Posttraumatic stress disorder: an evidence-based approach

The interventions used in the clinical management of posttraumatic stress disorder (PTSD) focus on: 1. Prevention of the development of the disorder, after a traumatic event 2. Treatment of the disorder, once it is already established, 3. Maintenance of long term functioning and quality of life. A variety of psychotherapies and pharmacological treatments have been proposed as therapeutic options in the treatment of PTSD. However, many of these treatment modalities lack scientific background. In this article authors present the treatment modalities of PTSD which are supported by scientific evidence and discuss its applications and drawbacks.     

Posttraumatic stress disorder

The authors review posttraumatic stress disorder in terms of clinical features, historical development and phenomenology, and relationship to other psychiatric disorders. Treatment modalities are detailed.     

Posttraumatic stress disorder after pre-eclampsia: an exploratory study

Information about the psychological sequelae of pre-eclampsia (PE) is scarce. Post-traumatic stress disorder (PTSD) may develop after exposure to a stress condition. This study explored whether PE predisposes to PTSD in patients and their partners. Primiparas with a recent history of preterm PE (n=18), preterm birth (PT; n=29), term PE (n=23), or uneventful term birth (C; n=43), and most of their partners completed questionnaires measuring PTSD, depression and related psychological factors. About one-fourth of patients developed PTSD after preterm PE as well as after PT. It occurred in 17% after term PE and in none of the control subjects. A substantial minority of partners was also affected. PTSD symptoms were strongly related to individual psychological characteristics (peritraumatic dissociation, negative interpretations of symptoms, and thought suppression) rather than to objective indicators of condition-severity. The data suggest that PE predisposes to PTSD, primarily but not exclusively resulting from concomitant preterm birth.     

Posttraumatic stress disorder: diagnostic criteria

This article reviews aspects of the clinical characterization of the Postttraumatic Stress Disorder (PTSD). The disgnostic criteria used in DSM-IV and ICD-10 are presented. The Acute Reaction to Stress is defined and contrasted to the operational criteria which define the PTSD. The importance of the partial expression of the PTSD syndrome in victims of trauma is highlighted. Systematic studies within this patient population is characterized as a unmet need in public health. Addressing such a need is a major step towards the proper diagnosis and treatment of this clinical syndrome.     

Maintenance of an insanity defense under Montana's "abolition" of the insanity defense

In 1979, Montana's insanity defense was replaced with the more restrictive mens rea defense, a change that has been described as an example of "abolition" of the insanity defense. The authors identified cases in which mental health was an issue in seven Montana counties for 3 years before and 3 years after the 1979 reform. They found that acquittals based on the insanity plea markedly declined, but that dismissals based on incompetence to stand trial increased substantially following the reform. They conclude that dismissal based on incompetence to stand trial became a substitute for acquittal based on the insanity plea under mens rea.     

Posttraumatic stress disorder six months after an earthquake

Background and aims  Various studies assessed rates of post-traumatic stress disorder (PTSD) following natural disasters including earthquakes. Yet, samples were often non-representative or small or both. This study aims to assess the prevalence of PTSD and predictors of PTSD 6 months after an earthquake in a rural region of Italy. Methods  A questionnaire was handed out to a representative sample of approximate 3,000 people in the region of Molise in Italy 6 months after an earthquake in October/November 2002. The questionnaire assessed socio-demographic characteristics, aspects of the event, the experience of symptoms immediately after the earthquake, and symptoms of PTSD. Results  Questionnaires of 2,148 people were returned, representing a response rate of 73.7%. The final analysis was based on 1,680 people. The screening tool provided a PTSD prevalence rate of 14.5%. Male gender, age under 55 years, and better school education predicted lower rates of PTSD. More variance was explained when psychological symptoms of immediately after the event were also included as predictors. Conclusion  The findings on predictors are consistent with the literature. Whilst personal characteristics explain only a small variance of PTSD six months after the event, early psychological distress allows a better prediction of who is likely to have PTSD 6 months later.     

Posttraumatic stress disorder among children clinically diagnosed as borderline personality disorder

Using the Diagnostic Interview for Children and Adolescents, Revised Version (DICA-C-R), the authors evaluated 19 children ages 7 to 14 who had recently been clinically diagnosed as borderline personality disorder by DSM-III-R criteria. The results reveal that 78.9% of these children reported significant traumatic experiences, with 36.8% fitting DICA-C-R criteria for posttraumatic stress disorder. These findings raise the possibility that a diagnosis of borderline personality in childhood can often represent posttraumatic stress disorder.     

Posttraumatic stress disorder: the psychoanalytic approach

The authors approach the posttraumatic stress disorder according to its importance within the epidemiologic studies and public health figures. A brief history on how the concepts of psychic trauma developed within psychoanalysis is presented. The importance given by Freud to traumatic events as a determinant of neurosis is revisited. Trauma is discussed as part of the internal world perspective and not as dependent upon the external events. The importance of the use of psychoanalytic techniques to treat some cases of PTSD is highlighted.     

Posttraumatic stress disorder: the stressor criterion

Posttraumatic stress disorder (PTSD) was officially introduced into psychiatric nomenclature in 1980, when it was incorporated into DSM-III. There is as yet little empirical research on the validity of the diagnosis. Literature on disasters, civilian and wartime, and on more ordinary stressful life events does not support the view that extreme stressors form a discrete class of stressors in terms of the probability of psychiatric sequelae or the distinctive nature of subsequent psychopathology. Extraordinary stressors are like more ordinary stressful events with respect to their complex differential effects upon individuals. Personal characteristics and the nature of the social environment modify the likelihood and form of the response of individuals to all types of stressors.     

Posttraumatic stress disorder as a result of mass trauma

There is a large body of literature on the psychological consequences of trauma experienced by individuals, but there are few studies of the acute and long-term effects of mass trauma on victimized communities. Acute stress reactions are expected, and overall resilience in the aftermath of major disasters is the rule rather than the exception. However, the available literature on mass trauma suggests that certain factors may provide clues to identifying persons at greater risk for posttraumatic stress disorder (PTSD). The severity of the trauma and the accessibility of support systems may affect long-term outcome. In industrialized countries, mass violence caused by malicious human intent may be a more virulent precursor to PTSD than other types of mass trauma, such as technological or natural disasters. School-aged children, women, persons with existing psychiatric illness, those who experienced significant losses or threat to life, those who have insufficient psychological and social support systems, and persons who exhibit symptoms of functional impairment may be at greater risk for PTSD. The findings of a population study of 2 traumatized communities are discussed. Early intervention in communities suffering mass trauma should consist of general support and bolstering of the recovery environment rather than psychological treatment; some forms of early psychological interventions may worsen outcome. There is a great unmet need for treatment and intervention guidelines for victims of mass trauma, and well-designed studies are warranted.     

Posttraumatic stress disorder: a state-of-the-science review

This article reviews the state-of-the-art research in posttraumatic stress disorder (PTSD) from several perspectives: (1) Sex differences: PTSD is more frequent among women, who tend to have different types of precipitating traumas and higher rates of comorbid panic disorder and agoraphobia than do men. (2) Risk and resilience: The presence of Group C symptoms after exposure to a disaster or act of terrorism may predict the development of PTSD as well as comorbid diagnoses. (3) Impact of trauma in early life: Persistent increases in CRF concentration are associated with early life trauma and PTSD, and may be reversed with paroxetine treatment. (4) Imaging studies: Intriguing findings in treated and untreated depressed patients may serve as a paradigm of failed brain adaptation to chronic emotional stress and anxiety disorders. (5) Neural circuits and memory: Hippocampal volume appears to be selectively decreased and hippocampal function impaired among PTSD patients. (6) Cognitive behavioral approaches: Prolonged exposure therapy, a readily disseminated treatment modality, is effective in modifying the negative cognitions that are frequent among PTSD patients. In the future, it would be useful to assess the validity of the PTSD construct, elucidate genetic and experiential contributing factors (and their complex interrelationships), clarify the mechanisms of action for different treatments used in PTSD, discover ways to predict which treatments (or treatment combinations) will be successful for a given individual, develop an operational definition of remission in PTSD, and explore ways to disseminate effective evidence-based treatments for this condition.     

Posttraumatic stress disorder: characteristics and treatment

This Distance Rounds reviews the DSM-IV definition of posttraumatic stress disorder (PTSD) and associated features. PTSD is a prevalent mental health problem that occurs in some people after combat or civilian trauma and is influenced by certain risk factors. Psychotherapy and pharmacotherapy have both been found efficacious, and treatment selection should be tailored to the individual patient. Pharmacotherapy options include selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, atypical antipsychotics, mood stabilizers, and medications for trauma-related nightmares. Treatment often involves multiple modalities.     

Posttraumatic stress disorder and blindness

Four cases of posttraumatic stress disorder in blind patients are described. They demonstrate the importance of visual imagery in the processing of traumatic events and highlight the disruption of selective attention in this disorder.     

Posttraumatic stress disorder and bipolar mood disorder

Bipolar disorder (BD) is not only an endogenous condition. Severe negative life events have been shown to influence the development of the first episode and lifetime course of BD. Posttraumatic stress disorder (PTSD) is a severe and incapacitating mental condition that affect a significant proportion of the general population at some time in their lives. The concomitant presence of BD and PTSD has been shown to be more frequent than previously suggested and psychotic patients with trauma histories have a tendency to present more severe symptoms and are more proned to present substance use disorders. Trauma-related intrusive memories and nightmares of PTSD have been associated with mood changes. Also, kindling and behavioral sensitization have been proposed to explain the etiology and course of both disorders. Pharmacological approaches for this comorbidity are still based on empirical or not controlled approaches. In this article, we critically review the current literature regarding this co morbid condition, and highlight some aspects related to epidemiology, etiology, course and pharmacological treatment of both disorders. Overall, our review emphasizes the importance of systematically evaluate trauma histories in patients with BD.     

Posttraumatic stress disorder as a consequence of the POW experience

To estimate the relative contributions of trauma and premorbid disposition in the development and persistence of posttraumatic stress disorder (PTSD) symptoms, we conducted structured psychiatric interviews of 62 former World War II POWs. Half these men satisfied DSM-III criteria for PTSD in the year following repatriation. Eighteen (29%) continued to meet the criteria for PTSD 40 years later. Family history of mental illness and preexisting psychopathology were at best only weakly correlated with persistent PTSD symptoms. The strongest predictors of PTSD were proportion of body weight lost and the experience of torture during captivity. This study demonstrates that former POWs frequently develop posttraumatic stress disorder and that for one half of those who develop the symptoms, they persist for over 40 years. Familial risk factors and preexisting psychopathology are superseded by the overwhelming nature of the trauma. The persistence of the symptoms for many years is a reflection of the severity of the trauma.