Recognizing increased risk of depressive comorbidity after myocardial infarction: looking for 4 symptoms of anxiety-depression

BACKGROUND: Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression. METHODS: One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD(4)) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness). RESULTS: Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD(4), alpha = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD(4)>or=3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6-12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0-42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0-27.6, p < 0.0001). CONCLUSIONS: Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD(4) represents an easy way to recognize the increased risk of post-MI depression.     

Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia

Background: Posttraumatic stress disorder (PTSD) is common in refugees but its association with longer-term psychosocial dysfunction remains unclear. We examined whether a subgroup of refugees with comorbid PTSD and depression were at particularly high risk of disability. We also investigated whether specific trauma experiences were linked to this comorbid pattern. Methods: Consecutive Bosnians (and one or two compatriots nominated by them) were recruited from a community centre, yielding a total sample of 126 participants (response rate 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) and the depression module of the Structured Clinical Interview (SCID) (First et al., 1997). Results: Three diagnostic groupings emerged: normals (n=39), pure PTSD (n=29), and comorbid PTSD and depression (n=58). Of four trauma dimensions derived from principle components analysis (human rights violations, dispossession and eviction, life threat and traumatic loss), life threat alone was associated with pure PTSD, with life threat and traumatic loss both being associated with comorbidity. Compared to normals and those with pure PTSD, the comorbid group manifested more severe PTSD symptoms as well as higher levels of disability on all indices (global dysfunction: odds RATIO=5.0, P<0.001, distress: odds RATIO=6.0, P<0.001, social impairment: odds ratio 5.9, P<0.001, and occupational disability: odds ratio 5.0, P<0.001). Limitations: Recruitment was not random, the sample size was modest, and trauma event endorsement was based on retrospective accounts. Conclusions: The combination of life threat and traumatic loss may be particularly undermining to the psychological well-being of refugees and consequent comorbidity of PTSD and depression may be associated with longer-term psychosocial dysfunction. The findings raise the question whether the comorbid pattern identified should be given more recognition as a core posttraumatic affective disorder.     

Comorbidity burden and its impact on psychosocial morbidity in depressed outpatients

BACKGROUND: Many studies have examined the co-occurrence of depression and one or two nondepressive disorders; however, little research has looked at broad spectrum comorbidity (i.e., comorbidity across several diagnostic categories) in depressed patients. Research on diagnostic practices in routine clinical settings--in which unstructured interviewing is the norm--suggests that comorbid conditions are often not detected [Zimmerman, M., Mattia, J. 1999. Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Compr. Psychiatry, 40, 182-191]. In this study we examined the independent impact of different comorbid diagnostic categories on psychosocial morbidity in psychiatric outpatients with Major Depressive Disorder (MDD). METHODS: Participants were drawn from a pool of 1000 psychiatric outpatients interviewed with the Structured Clinical Interview for DSM-IV diagnoses (SCID-IV; [First, M.B., Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1995. Structured Clinical Interview for DSM-IV (SCID). American Psychiatric Association, Washington, D.C.]). We compared the demographics, clinical characteristics, and psychosocial functioning of depressed outpatients with and without different axis I comorbidities, then conducted multivariate analyses to determine the respective impact of comorbid axis I disorders. RESULTS: Three hundred and seventy-three patients had a principal diagnosis of unipolar MDD. One hundred twenty-nine (34.6%) were diagnosed with MDD only, and 244 (65.4%) had MDD and at least one other axis I disorder. Comorbidity was associated with longer duration of index episode, more psychiatric morbidity, and more social and occupational impairment. There was also a significant relationship between increasing number of comorbid axis I disorders and greater psychiatric and psychosocial impairment. In regression analyses, comorbidity burden (i.e., the number of comorbid axis I disorders) showed the strongest relation to psychiatric and psychosocial impairment. LIMITATIONS: This is not a random sample of depressed outpatients and, thus, may not be generalizable to all outpatients with depression. Second, Axes II and III comorbidity were not assessed. CONCLUSIONS: Comorbidity burden showed the strongest relation to impairment over and above the presence of any particular class of disorders.     

The concept of post-traumatic mood disorder

Post-traumatic stress disorder (PTSD) is frequently comorbid with depression. A number of studies have been conducted to compare individuals suffering from comorbid PTSD and depression with individuals suffering from PTSD alone or depression alone. Comorbidity of PTSD and depression is associated with more severe symptoms as well as higher levels of disability compared to individuals with PTSD alone. A severity of overall symptoms is three to fivefold greater in subjects with comorbid PTSD and depression compared to those with PTSD alone. The comorbid group is five times more likely to manifest functional impairment compared to those diagnosed with PTSD alone. Patients with comorbid PTSD and depression have higher depression, impulsivity, and hostility scores and are significantly more likely to make a suicide attempt compared to subjects with depression alone. Depressed subjects with comorbid PTSD tend towards earlier age of first hospitalization and a higher number of hospitalizations compared to depressed individuals without comorbid PTSD. Lower affinity of alpha-2 adrenoreceptors and higher plasma tyrosine availability to the brain are associated with comorbid PTSD and depression, but not with PTSD alone. Individuals with comorbid PTSD and depression do not exhibit the classic rapid eye movement sleep architectural modifications associated with depression, despite the fact that several other psychophysiological indices of dysphoria are detectable in their sleep. In fenfluramine challenge studies, depressed patients with comorbid PTSD have lower plasma cortisol compared to depressed patients without comorbid PTSD. Cortisol levels increase with age and the number of previous major depressive episodes is a predictor of the cortisol response to fenfluramine administration in depressed patients without PTSD, but not in depressed patients with comorbid PTSD. Depressed subjects with comorbid PTSD have higher cerebrospinal fluid homovanillic acid levels compared with depressed subjects without comorbid PTSD. Thus, studies suggest that patients suffering from comorbid PTSD and depression differ clinically and biologically from individuals with PTSD alone or depression alone. It is possible that some or all individuals diagnosed with comorbid PTSD and depression have a separate psychobiological condition that can be termed "post-traumatic mood disorder". Future clinical and neurobiological studies may not only advance our understanding of the role of environmental and genetic factors in the etiology and pathogenesis of stress-related disorders, but also be useful in refining conceptions of stress-related disorders themselves and possible approaches to the treatment of these conditions.     

An exploration of comorbid depression among female victims of intimate partner violence with posttraumatic stress disorder

BACKGROUND AND METHODS: Factors contributing to posttraumatic stress disorder (PTSD) and comorbid major depression (MDD) were investigated among female victims of intimate partner violence (IPV). RESULTS: High levels of PTSD (75% of the sample) and MDD (54% of the sample) were observed. Individuals with both PTSD and MDD reported significantly greater levels of PTSD and depression symptoms than individuals with either PTSD alone or without major psychopathology. Individuals with comorbid PTSD and MDD had more maladaptive depressogenic cognitive styles than individuals without PTSD. The three groups were comparable in terms of pre-abuse mental health, childhood trauma history, and relationship violence variables and injuries. Maladaptive schemas did not contribute to the identification of comorbidity caseness, whereas PTSD severity and prior trauma did. Psychological aggression by an abuser and PTSD severity accounted for 52% of the variance in depressive symptoms. LIMITATIONS: Cross-sectional design and lack of trauma-specific cognitive measures. CONCLUSIONS: The findings confirm that comorbid PTSD and MDD is common among IPV victims. The mechanisms that contribute to comorbid depression, however, are unclear, and prospective studies are necessary to delineate the roles that psychological abuse, PTSD severity and prior trauma experiences may have in the development of depression following IPV.     

Posttraumatic stress disorder in outpatients with depression: Still a missed diagnosis

Comorbidity between major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) is a well-established fact but has been studied little among MDD patients and even less among outpatients. We assessed the prevalence and characteristics of comorbid MDD–PTSD patients in a sample of MDD outpatients in an effort to elucidate possible causes of MDD–PTSD comorbidity. A semistructured clinical interview was applied to 101 outpatients with MDD. Sociodemographic factors, psychiatric history, the presence of PTSD, and MDD–PTSD comorbidity were recorded. The prevalence of MDD–PTSD comorbidity was 38.6%, with 26.7% suffering currently from PTSD. The average duration of PTSD was 16 years, and in most cases (79.5%) PTSD started earlier than or simultaneously with MDD. Only 28.8% of patients with PTSD had a documented diagnosis in their medical record. The most significant factors predicting MDD–PTSD comorbidity were found to be chronic depression, a history of prolonged or repeated trauma, male gender, a younger age at onset of psychological symptoms, lower education, and a lower level of functioning. Our findings indicate that MDD–PTSD comorbidity still remains an overlooked fact. Prolonged trauma seems to be a major risk factor for MDD–PTSD comorbidity, predisposing subjects to PTSD and later on or simultaneously to comorbidity with MDD.     

Psychiatric treatment seeking and psychosocial impairment among young adults with depression

BACKGROUND: We report data on 1-year prevalence and comorbidity of depression, related impairment, treatment need, and psychiatric treatment among young adults. METHODS: A sample of young urban adults (n=245) mean age 21.8 years was screened from a baseline population of 706 high-school students and given a semistructured clinical interview to evaluate 12-month prevalence of depression, psychosocial functioning according to DSM-IV GAF scale, need for psychiatric treatment, and use of mental health services. RESULTS: One in 10 young adults suffered from depression with associated psychosocial impairment, the female-to-male-ratio being approximately 2:1. Most depressive disorders were comorbid with other DSM-IV disorders, depression usually occurring secondary to other disorders. Comorbidity was related to impairment, treatment need, and treatment contacts. Less than half of the depressed young adults had ever contacted mental health services, and less than one-third reported treatment contacts during the index episode. Males were less likely than females to report previous treatment contacts or intention to refer to mental health services for their problems, but treatment contacts during the index episode were reported equally often by both sexes. CONCLUSIONS: A minority of the severely depressed young adults with associated impairment had sought treatment. Except for subjects with dysthymia, no gender difference emerged in treatment contact rates during the 12-month depression episode. Comorbidity showed important clinical implications by its relation to severity of depression and treatment contacts.     

Etiology of depression comorbidity in combat-related PTSD: A review of the literature

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD–depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.     

A preliminary study of negative appraisals and dysfunctional coping associated with post‐traumatic stress disorder symptoms following myocardial infarction

Objectives . To investigate associations between post‐traumatic stress disorder (PTSD) symptoms following myocardial infarction (MI) and subjective experience of MI, negative perception of consequences, negative appraisals of symptoms, and use of dysfunctional coping strategies, as described by Ehlers and Clark's (2000) model of PTSD. Design . Cross‐sectional questionnaire study of people who experienced a MI within the previous 12 weeks (N = 74; 51% response rate). Methods . Participants completed questionnaires assessing PTSD symptoms, subjective experience of MI, perception of consequences, appraisal of symptoms, and dysfunctional coping strategies. Results . Of the participants, 16% met DSM‐IV criteria for PTSD and a further 18% reported moderate to severe PTSD symptoms. People with PTSD symptoms also had more somatic symptoms, anxiety, depression, and social dysfunction. PTSD symptoms were associated with perceived severity and danger of MI, a history of psychological problems, previous trauma, negative appraisal of symptoms, perceived severe consequences, and dysfunctional coping strategies. These variables were entered into a regression with MI and past history variables on Step 1, and appraisal and coping variables on Step 2. This showed that perceived consequences and dysfunctional coping were strongly associated with PTSD symptoms after controlling for MI and past history variables. Conclusion . The results of this preliminary study suggest perception of consequences and dysfunctional coping may be important in PTSD symptoms following MI.     

Repressive coping style,acute stress disorder,and posttraumatic stress disorder after myocardial infarction

OBJECTIVE: The study examined the associations between repressive coping style, acute stress disorder (ASD) and subsequent posttraumatic stress disorder (PTSD) after myocardial infarction (MI) to ascertain the efficacy of repressive coping style in immediate and long-term adjustment to stress. METHODS: A total of 116 MI patients were examined twice: within a week of their MI (time 1) and 7 months later (time 2). At time 1, repressive coping style, perceived threat, and ASD were measured by self-report questionnaires. In addition, medical measures indicative of the severity of the MI were obtained from patients' hospital records. At time 2, PTSD was assessed. The distribution of the repressive coping style was compared with that of 72 matched control subjects. RESULTS: Findings revealed the adaptiveness of repressive coping style both in the immediate and longer-term aftermath of MI: repressors endorsed less ASD and PTSD than nonrepressors. In addition, the contribution of repressive coping style to PTSD was unique and beyond the implications of severity of MI, perceived threat, and immediate ASD. CONCLUSIONS: The findings support the role of repressive coping style as a stress-buffer; several mechanisms that explain this role are suggested.     

Sexual dysfunction in male posttraumatic stress disorder patients

BACKGROUND: Previous studies have suggested that sexual dysfunction may be associated with posttraumatic stress disorder (PTSD). Yet such studies have not examined a full range of sexual functioning and have not accounted for the possibility that medication used to treat PTSD may contribute to sexual dysfunction. OBJECTIVE: The current study compares the various components of sexual functioning among three groups of males: (1) untreated PTSD patients (n = 15), (2) PTSD patients currently treated with selective serotonin reuptake inhibitor (SSRI) agents (n = 27) and (3) a group of normal controls (n = 49). METHODS: All participants completed an 18-item questionnaire for assessment of sexual functioning. Those with PTSD also completed the Impact of Events Scale and the Symptom Check List-90 (SCL-90). RESULTS: Untreated and treated PTSD patients had significantly poorer sexual functioning in all domains (desire, arousal, orgasm, activity and satisfaction) as compared to normal controls. Those treated with SSRI had greater impairment in desire, arousal and frequency of sexual activity with a partner. There was a high correlation between sexual dysfunction among the PTSD group and the anger-hostility subscale of the SCL-90. CONCLUSIONS: PTSD appears to be associated with pervasive sexual dysfunction that is exacerbated by treatment with SSRIs. PTSD may represent a heterogeneous syndrome. Patients with PTSD have a high rate of comorbid panic disorder, major depression and anxiety, and it could thus be argued that these comorbid disorders, rather than PTSD, accounted for the observed result. Future research aimed at understanding comorbidity and heterogeneity should help to illuminate the psychobiology of PTSD and eventually guide both medication and psychosocial treatments.     

Psychiatric comorbidity in veterans with chronic PTSD treated at Center for Crisis Intervention, Zagreb University Hospital Center

Epidemiological and clinical studies provide evidence that veterans with chronic PTSD can be at risk of relapse with respect to a number of high-risk behaviors, including attempted suicide, violence, and misuse of alcohol and drugs. AIM, PATIENTS AND METHODS: The aim of our study was to assess the prevalence of psychiatric comorbidity in veterans with chronic PTSD treated at Center for Crisis Intervention, Zagreb University Hospital Center, for 4 years. The diagnosis of PTSD and comorbid psychiatric diagnosis were confirmed according to DSM-IV criteria. RESULTS AND DISCUSSION: Study results showed PTSD without comorbid psychiatric diagnosis to persist in 25.3%, and PTSD with comorbid psychiatric diagnosis in 74.7% of study subjects. The most common psychiatric disorders were depression, personality disorders, and alcoholism. CONCLUSION: It is important to recognize other comorbid disorders because of the increased risk of suicidal behavior. Accordingly, therapeutic intervention should be adjusted to each individual case.     

Age effects on cortisol levels in depressed patients with and without comorbid post-traumatic stress disorder, and healthy volunteers

BACKGROUND: Post-traumatic stress disorder (PTSD) and major depression are frequently comorbid. Age and major depression are associated with higher cortisol levels and dexamethasone resistance, whereas PTSD is associated with lower cortisol and dexamethasone supersensitivity. Therefore, we examined the effect of age on the hypothalamic-pituitary-adrenal (HPA) system in depressed patients with and without PTSD. METHODS: Thirty-one depressed patients without PTSD, 12 depressed patients with PTSD, and 23 healthy volunteers were studied on 2 days. Subjects received single-blind placebo on day 1 and fenfluramine on day 2. Cortisol levels were drawn before challenge and for 5 h thereafter. RESULTS: Cortisol levels increase with age in depressed patients without PTSD but not in depressed patients with PTSD or in healthy volunteers. Number of previous major depressive episodes was a predictor of the cortisol response to fenfluramine administration in depressed patients without PTSD. CONCLUSIONS: The results of our study highlight the importance of considering age in psychobiology. Further research is needed to fully delineate the role of age in abnormalities of the HPA axis found in major depression and PTSD.     

Depression and anxiety as predictors of heart rate variability after myocardial infarction

BACKGROUND: Reduced heart rate variability (HRV) is a prognostic factor for cardiac mortality. Both depression and anxiety have been associated with increased risk for mortality in cardiac patients. Low HRV may act as an intermediary in this association. The present study examined to what extent depression and anxiety differently predict 24-h HRV indices recorded post-myocardial infarction (MI). METHOD: Ninety-three patients were recruited during hospitalization for MI and assessed on self-reported symptoms of depression and anxiety. Two months post-MI, patients were assessed on clinical diagnoses of lifetime depressive and anxiety disorder. Adequate 24-h ambulatory electrocardiography data were obtained from 82 patients on average 78 days post-MI. RESULTS: In unadjusted analyses, lifetime diagnoses of major depressive disorder was predictive of lower SDNN [standard deviation of all normal-to-normal (NN) intervals; beta=-0.26, p=0.022] and SDANN (standard deviation of all 5-min mean NN intervals; beta=0.25, p=0.023), and lifetime anxiety disorder of lower RMSSD (root mean square of successive differences; beta=-0.23, p=0.039). Depression and anxiety symptoms did not significantly predict HRV. After adjustment for age, sex, cardiac history and multi-vessel disease, lifetime depressive disorder was no longer predictive of HRV. Lifetime anxiety disorder predicted reduced high-frequency spectral power (beta=-0.22, p=0.039) and RMSSD (beta=-0.25, p=0.019), even after additional adjustment of anxiety symptoms. CONCLUSIONS: Clinical anxiety, but not depression, negatively influenced parasympathetic modulation of heart rate in post-MI patients. These findings elucidate the physiological mechanisms underlying anxiety as a risk factor for adverse outcomes, but also raise questions about the potential role of HRV as an intermediary between depression and post-MI prognosis.     

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.     

Platelet 5-HT concentration and comorbid depression in war veterans with and without posttraumatic stress disorder

BACKGROUND: The serotonergic system is implicated in the pathophysiology of posttraumatic stress disorder (PTSD) and depression. The present study focused on platelet serotonin (5-HT) concentration and symptoms of comorbid depression in war veterans with or without PTSD. METHODS: PTSD and depression were evaluated using Clinician Administered PTSD Scale, Davidson Trauma Scale, Montgomery-Asberg Depression Rating Scale and Hamilton Anxiety Scale. Sixty-five male drug-free war veterans (48 with PTSD and 17 without PTSD) and 65 age- and sex-matched healthy controls were studied. RESULTS: Comorbid depression occurred in 54 and 31% of war veterans with PTSD and without PTSD, respectively. Platelet 5-HT concentration was similar in the groups of depressed and nondepressed war veterans with or without PTSD and healthy controls. Platelet 5-HT concentration was found to differ between war veterans with various degrees of appetite loss. A positive correlation was observed between platelet 5-HT concentration and severity of appetite loss in veterans with PTSD. There was no relationship between platelet 5-HT concentration and severity of other symptoms of PTSD or depression. LIMITATIONS: War veterans included in the study were outpatients. CONCLUSIONS: War veterans with PTSD had a high incidence of comorbid depression, that was not related to platelet 5-HT concentration. The marked relationship between platelet 5-HT concentration and severity of appetite loss, suggested that 5-HT system is involved in the regulation of appetite, at least in depressed war veterans with PTSD.     

Impact of PTSD comorbidity on one-year outcomes in a depression trial

Low-income African American, Latino, and White women were screened and recruited for a depression treatment trial in social service and family planning settings. Those meeting full criteria for major depression (MDD; N = 267) were randomized to cognitive-behavior therapy (CBT), antidepressant medication, or community mental health referral. All randomly assigned participants were evaluated by baseline telephone and clinical interview, and followed by telephone for one year. Posttraumatic stress disorder (PTSD) comorbidity was assessed at baseline and one-year follow-up in a clinical interview. At baseline, 33% of the depressed women had current comorbid PTSD. These participants had more exposure to assaultive violence, had higher levels of depression and anxiety, and were more functionally impaired than women with depression alone. Depression in both groups improved over the course of one year, but the PTSD subgroup remained more impaired throughout the one-year follow-up period. Thus, evidence-based treatments (antidepressant medication or structured psychotherapy) decrease depression regardless of PTSD comorbidity, but women with PTSD were more distressed and impaired throughout. Including direct treatment of PTSD associated with interpersonal violence may be more effective in alleviating depression in those with both diagnoses.     

Etiopathogenic perspectives on chronic psycho traumatic and chronic psychotic symptoms: The hypothesis of a hyperdopaminergic endophenotype of PTSD

Post traumatic stress disorder (PTSD) is a complex and heterogeneous disorder, which specific symptoms are re-experiencing, increased arousal and avoidance of stimuli associated with the trauma. PTSD has much comorbidity like depression, substance abuse, somatic complaints, repeated dissociative phenomena and transitory or chronic psychotic reactions. PTSD can manifest itself in different clinical forms: some patients present higher symptoms in one domain as compared to another, probably because of abnormalities in different neurobiological systems. Hyposerotonergic and hypernoradrenergic PTSD endophenotypes have been previously identified and the purpose of this paper is to focus on the hypothesis of a hyperdopaminergic endophenotype. The current review discusses several entities: PTSD with psychotic features with or without depression, the comorbide use of psychoactive substances that increase psychotic symptoms and traumatic brain injuries as agents of psycho traumatic and psychotic features. For all of these nosographic entities, the dopaminergic neuromodulation may play a central role. The hypothesis of a hyperdopaminergic endophenotype of PTSD opens up new research and therapeutic perspectives. Although antipsychotics are frequently used for people with PTSD further studies are needed to develop a consensus on the guidelines for treating the psychotic forms of PTSD.     

Symptoms of posttraumatic stress disorder in patients who have had a myocardial infarction

Symptoms of posttraumatic stress disorder (PTSD) and risk factors for recurrent ischemia were evaluated in 65 survivors of a myocardial infarction (MI) at baseline and 6 months afterward. PTSD patients had more uncontrolled cardiovascular risk factors at baseline. Patients with PTSD (N=14) were offered trauma-focused cognitive-behavior treatment (CBT) plus a nonspecific intervention to improve adherence to medical recommendations. Adherence to aspirin improved in recipients of the nonspecific intervention (N=8); PTSD symptoms and cardiovascular risk improved in patients who received CBT (N=6). PTSD may be a treatable risk factor for poor post-MI outcome. Further research is needed to evaluate treatment options.     

Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse

Studies have shown differences in neuropsychological functioning between groups with posttraumatic stress disorder (PTSD) and control participants. Because individuals with PTSD often have a history of comorbid alcohol abuse, the extent to which an alcohol confound is responsible for these differences remains a concern. The current study compares neuropsychological testing scores in 4 groups of veterans with and without PTSD (PTSD+ and PTSD-, respectively) and with and without a history of alcohol abuse (ETOH+ and ETOH-, respectively): n for PTSD+/ETOH- = 30, n for PTSD+/ETOH- = 37, n for PTSD-/ETOH+ = 30, and n for PTSD-/ETOH- = 31. Results showed that PTSD, when alcohol, educational level, vocabulary, and depression are controlled for, was associated with decreased verbal memory, attention, and processing speed performance. Alcohol abuse history was associated with decreased visual memory performance. By controlling for alcohol and depression, the authors can more conclusively demonstrate that verbal memory and attention differences are associated with PTSD.