTSD symptoms.     

Assessment and psychological treatment of posttraumatic stress disorder in older adults

Knowledge regarding the assessment and treatment of posttraumatic stress disorder in older adults continues to be limited in both psychological research and practice. This article provides a summary of this literature. In particular, the psychometric properties of several posttraumatic stress disorder assessment measures in their use with older individuals are reviewed. Although the evidence base on effective treatments for posttraumatic stress disorder in older adults is virtually nonexistent, this article highlights the innovative clinical endeavors that have been conducted in this regard. Explicit suggestions for best practices are made.     

The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events

OBJECTIVE: The authors examined the relationship of borderline personality disorder to posttraumatic stress disorder (PTSD) with respect to the role of trauma and its timing. METHOD: The Trauma History Questionnaire and the PTSD module of the Structured Clinical Interview for DSM-III-R were administered to 180 male and female outpatients with a diagnosis of one or more DSM-III-R personality disorders. Path analysis was used to evaluate the relationship between borderline personality disorder and PTSD. RESULTS: High rates of early and lifetime trauma were found for the subject group as a whole. Compared to subjects without borderline personality disorder, subjects with borderline personality disorder had significantly higher rates of childhood/adolescent physical abuse (52.8% versus 34.3%) and were twice as likely to develop PTSD. In the path analysis of the relationship between borderline personality disorder and PTSD, none of the different types of paths (direct path, indirect paths through adulthood traumas, paths sharing the antecedent of childhood abuse) was significant. The associations with both trauma and PTSD were not unique to borderline personality disorder; paranoid personality disorder subjects had an even higher rate of comorbid PTSD than subjects without paranoid personality disorder, as well as elevated rates of physical abuse and assault in childhood/adolescence and adulthood. CONCLUSIONS: The associations of personality disorder with early trauma and PTSD were evident, but modest, in borderline personality disorder and were not unique to this type of personality disorder. The results do not appear substantial or distinct enough to support singling out borderline personality disorder from the other personality disorders as a trauma-spectrum disorder or variant of PTSD.     

Trauma and posttraumatic stress disorder in an urban Xhosa primary care population: prevalence,comorbidity, and service use patterns

Despite increased awareness of the prevalence and morbidity of psychiatric illnesses, relatively few studies have been undertaken in primary care settings in the African context. The authors determined the prevalence of trauma exposure and posttraumatic stress disorder (PTSD) in a South African township primary health care clinic and assessed associated demographic factors, comorbidity, service use, service satisfaction, and quality of life. Subjects were directly interviewed using translated, standardized instruments to assess variables described. Retrospective chart analysis assessed clinician case identification and psychotropic drug-prescribing habits. Of the 201 participants, 94% reported exposure to traumatic events (mean, 3.8). Trauma was associated with single status (p =.01), and PTSD was associated with poverty and single status (p =.04). Both sexes were equally likely to develop PTSD. PTSD (current; 19.9%), depression (37%), and somatization disorder (18.4%) were the most common diagnoses. Comorbidity with PTSD was high and included depression (75%, p <.01), somatization (35%, p <.01), and panic disorder (25%, p <.01). Levels of functional impairment were higher for subjects with PTSD, depression, and somatization than for those without (p <.05). PTSD comorbid with depression compounded impairment (p =.04). Levels of trauma, PTSD, and depression did not increase service use or dissatisfaction with services. Clinicians did not identify trauma (0%) or psychopathology (0%), and psychotropic medication was prescribed for only 1% of participants. In this population, trauma and PTSD were highly prevalent and associated with significant unidentified morbidity and comorbidity. Patients remain untreated for years in the current system of primary care consultations.     

Traumatic events, posttraumatic stress disorder, attachment style, and working alliance in a sample of people with psychosis

There is a high incidence of trauma and posttraumatic stress disorder (PTSD) in people with a diagnosis of psychosis. Sequelae of trauma may affect the ability to engage in both attachment and therapeutic relationships. This study investigated associations between trauma histories, PTSD, attachment styles, and working alliance in a sample of 110 individuals with psychosis and substance misuse. Anxious attachment was associated with number of interpersonal traumas and PTSD reported, but there were no associations between trauma and alliance. There were discrepancies in number of traumatic events reported by care coordinators and patients. The findings of this study highlight the potential use of attachment theory in working with trauma and PTSD in psychosis.     

Traumatic memories of childbirth relate to maternal postpartum posttraumatic stress disorder

The trauma memory is a crucial feature of PTSD etiology and maintenance. Nonetheless, the nature of memories associated with childbirth-related posttraumatic stress disorder (CB-PTSD) requires explication. The present study, as part of a larger project on psychological outcomes of childbirth, utilized a multi-method approach to characterize childbirth memories in relation to CB-PTSD symptoms. We here assessed 413 women who completed self-report measures pertaining to CB-PTSD, postpartum depression, and childbirth memories. Additionally, a subset of 209 women provided written childbirth narratives, analyzed using Linguistic Inquiry and Word Count software. Women endorsing CB-PTSD symptoms on the PTSD-Checklist (PCL)-5 reported more incoherent childbirth memories with more emotional and sensory details, and more frequent involuntary recall and reliving of the memory. They also indicated the childbirth experience was more central to their identity. Written narratives in those with probable CB-PTSD were characterized by less (positive) affective processes, and more cognitive processes. We infer that childbirth memories in women who endorse symptoms of CB-PTSD in the early postpartum period resemble those described in the general PTSD literature. This suggests that childbirth may be experienced as traumatic and evoke a traumatic memory, implicated in symptom endorsement. Opportunities for therapeutic interventions modifying traumatic memories of childbirth in women at risk for CB-PTSD need to be investigated. Future research examining characteristics of traumatic childbirth memories is needed to advance our understanding of this overlooked postpartum condition.     

Childhood antecedents of exposure to traumatic events and posttraumatic stress disorder

OBJECTIVE: The authors prospectively examined childhood antecedents of exposure to traumatic events to estimate the risk of posttraumatic stress disorder (PTSD) among those exposed to trauma. METHOD: Two consecutive cohorts of children entering first grade of a public school system in a large mid-Atlantic city in the mid-1980s were followed into young adulthood (mean age=21). Exposure to traumatic events and PTSD were assessed in 75% of the original cohort (N=1,698). Childhood assessments, conducted upon entry into the first grade, included standardized measures of reading readiness, teacher ratings of behavioral problems, and child self-reports about depression and anxiety. Family characteristics were assessed by parental report. RESULTS: Young adults who had been rated by their first grade teacher as having aggressive/disruptive behavior problems were more likely to experience traumatic assaultive violence events (e.g., being mugged/threatened with a weapon, badly beaten-up) (relative risk=2.6) but not PTSD following trauma exposure. Youths with high levels of self-rated depressive and anxious feelings in first grade were more likely to experience PTSD once exposed to trauma (relative risk=1.5). Youths who scored in the highest quartile on a reading test in the first grade were at lower risk for exposure to assaultive violence traumas. CONCLUSIONS: Childhood behavioral and depressive/anxious problems may influence the risk for PTSD directly by increasing the vulnerability to the PTSD effects of trauma exposure, and indirectly by increasing the likelihood of exposure to assaultive violence.     

Imagery and posttraumatic stress disorder: an overview

A review of theories of traumatic neurosis or posttraumatic stress disorder reveals a relative neglect of the role of posttraumatic imagery. The broad range of imagery has not been recognized, nor its role in the disorder adequately formulated. A two-dimensional framework for understanding posttraumatic stress disorder based on 1) repetitions of trauma-related images, affects, somatic states, and actions and 2) defensive functioning puts into perspective the centrality of traumatic imagery, implies a reorganization of DSM-III criteria, points to new directions for research, and clarifies diagnostic and clinical confusion.     

Symptoms of depression and posttraumatic stress disorder in an outpatient population before and after Hurricane Katrina

The aim of the present investigation was to evaluate symptoms of depression and posttraumatic stress disorder (PTSD) in an outpatient psychiatric population before and after Hurricane Katrina. The sample consisted of 156 patients (110 females; M(age)=41.2 years, SD=10.9) at an outpatient psychiatric clinic who completed measures of psychological symptoms as part of their regular clinical care in the month before (n=76; 49%) and the 1 month after (n=80; 51%) Hurricane Katrina made landfall. Partially consistent with prediction, depression scores were significantly higher in the month following the hurricane, but PTSD scores were not significantly different. Depressive symptoms after the hurricane were predicted by watching television coverage of the looting that occurred in New Orleans and by the amount of time the participant was without electricity. Symptoms of PTSD after the hurricane were predicted by the participants' use of general television viewing as a coping strategy, the amount of time they spent watching television coverage of the looting in New Orleans, and the use of prayer as a coping behavior. Of these variables, only prayer was associated with a decrease in PTSD symptoms. Findings are discussed in relation to the need for collaborative efforts between clinically oriented and research-oriented institutions to study the impact of large-scale disasters on a variety of populations.     

Risk factors for premenstrual dysphoric disorder in a community sample of young women: the role of traumatic events and posttraumatic stress disorder

BACKGROUND: There is some evidence that the onset and course of premenstrual syndrome is related to stress; however, few studies have explored the role of traumatic events and post-traumatic stress disorder (PTSD) as risk factors for the development of premenstrual dysphoric disorder (PMDD). METHOD: A community cohort of 1488 women (aged 14-24 years at baseline) were prospectively and longitudinally evaluated up to 3 times over a period of about 42 months from 1995 to 1999. The DSM-IV version of the Munich-Composite International Diagnostic Interview was used to establish PMDD and PTSD diagnostic status; stressful life events and conditions were assessed with the Munich Events List and the Daily Hassles Scale. Prevalence and incidence of either threshold or subthreshold PMDD from baseline to the second follow-up were calculated. Risk factors, including prior comorbid mental disorders and traumatic events, were examined using logistic regression analysis. RESULTS: The incidence of threshold PMDD was 3.0%. The most powerful predictors were subthreshold PMDD at baseline (OR = 11.0, 95% CI = 4.7 to 25.9). Traumatic events greatly increased the odds of developing PMDD at follow-up (OR = 4.2, 95% CI = 1.2 to 12.0). Other predictors were a history of anxiety disorder (OR = 2.5, 95% CI = 1.1 to 5.5) and elevated daily hassles scores (OR = 1.6, 95% CI = 1.1 to 2.3). Both were also associated with the risk of developing subthreshold PMDD, although the association was less robust. CONCLUSIONS: Traumatic events and pre-existing anxiety disorders are risk factors for the development of PMDD. The underlying mechanisms are unknown, making further investigation necessary.