Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors

OBJECTIVE: To describe rates and concordance of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in adolescent childhood cancer survivors and their mothers and fathers. METHOD: Participants were 150 adolescent survivors of childhood cancer, 146 mothers, and 103 fathers who completed the Impact of Events Scale-Revised, the Posttraumatic Stress Disorder Reaction Index, and the PTSD module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. RESULTS: PTSS are common in families of childhood cancer survivors. Parents reported more symptomatology than former patients. Mothers and fathers had relatively equal rates of current PTSD and levels of PTSS. Nearly 30% of mothers met diagnostic criteria since their child's diagnosis, with 13.7% currently experiencing PTSD. Nearly 20% of families had at least one parent with current PTSD. Ninety-nine percent of the sample had at least one family member reexperiencing symptoms. CONCLUSIONS: Both PTSD and PTSS help in understanding the experience of adolescent cancer survivors and their families. Within families of childhood cancer survivors, it is likely that some member may be experiencing treatable bothersome memories, arousal, or avoidance specific to the cancer experience.     

Brief report: post-traumatic stress during emerging adulthood in survivors of pediatric cancer

OBJECTIVE: To examine post-traumatic stress symptoms (PTSS) and disorder (PTSD) among survivors of childhood cancer and comparison peers during the transition to emerging adulthood. METHOD: From elementary and middle school, we prospectively followed a cohort of 56 cancer survivors, 60 comparison peers, and their parents. Assessments were completed after the youth's 18th birthday using questionnaires and a semi-structured psychiatric interview. Healthcare providers rated treatment severity and late effects. RESULTS: Survivors and comparison peers did not differ on rates of PTSS or PTSD, but comparison peers reported more dissociative experiences than survivors. Late effects were associated with a greater number of past PTSS. Of the 16 cancer survivors who reported a traumatic event, five (31%) were cancer-related. CONCLUSIONS: Levels of PTSS were similar for survivors and comparison peers. Research with other potentially traumatic diseases or treatments (e.g., amputations, brain tumors) is needed. The role of methodology and contextual factors in the assessment of PTSS/PTSD is discussed.     

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

Objective To examine posttraumatic stress symptoms (PTSS) inparents of children with cancer as a function of time sincediagnosis, treatment status, and relapse history, and as comparedto parents of healthy children. Method Participants includedparents of 199 children with cancer, comprising a cross-sectionalsample of diagnoses and treatment phases, ranging from currentlyon therapy to long-term survivors, and 108 parents of healthychildren obtained via acquaintance control methods. Parentscompleted a standardized self-report measure of PTSS. ResultsWithin the cancer group, parental report of PTSS differed asa function of treatment status and time since diagnosis. Parentsof children on active treatment endorsed similar levels of PTSSas control parents, whereas parents of children off treatmentreported significantly lower levels of PTSS than did controls.Similarly, parents of long-term survivors reported significantlylower levels of PTSS than did controls, while parents of recentlydiagnosed children did not differ from controls on PTSS. Incontrast, parents of children who had suffered a relapse reportedsignificantly higher levels of PTSS, and were much more likelyto be identified as a posttraumatic stress disorder (PTSD) case.Conclusions As a group, parents of children with cancer didnot demonstrate any evidence of increased PTSS relative to parentsof healthy children. Time since diagnosis, child treatment status,and relapse history are significant determinants of parent PTSS.Only parents of children who experienced a relapse appear tobe at increased risk of PTSD. The current results appear discrepantfrom the existing literature, and possible explanations forthese discrepancies are examined.     

Posttraumatic growth in adolescent survivors of cancer and their mothers and fathers

OBJECTIVE: To describe posttraumatic growth (PTG) following childhood cancer survival and its association with demographic and disease/treatment variables, perceived treatment severity and life threat, and posttraumatic stress symptoms (PTSS). METHOD: Adolescent survivors of cancer (N = 150, ages 11-19), at least 1 year after treatment, and their mothers (N = 146) and fathers (N = 107) completed self-report measures of perceived treatment intensity and PTSS and a semistructured interview designed to identify posttraumatic responses and indicators of PTG including perceived positive changes for self, relationships, and life goals. RESULTS: A majority of adolescents and their mothers and fathers reported PTG. Greater perceived treatment severity and life threat, but not objective disease severity, was associated with PTG. PTG and PTSS were positively associated for the adolescent cancer survivors. Diagnosis after age 5 resulted in more perceived benefit and greater PTSS for adolescent survivors. CONCLUSION: Clarification of the concept and measurement of PTG after childhood cancer is warranted, as are prospective studies of the association of PTG and PTSS and the role of demographic variables and illness-specific appraisals.     

Parental distress during pediatric leukemia and posttraumatic stress symptoms (PTSS) after treatment ends

OBJECTIVE: To evaluate prospectively the association between parental anxiety during treatment for childhood leukemia and posttraumatic stress symptoms (PTSS) after treatment ends. A secondary goal is to explore concurrent variables associated with parental avoidance after treatment ends. METHODS: This is a longitudinal follow-up study of 113 parents of children treated for leukemia who previously participated in a study of procedural distress during treatment. Data included parental self-report questionnaires completed during treatment and after treatment. RESULTS: Using hierarchical multiple regression, we found anxiety during treatment to be a significant predictor of later PTSS for mothers, but not fathers. Anxiety, self-efficacy, posttraumatic growth and length of time since treatment ended were associated with parental avoidance. CONCLUSIONS: Highly anxious parents are at risk for PTSS and may benefit from approaches that decrease anxiety during treatment and afterward. Enhancing self-efficacy related to follow-up care and identifying positive aspects of the traumatic experiences are suggested as treatment approaches for families after cancer treatment.     

Families Surviving Childhood Cancerf: A Comparison of Posttraumatic Stress Symptoms with Families of Healthy Children

Compared posttraumatic stress symptoms in 309 8-to 20-year-oldsurvivors of childhood cancer and their parents with healthychildren and their parents who responded to child-related stressors.The relationship of child demographic, cancer and treatment,and family and social support factors with posttraumatic stresssymptoms was analyzed also. Results indicate that mothers andfathers of childhood cancer survivors showed significantly higherlevels of posttraumatic stress symptoms than comparison parents.The survivors themselves did not differ from their healthy counterparts.Past perceived life threat and family and social support resourcescontributed to posttraumatic stress symptoms in survivors andtheir parents. Survivor mother and child and survivor fatherand child symptoms were associated. Implications for the long-termfunctioning of families of survivors and suggestions for preventiveinterventions are discussed.     

Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care

Symptoms of depression and posttraumatic stress are among the most studied psychological difficulties among soldiers. Such symptoms have been linked to a history of adverse events among both civilians and combat veterans. There is a paucity of research on this topic that can be applied to an active duty clinical population. Intake screening data were reviewed for 1,626 soldiers presenting to an outpatient mental health clinic to identify variables, including history of potentially traumatic experiences, associated with screened symptoms of posttraumatic stress disorder (PTSD) and depression. Demographics such as age, gender, and military rank, as well as number of adverse childhood experiences were significant predictors of screened PTSD and depression. A history of deployment to a combat zone predicted screened PTSD, but not depression. The role of childhood abuse as a risk factor is discussed and highlighted in the etiology of symptoms for soldiers seeking mental health care.     

PTSD after traumatic injury: an investigation of the impact of injury severity and peritraumatic moderators

Presence of injury is often examined as a risk factor for posttraumatic stress disorder (PTSD); however, results have been mixed regarding the relationship between injury severity and PTSD symptoms (PTSS). The present study examined subjective and objective injury severity ratings in traumatic injury victims to determine if they differentially predict PTSS. Results demonstrated that subjective, not objective, injury severity predicted PTSS at six weeks and three months post-trauma. The moderating impact of peritraumatic factors was also examined. Peritraumatic dissociation moderated the impact of subjective injury severity on PTSS. Findings indicate that subjective injury severity should be incorporated into early screeners for PTSD risk.     

Brief report: the impact of maternal posttraumatic stress disorder symptoms and child gender on risk for persistent posttraumatic stress disorder symptoms in child trauma victims

OBJECTIVE: To longitudinally examine the impact of maternal posttraumatic stress disorder symptoms (PTSS) on child adjustment following a child's traumatic injury, focusing on child gender differences. METHODS: Forty-one child traumatic injury victims aged 8-18 years and their biological mothers were interviewed over two follow-ups (6 weeks and 7 months). Children were administered the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale for Children and Adolescents (CAPS-CA), whereas mothers completed the CAPS. RESULTS: Six weeks post trauma, maternal PTSS were significantly related to PTSS in boys but not in girls. However, at 7 months, maternal PTSS were strongly related to child PTSS in both boys and girls. Significant 6-week maternal distress-child gender interactions suggested that maternal PTSS, especially avoidance, predicted greater 7-month PTSS but that this was primarily because of a significant relationship in females. CONCLUSIONS: Maternal distress was found to negatively impact subsequent child adjustment, particularly in females. These results underscore the importance of considering family-centered interventions for child PTSD, especially in girls.     

Trauma spectrum adaptation: somatic symptoms in long-term pediatric cancer survivors

The authors assessed somatic symptoms and the degree of association among somatic symptoms, global adjustment, trauma symptoms, and personality characteristics in long-term pediatric cancer survivors. Forty cancer survivors completed self-report questionnaires and clinical interviews. Participants' level of somatic symptoms fell between nonclinic and psychiatric populations. Somatic symptom scores correlated with general adjustment in the negative direction and with posttraumatic stress disorder (PTSD) scores in the positive direction. The majority of participants met at least partial current PTSD criteria. Because these survivors demonstrate a repressive adaptive style but endorse somatic symptoms, the latter may represent a method for detecting trauma-related distress in this population.     

Identity in adolescent survivors of childhood cancer

OBJECTIVE: To investigate identify formation among adolescent survivors of childhood cancer. Family functioning, perceived emotional support from family and peers, life stress, and anxiety produced by the cancer experience also were examined as they influenced identity development. METHOD: Participants were 52 adolescent survivors and their mothers recruited from a medical center and 42 healthy adolescent counterparts and their mothers recruited from the community. RESULTS: A greater frequency of survivors than their healthy peers was found within the foreclosed identity status. Factors associated with the foreclosed identity status included the cancer diagnosis, symptoms of posttraumatic stress disorder (PTSD), and family functioning characterized by greater levels of conflict. CONCLUSIONS: Data were interpreted to suggest that the foreclosed identity status may serve a protective function in assisting survivors to cope with the stressors of the cancer experience.     

Posttraumatic Stress Disorder Among Mothers of Pediatric Cancer Survivors: Diagnosis, Comorbidity, and Utility of the PTSD Checklist as a Screening Instrument

Objective: To examine posttraumatic stress disorder (PTSD) inmothers of survivors of childhood cancer. Comorbidity of anxietyand depressive disorders, prevalence of subclinical PTSD, andthe utility of a self report measure as a screening instrumentfor PTSD were also investigated. Method: Mothers (n = 65) completed a questionnaire self-reportPTSD checklist (PCL-C). Mothers were administered several modulesof the SCID: nonpatient edition by telephone, including thePTSD, Generalized Anxiety, and Major Depressive Disorder modules. Results: We diagnosed 6.2% of the sample with current PTSD.An additional 20% had subclinical PTSD. One of four motherswith PTSD diagnoses had a comorbid diagnosis of an anxiety anddepressive disorder. The PCL-C evidenced diagnostic utilityas a screening instrument. However, a moderate number of false-positiveswould result if the recommended cut-off on the instrument wasused. Conclusions: The PCL-C had diagnostic utility in screening mothersof childhood cancer survivors. The presence of comorbid diagnosessuch as anxiety and depression should be examined.     

Sense of coherence moderates late effects of early childhood Holocaust exposure

This study evaluated child Holocaust survivors with an emphasis on potential protective factors facilitating participants' adaptation to post-Holocaust life. We examined Antonovsky's (1979, 1987) salutogenic paradigm, testing the mediating and moderating effect of participants' sense of coherence (SOC) on the association between early childhood deprivation due to Holocaust persecution and posttraumatic stress later in life. The nonclinical sample, composed of 203 child Holocaust survivors born between 1935 and 1944 completed questionnaires on Holocaust survival exposure, inventories on current health, posttraumatic stress, and SOC. The results indicated that SOC moderates the association between traumatic experiences during the war and posttraumatic stress, and SOC acts as a protective factor, buffering the impact of traumatic Holocaust experiences on child survivors in old age. Survivors with a less coherent perspective on the meaning of their life showed greater vulnerability for posttraumatic complaints. The moderating role of the SOC may suggest promising avenues of therapeutic interventions for child Holocaust survivors and other adults with early childhood trauma.     

Secondary traumatization and attachment among wives of former POWs: a longitudinal study

The aim of the present study was to examine the directionality of the association between post-traumatic stress symptoms (PTSS) and attachment insecurities across time among indirect trauma survivors. Wives of former prisoners of war (ex-POWs), with and without post-traumatic stress disorder (PTSD), and comparable controls were assessed 30 (T1) and 38 (T2) years after the Yom Kippur War. As expected, wives of ex-POWs endorsed higher PTSS compared to wives of controls. Wives of ex-POWs with PTSD endorsed higher PTSS and higher attachment avoidance compared to wives of ex-POWs without PTSD and controls. There were significant associations between PTSS and attachment insecurities. Contrary to the hypothesis, the relationship between PTSS and attachment insecurities among wives of ex-POWs was unidirectional, with attachment anxiety at T1 predicting PTSS at T2, and not vice versa. Results indicate that attachment anxiety might act as a risk factor for secondary traumatic reactions.     

Posttraumatic stress and related impairment in survivors of childhood cancer in early adulthood compared to healthy peers

OBJECTIVE: To compare rates of posttraumatic stress disorder (PTSD) and related impairment between childhood cancer survivors in early adulthood and healthy peers. METHODS: Cancer survivors (n = 57) and comparison group (n = 83) completed measures of PTSD, depression, health-related quality of life (HRQOL), mood, and satisfaction with life (SWL). RESULTS: The cancer survivor group was more likely to have PTSD than the control group (odds ratio = 4.67, p < .05) but was not more likely to experience subclinical PTSD symptoms. The groups differed on physical HRQOL, F(1, 140) = 15.02, p < .001, and positive affect, F(1, 140) = 7.03, p < .01, but did not differ on depression, SWL, psychosocial HRQOL, and negative mood. Those in the survivor group with PTSD (n = 10) experienced more depression and negative affect, worse HRQOL and SWL, perceived their cancer to impact developmental tasks more, and were older at the time of diagnosis compared with those without PTSD (n = 47). CONCLUSIONS: Although most are well adjusted, childhood cancer survivors in early adulthood are more likely to have PTSD and to experience significant impairment compared with healthy peers.     

Posttraumatic stress symptoms in parents of children with acute burns

OBJECTIVE: To develop a model of risk factors for posttraumatic stress disorder (PTSD) symptoms in parents of children with burns. METHODS: Immediately following the burn and 3 months later, parents reported on their children's and their own psychological functioning and traumatic stress responses. RESULTS: Approximately 47% of the parents reported experiencing significant posttraumatic stress symptoms 3 months after the burn. Our model indicates three independent pathways to PTSD symptoms (i.e., parent-child conflict, parents' dissociation, and children's PTSD symptoms). Additionally, parents' anxiety predicted increased parent-child conflict, conflict with extended family and size of the burn predicted parents' dissociation, and size of the burn and children's dissociation predicted children's PTSD symptoms. CONCLUSIONS: This study suggests that many parents of children with burns suffer from posttraumatic stress symptoms. Interventions that target factors such as family conflict, children's symptoms, and parents' acute anxiety and dissociation may diminish the risk for PTSD.     

The Relationship of Psychological Trauma and Dissociative and Posttraumatic Stress Disorders to Nonsuicidal Self-Injury and Suicidality: A Review

We reviewed research on the relationship between (a) exposure to psychological trauma and (b) nonsuicidal self-injury (NSSI) and suicidality (suicidal ideation [SI] and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the special issue of the Journal of Trauma & Dissociation on these topics. Exposure to childhood sexual abuse is the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also are associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with a discussion of implications for clinical practice and future directions for scientific research.     

The relation of PTSD symptoms to migraine and headache-related disability among substance dependent inpatients

Despite emerging evidence for the comorbidity of posttraumatic stress disorder (PTSD) and migraine, few studies have examined the relation of PTSD and migraine, particularly among clinical populations at-risk for both conditions (e.g., substance-dependent patients). This study examined the role of PTSD symptoms in migraine and headache-related disability within a sample of 153 substance-dependent inpatients (37.25 % female, Mean age 36.46). PTSD symptoms predicted both migraine and headache-related disability above and beyond gender, depression and anxiety symptoms, the experience of a Criterion A traumatic event, and current alcohol use disorder. Findings highlight the strong association between migraine and PTSD symptoms in a unique population at risk for both conditions.     

Affect management in group therapy for women with posttraumatic stress disorder and histories of childhood sexual abuse

Affect dysregulation is pervasive among women with histories of childhood sexual abuse. It is an important aspect of the clinical presentation of posttraumatic stress disorder (PTSD), a disorder that frequently characterizes survivors of childhood abuse. Based on distinctions between approach and avoidance orientations to coping, there is controversy regarding whether initial treatment for trauma survivors should employ an exposure-based approach to increase affect or an affect-management approach to reduce it. In this article, we review theoretical and empirical literature regarding affect dysregulation and its relations with childhood sexual abuse and PTSD. We then describe a new affect-management group for adult survivors of childhood sexual abuse that is based on a stage approach to the treatment of trauma. This group emphasizes skill acquisition, symptom reduction, and patient stabilization. Affect-management strategies such as mindfulness, crisis planning, and challenging distorted thinking are presented to patients. Preliminary research findings support the use of this treatment.     

Unresolved attachment, PTSD, and dissociation in women with childhood abuse histories

The primary objective of this study was to examine unresolved trauma as assessed by the Adult Attachment Interview and current psychiatric symptoms, focusing on posttraumatic stress disorder (PTSD) and dissociation, in a group of adult female childhood abuse survivors. The authors examined psychiatric symptoms and attachment representations in a group with (n = 30) and without (n = 30) abuse-related PTSD. The findings revealed that unresolved trauma carried a 7.5-fold increase in the likelihood of being diagnosed with PTSD and was most strongly associated with PTSD avoidant symptoms rather than dissociative symptoms. The utility of a PTSD framework for understanding unresolved trauma and the role of intentional avoidance of trauma cues in the maintenance of traumatized states of mind are discussed.