On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice

BACKGROUND: Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients. METHOD: 1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder. RESULTS: No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion. CONCLUSION: In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.     

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

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

Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial

OBJECTIVE: To evaluate the efficacy of individual trauma-focused cognitive-behavioral therapy (CBT) for treating posttraumatic stress disorder (PTSD) in children and young people. METHOD: Following a 4-week symptom-monitoring baseline period, 24 children and young people (8-18 years old) who met full DSM-IV PTSD diagnostic criteria after experiencing single-incident traumatic events (motor vehicle accidents, interpersonal violence, or witnessing violence) were randomly allocated to a 10-week course of individual CBT or to placement on a waitlist (WL) for 10 weeks. RESULTS: Compared to the WL group, participants who received CBT showed significantly greater improvement in symptoms of PTSD, depression, and anxiety, with significantly better functioning. After CBT, 92% of participants no longer met criteria for PTSD; after WL, 42% of participants no longer met criteria. CBT gains were maintained at 6-month follow-up. Effects of CBT were partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD. CONCLUSIONS: Individual trauma-focused CBT is an effective treatment for PTSD in children and young people.     

Comorbidity of axis I disorders in patients with traumatic grief.

BACKGROUND: Traumatic grief has been found to be a distinct disorder from both depression and anxiety; however, there is no information in the literature regarding comorbidity of traumatic grief with other psychiatric disorders. METHOD: Twenty-three bereaved subjects who presented for treatment of traumatic grief symptomatology were included in this study. The Inventory of Complicated Grief (ICG) was used to confirm the presence of traumatic grief and assess its severity. In addition, the Structured Clinical Interview for DSM-IV was performed. RESULTS: Most subjects met criteria for a current or lifetime Axis I diagnosis. Fifty-two percent (N = 12) met criteria for current major depressive disorder, and 30% (N = 7), for current posttraumatic stress disorder (PTSD). ICG scores and functional impairment were higher among patients with more than one concurrent Axis I diagnosis. CONCLUSION: Comorbid major depressive disorder and PTSD may be prevalent in patients presenting for treatment of traumatic grief.     

Children of terrorism survivors: Physiological reactions seven years following a terrorist incident

Objective

The aim of this study was to examine psychiatric illness and physiological indicators in the children of Oklahoma City bombing survivors seven years after the event.

Methods

A study of 17 Oklahoma City bombing survivors and their 21 adolescent and young-adult children conducted seven years after the disaster used structured diagnostic interviews to examine psychiatric outcomes. Physiological measurements included heart rate, systolic blood pressure, diastolic blood pressure, and physiological reactivity measured in response to a semi-structured bombing-reminder interview.

Results

Results revealed a statistically significant positive association between survivors and their children with respect to both post-disaster and current posttraumatic stress disorder (PTSD). Also, children whose parents met diagnostic criteria for either post-disaster or current major depression were more likely to meet criteria for a post-disaster behavior disorder and for any post-disaster psychiatric disorder than children whose parents did not meet criteria for post-disaster or current major depression. Survivors' children meeting criteria for any post-disaster psychiatric diagnosis had higher heart rates during the pre-test, test, and post-test periods than children who did not meet criteria for any disorder. Children whose survivor parents met criteria for bombing-related PTSD and for any post-disaster psychiatric disorder had greater heart rate reactivity than those whose parents did not.

Conclusion

Findings of this study support previous literature on the relationships between children's psychiatric illness and physiological reactions and suggest interactions between disaster survivors' psychiatric illness and their children's psychiatric and physiological status.     

Posttraumatic stress disorder in a psychosomatic outpatient clinic. Gender effects, psychosocial functioning, sense of coherence, and service utilization

BACKGROUND: The lifetime prevalence of DSM-IV traumatic events and posttraumatic stress disorder (PTSD) was assessed in outpatients of a tertiary referral mental health center; differences in psychopathology and service utilization between PTSD and non-PTSD patients were evaluated. METHODS: Five hundred eighty-three outpatients (35.3 years, S.D.=12.5; 74.3% women and 25.7% men), who had been initially examined by clinically experienced medical and psychological psychotherapists, were investigated by means of standardized trauma-specific questionnaires. RESULTS: Of the patients, 61.1% reported at least one traumatic event during their lifetime, but only 34.3% of the total sample met the DSM-IV (A1 and A2) criteria. The lifetime prevalence of PTSD-positive screening was 10.1%. In 2.7% of these patients, PTSD had been diagnosed in clinical routine (ICD-10: F43.1); 6.6% of the men and 11.3% of the women met the diagnostic criteria for lifetime prevalence of PTSD. All in all, patients with PTSD had higher levels of depression and anxiety and lower levels of sense of coherence (P < .001) than did patients without PTSD (all P < .001). In addition, PTSD patients reported significantly higher rates of medical consultations (P < .001), psychotropic medication (P < .001), and psychotherapy (P < .001). CONCLUSIONS: About one third of the outpatients suffered from DSM-IV traumas, and 10%, from PTSD. However, PTSD had been diagnosed only in very few patients within the routine diagnostic procedure. These findings suggest that PTSD is frequently overlooked not only in primary but also in tertiary care settings. Finally, our study supports previous results that PTSD patients use more service utilization and are more affected by psychopathology symptoms.     

创伤后应激障碍的记忆损害与脑结构磁共振研究

目的 探讨创伤后应激障碍(post-traumatic stress disorder,PTSD)患者的记忆功能损害以及结构性核磁共振的变化.方法 收集符合美国精神障碍诊断与统计手册第四版诊断标准的16例PTSD患者、17例首发抑郁症患者和28名正常对照.采用临床应用的PTSD诊断量表(Clinician Administered PTSD Scale,CAPS)、汉密尔顿焦虑量表、汉密尔顿抑郁量表评定临床症状;韦氏记忆量表评定记忆功能;以磁共振静态三维结构进行影像学检查.结果 PTSD组理解记忆、延迟理解记忆、视觉再生、延迟视觉再生得分均明显低于对照组和抑郁症组(P均小于0.05).PTSD组视觉再生、延迟视觉再生记忆成绩与CAPS得分呈负相关(r=-0.66,P<0.05;r=-0.53,P均小于0.05),但与情绪症状评分均无相关性(P均大于0.05).PTSD组和抑郁症组的额叶、颞叶灰质体积均明显小于对照组(未校正的P<0.001);而PTSD组颞叶灰质体积小于抑郁症组(未校正的P<0.001).结论 PTSD的记忆损害与创伤症状而非抑郁症状明显相关,而其脑结构损害也与抑郁症有所不同,提示PTSD的记忆损害可能独立于抑郁症状之外.     

Symptoms of posttraumatic stress disorder in a community sample of low-income pregnant women

OBJECTIVE: The purpose of this study was to examine symptoms of posttraumatic stress disorder (PTSD) in a community sample of low-income pregnant women who met the DSM-IV diagnostic criteria for the disorder. METHOD: Pregnant women (N=948) were screened for trauma, PTSD, depression, and co-occurring illicit substance use. PTSD symptoms were compared in traumatized pregnant women and a sample of nonpregnant traumatized women from the National Comorbidity Survey. RESULTS: Suicidal thoughts and a high degree of psychiatric comorbidity were common in pregnant women with PTSD. Pregnant women were selectively and significantly less likely to endorse reexperiencing symptoms of PTSD (29.5%, N=82), compared to nonpregnant women (79.4%, N=464). CONCLUSIONS: PTSD in pregnancy was associated with comorbidity, poor health behaviors, and lower recall of memory-related PTSD symptoms. Further prospective study is needed.     

Trauma and Posttraumatic Stress Disorder in Primary Care Patients

BACKGROUND: This article examines the nature of psychological trauma and posttraumatic stress disorder (PTSD) in 504 patients recruited from primary care settings. METHOD: Patients were screened for anxiety in waiting rooms at 14 general medical settings, and those with a sufficient number and severity of anxiety symptoms were administered a standardized diagnostic clinical interview. Those who met DSM-IV criteria for an anxiety disorder and who were willing to participate were included in this study. Of the 504 patients, 185 met DSM-IV criteria for PTSD. RESULTS: Results indicated that 418 (83%) of primary care patients in our sample reported at least 1 traumatic event in their lifetime. The most prevalent traumas experienced by the entire sample of participants were witnessing others being seriously injured or killed, serious accidents, and rape. Of those participants with PTSD, rape was the strongest predictor of a PTSD diagnosis. Analyses examining gender differences indicated that, for women, a history of other unwanted sexual contact or witnessing a sexual assault, being attacked with a weapon or with intent to kill, or witnessing someone being injured were found to be risk factors for a PTSD diagnosis. Examination of clinical characteristics indicated a high rate of comorbidity of psychiatric disorders among patients with PTSD, including high rates of alcohol/substance abuse, depression, and suicide attempts. CONCLUSION: These findings emphasize the continued need to assess patients presenting at general medical facilities about trauma history.     

Early post-traumatic stress disorder in relation to acute stress reaction: an ICD-10 study among help seekers following an earthquake

Disaster research related to earthquakes has almost exclusively dealt with their long-term psychosocial impact; besides, diagnoses were previously based only on DSM criteria. Therefore, it is pertinent to assess stress-related reactions of earthquake victims during the early post-disaster period through the application of ICD-10 criteria. For the first 3 weeks following an earthquake, 102 help-seekers were assessed based on a checklist of sociodemographic variables and a semi-structured interview for the detection of acute stress reaction (ASR) and posttraumatic stress disorder (PTSD) according to ICD-10. Forty-four subjects (43%) fulfilled the ICD-10 criteria for PTSD; all but one of them had suffered ASR. Moreover, among a series of potential predictors for PTSD, ASR was found to be the only significant one; this indicates a definite association between ASR and early development of PTSD. Logistic regression to predict group membership (PTSD/no PTSD) based on specific ASR symptoms showed that accelerated heart rate and feelings of derealization were the only significant predictors for early PTSD. Individuals who fulfill the ICD-10 diagnostic criteria for ASR following an earthquake are at high risk for subsequent occurrence of early PTSD. Increased heart rate and feelings of derealization within the first 48 h after the traumatic event appear to be the principal factors associated with the development of early PTSD. In addition to their potential value for timely prevention and treatment, these findings raise important nosological issues pertaining to the current diagnostic classification of stress-related disorders (ICD-10 versus DSM-IV).     

Diagnostic utility and factor structure of the PTSD Checklist in older adults

ABSTRACT Background: Little research has examined the diagnostic utility and factor structure of commonly used posttraumatic stress disorder (PTSD) assessment instruments in older persons. Methods: A total of 206 adults aged 60 or older (mean age = 69 years; range = 60-92), who resided in the Galveston Bay area when Hurricane Ike struck in September 2008, completed a computer-assisted telephone interview two-five months after this disaster. Using the PTSD Checklist (PCL), PTSD symptoms were assessed related both to this disaster and to participants' worst lifetime traumatic event. Total PCL scores were compared to PCL-based, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)-derived probable diagnoses of PTSD to determine optimal cut scores. Confirmatory factor analyses (CFAs) were conducted to evaluate PTSD symptom structure. Results: Receiver operating characteristic analyses indicated that a PCL score of 39 achieved optimal sensitivity and specificity in assessing a PCL-based, algorithm-derived DSM-IV diagnosis of worst event-related PTSD; and that a score of 37 optimally assessed probable Ike-related PTSD. CFAs revealed that a recently proposed five-factor model - comprised of re-experiencing, avoidance, numbing, dysphoric arousal, and anxious arousal factors - provided a better fitting representation of both worst event- and disaster-related PTSD symptoms than alternative models. Current Ike-related anxious arousal symptoms demonstrated a significantly stronger association with current generalized anxiety than depressive symptoms, thereby supporting the construct validity of this five-factor model of PTSD symptomatology. Conclusions: A PCL score of 37 to 39 may help identify probable PTSD in older persons. The expression of PTSD symptoms in older adults may be best characterized by a recently proposed five-factor model with distinct dysphoric arousal and anxious arousal clusters.     

Screening for post-traumatic stress disorder in female Veteran's Affairs patients: validation of the PTSD checklist

We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996–January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82–0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.     

New findings on alternative criteria for PTSD in preschool children

OBJECTIVE: An alternative set of criteria for posttraumatic stress disorder (PTSD) for preschool children was analyzed for validity. METHOD: Sixty-two traumatized children and 63 healthy controls, aged 20 months through 6 years, were assessed. The traumatic experiences included motor vehicle collisions, accidental injuries, abuse, and witnessing violence. The number of symptoms required for clusters C and D and the utility of proposed symptoms were systematically analyzed. RESULTS: No cases met the DSM-IV algorithm for PTSD. Cluster B was endorsed 67.9% of the time. The proportion of cases meeting the cluster C threshold was 2% when three symptoms were required, 11% when two symptoms were required, and 39% when one symptom was required. The rate of cluster D was 45% when two symptoms were required and 73% when one symptom was required. Four novel symptoms did not substantially add to the diagnostic validity of the criteria. The optimal algorithm (one cluster B symptom, one cluster C symptom, and two cluster D symptoms) diagnosed PTSD at a rate of 26%. Measures of comorbid symptoms concurrently provided convergent validation to support this revised algorithm. CONCLUSION: Revisions to the DSM-IV PTSD criteria continue to be supported so that highly symptomatic young children can be diagnosed.     

Is PTSD caused by traumatic stress?

Sequential subjects (N=103) presenting for pharmacologic treatment of major depression were examined prior to treatment for history of traumatic experiences. Subjects were also examined for symptoms of posttraumatic stress disorder (PTSD). Two blinded raters subsequently judged whether subjects' experiences met DSM-IV criteria for trauma (criterion A of PTSD). Among 54 subjects scored by both raters as having experienced trauma, 42 (78%) met all other DSM-IV criteria for PTSD. Among 36 subjects scored by both raters as not having experienced trauma, 28 displayed all other DSM-IV criteria for PTSD--also a rate of 78%. This equivalence suggests that in a treatment-seeking population, caution should be exercised in attributing the PTSD syndrome to trauma.     

Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study

OBJECTIVE: The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans. METHOD: Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews. RESULTS: The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders. CONCLUSIONS: Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.     

Traumatic and socially stressful life events among persons with social anxiety disorder

This study examined the frequency of reexperiencing, avoidance, and hyperarousal symptoms most often associated with posttraumatic stress disorder (PTSD) among 45 persons with social anxiety disorder and 30 nonanxious controls in response to an extremely stressful social event (which did not satisfy DSM-IV's PTSD Criterion A). Avoidance and hyperarousal in response to reminders of socially stressful events were common among patients; more than one-third would have met criteria for PTSD if these events satisfied DSM-IV PTSD Criterion A. Frequency of this PTSD-like symptom pattern did not differ among patients who did and did not experience another event that did satisfy PTSD Criterion A. Implications of these findings for the treatment of social anxiety disorder are discussed.     

Prevalence of exposure to potentially traumatic events and PTSD

OBJECTIVE: The aim of this study was to estimate the prevalence rate of exposure to potentially traumatic events (PTE) and posttraumatic stress disorder (PTSD) in a representative sample of the general population. METHOD: A representative community-based cohort from the canton of Zurich, Switzerland was interviewed in 1993 and 1999 at the age of 34/35 and 40/41 years, respectively, by means of a semi-structured diagnostic interview. RESULTS: The weighted lifetime prevalence of PTE in 1999 was 28%. Of the persons who reported exposure to PTE (criterion A), none met all the remaining criteria for PTSD according to the DSM-IV. Eleven persons (2 males and 9 females) met the criteria for subthreshold PTSD. This corresponds to a weighted 12-month prevalence for subthreshold PTSD of 1.30% (0.26 % for males; 2.21 % for females). In 1993, no participant met all criteria for PTSD according to the DSMIII- R. The weighted 12-month prevalence for subthreshold PTSD was 1.90 % (2.9 % for males; 0.9 % for females). CONCLUSION: The prevalence of exposure to PTE in Switzerland was relatively low. No single case of full PTSD was found in the sample, and even for subthreshold PTSD the prevalence was very low. The relatively stable socio-economic and political climate in Switzerland may contribute to a sense of safeness, which may protect Swiss citizens to some extent from developing PTSD in the aftermath of traumatic experiences.     

A pilot study of interpersonal psychotherapy for posttraumatic stress disorder

OBJECTIVE: This article describes pilot testing of interpersonal psychotherapy adapted for posttraumatic stress disorder (PTSD). Unlike most psychotherapies for PTSD, interpersonal psychotherapy is not exposure-based, focusing instead on interpersonal sequelae of trauma. METHOD: Fourteen consecutively enrolled subjects with chronic PTSD (DSM-IV) from various traumas received an open, 14-week interpersonal psychotherapy trial. RESULTS: Treatment was well tolerated: 13 subjects (93%) completed therapy. After 14 weeks, 12 of 14 subjects no longer met diagnostic criteria for PTSD, 69% responded (50% Clinician Administered PTSD Scale score decrement), and 36% remitted (score < or =20). Thirteen subjects reported declines in PTSD symptoms across all three symptom clusters. Depressive symptoms, anger reactions, and interpersonal functioning also improved. CONCLUSIONS: Treating interpersonal sequelae of PTSD appears to improve other symptom clusters. Interpersonal psychotherapy may be an efficacious alternative for patients who refuse repeated exposure to past trauma. This represents an exciting extension of interpersonal psychotherapy to an anxiety disorder.     

Mixed lateral preference in posttraumatic stress disorder

Recent research indicates that adults with posttraumatic stress disorder (PTSD) have a higher incidence of mixed laterality with respect to handedness than the rest of the population. To test if this relationship also occurs early in life, we evaluated children with history of interpersonal trauma. Fifty-nine traumatized children were evaluated with the Clinician Administered PTSD Scale for Children and Adolescents and the Edinburgh Handedness Inventory. Forty matched healthy controls were used for comparison. Increased mixed laterality was found in all children exhibiting symptoms of PTSD when compared with healthy controls, and children who met DSM-IV diagnostic criteria for PTSD had more mixed laterality than the subthreshold traumatized group (F = 7.71; df = 2,96; p = 0.001). Within the entire traumatized group, there was a positive correlation between PTSD symptom severity and mixed laterality. Mixed laterality was positively associated with PTSD symptoms in traumatized children, suggesting that neurological abnormalities may be related to degree of PTSD symptom expression.