Severity of injury does not have any impact on posttraumatic stress symptoms in severely injured patients

Background

Due to improved surgical techniques and more efficient decision making in treating severely injured patients, survival rates have increased over the years. This study was initiated to evaluate the incidence and identify risk factors for developing posttraumatic stress symptoms, using both extensive trauma-related data and data assessing the psychological trauma, in a population of severely injured patients.

Patients and methods

79 patients admitted to the Department of Multitrauma and Spinal Cord Injury at Sunnaas Rehabilitation Hospital from 2003 to 2005, prospectively completed semistructured psychological interviews and questionnaires, such as Impact of Event Scale-Revised. In addition, extensive injury-related data, such as injury severity score (ISS), new injury severity score (NISS), and probability of survival (PS) were collected.

Results

39% had multiple trauma, 34% had multiple injuries including spinal cord injuries, and 27% had isolated spinal cord injuries. Mean NISS was 31.5 (S.D. 13.7). 6% met diagnostic criteria for posttraumatic stress disorder (PTSD) and 9% met the criteria for subsyndromal PTSD. Injury-related data did not influence the prevalence of posttraumatic stress symptoms, however, some psychosocial variables did have a significant impact.

Conclusions

We found a low incidence of PTSD and subsyndromal PTSD. No significant differences were found between the patients suffering from posttraumatic stress symptoms and the non-symptoms group in relation to injury-related data such as ISS/NISS, PS, or multiple trauma versus spinal cord injury. The most evident risk factors for developing posttraumatic stress symptoms were symptoms of anxiety, female gender and negative attitudes toward emotional expression.     

Traumatic experiences in psychiatric outpatients

Fifty-four newly referred psychiatric outpatients were interviewed and a life history of severe traumatic experiences was taken. Forty-four gave a positive history, 17 of whom developed symptoms of post-traumatic stress (PTSS). Twelve met a past or current diagnosis of PTSD. Factors relating to the occurrence of PTSS included early trauma, more traumatic events, incest, perceiving the event as frightening, being physically injured, perceiving the event as being life threatening, seeing a physician, and being hospitalized. Age at trauma and differences between men and women are also discussed.     

A century of controversy surrounding posttraumatic stress-spectrum syndromes: The impact on DSM-III and DSM-IV

The authors describe historical clinical reports that preceded the development of criteria for posttraumatic stress disorder (PTSD) and influenced the formation of PTSD in DSM-IV. These reports were identified from extensive search of 19th- and 20th-century American and European medical literature. Relevant findings from the most representative reports are described and discussed. Since the mid-19th century, clinical syndromes resembling PTSD have been described. However, understanding of PTSD has been complicated by questions of nomenclature, etiology, and compensation. Nomenclature placed PTSD syndromes under existing psychiatric disorders: traumatic hysteria, traumatic neurasthenia, or traumatic neurosis. Etiological issues have been concerned often solely with organic factors, pre-existing personality impairments, intrapsychiatric conflicts, and social factors. Only after World War II and the concentration camp experiences did the role of severe trauma in PTSD become recognized. Even though controversy remains, much progress in understanding PTSD has been made.     

Multivariate assessment of explicit memory function in combat veterans with posttraumatic stress disorder

Declarative memory impairment is a frequent complaint of patients suffering from posttraumatic stress disorder (PTSD). We assessed memory, attention, visual spatial skills, and executive function in Vietnam combat veterans with (n = 19) and without (n = 13) PTSD. Although PTSD subjects demonstrated a generalized impairment relative to non-PTSD subjects on a majority of tasks, only attention and memory provided unique and independent prediction of PTSD versus non-PTSD status. Our findings suggest that memory functioning represents a neurocognitive domain of specific relevance to the development of PTSD in trauma-exposed individuals, which can be distinguished from generalized attentional impairment as well as the effects of trauma exposure severity, IQ, comorbid depression, history of alcohol use, and history of developmental learning problems.     

Sertraline, paroxetine, and venlafaxine in refugee posttraumatic stress disorder with depression symptoms

Three new antidepressants were used in treating posttraumatic stress disorder (PTSD) and symptoms of depression in Bosnian refugees. Thirty-two Bosnian refugees seeking treatment at a mental health clinic participated in a case series study. All received open trials of Sertraline (n = 15), Paroxetine (n = 12), or Venlafaxine (n = 5), with standard clinical doses. Overall, Sertraline and Paroxetine produced statistically significant improvement at 6 weeks in PTSD symptom severity, in depression, and in Global Assessment of Functioning. Venlafaxine produced improvement in PTSD symptom severity and in Global Assessment of Functioning, did not yield improvement in symptoms of major depressive disorder, and had a high rate of side effects. Notwithstanding improvement of symptoms, all 32 refugees remained PTSD positive at the diagnostic level at the 6-week follow-up.     

Trauma symptoms and PTSD-like profiles in perpetrators of intimate abuse

The presence of chronic trauma symptoms and similarity to a specific profile for post-traumatic stress disorder (PTSD) were assessed in a group 132 wife assaultive men and 44 demographically matched controls. Men who committed intimate abuse experienced more chronic trauma symptoms than nonabusive controls. A composite profile on the MCMI-II for wife assaulters demonstrated peaks on 82C (negative/avoidant/borderline), as have two independent studies of the profile of men diagnosed with PTSD. However, the assaultive population had higher scores on the antisocial personality scale and lower scores on anxiety and dysthymia. This PTSD-like profile on the MCMI-II was associated significantly with more frequent anger and emotional abuse of the subject's partner. The trauma origin for these men may have been parental treatment: experiencing frequent trauma symptoms as an adult was significantly related to negative recollections of parental treatment, specifically parental coldness/rejection and physical abuse.     

Trauma Exposure and Retention in Adolescent Substance Abuse Treatment

Trauma exposure and related symptoms interfere with adult adherence to drug treatment. Whether these findings hold true for adolescents is unknown. We examined trauma exposure, PTSD symptoms, and psychosocial functioning among 212 adolescents upon admission to long-term residential drug treatment and examined retention in treatment at 6 months. Seventy-one percent reported lifetime trauma exposure, and 29% of the trauma-exposed met criteria for current PTSD. Trauma-exposed adolescents reported more behavioral problems, with gender differences apparent. We divided the sample into three groups: no trauma exposure (21%), trauma-exposed without PTSD (59%), and trauma-exposed with PTSD (20%). Survival analysis showed that trauma-exposed adolescents without PTSD left treatment sooner than the nonexposed. Need for attention to trauma in substance abuse treatment programs is discussed.     

Experiences of torture and ill-treatment and posttraumatic stress disorder symptoms among Palestinian political prisoners

The relationship between the nature and severity of experiences of torture and ill-treatment and posttraumatic stress disorder (PTSD) symptoms was studied in 550 male nonhelp-seeking Palestinian political ex-prisoners from the Gaza Strip. Results showed that the more a prisoner had been exposed to physical, chemical and electric torture, psychological ill-treatment, and sensory deprivation or bombardment, the more he subsequently suffered from intrusive reexperiencing, withdrawal and numbness, and hyperarousal. Existential problems were not related to torture experiences. Furthermore, duration of imprisonment, health problems during the imprisonment, harassment during arrest and after release, family, marriage and economic difficulties all predicted intrusive reexperiences of trauma. Also, ex-prisoners who continued to be harassed by military authorities and had economic problems suffered more from withdrawal, numbness, and hyperarousal than others.     

Neurological,cognitive and attributional predictors of posttraumatic stress symptoms after traumatic brain injury

We investigated the relationship between the reporting of symptoms of posttraumatic stress disorder (PTSD) in a community sample of 66 survivors of severe traumatic brain injury (TBI) and measures of injury severity, memory, insight, and index-event attributions. Correlational analyses revealed that reporting of PTSD symptoms was related to level of insight and not associated with the severity of survivors' injury, educational background, premorbid or current IQ, or memory impairment. The severity of PTSD symptoms was also associated with external attributions to others of causality for the event.     

Hypothalamic-pituitary-adrenal activity among Armenian adolescents with PTSD symptoms

This study evaluated basal levels and responsiveness to exercise of plasma adrenocorticotropic hormone (ACTH), and serum thyroid stimulating hormone (TSH), growth hormone (GH) and cortisol among adolescents from two differentially exposed groups 61/2 years after the 1988 earthquake in Armenia. Severity of total PTSD and Category C and D symptoms were negatively correlated with baseline cortisol. Preexercise ACTH was significantly lower, and preexercise TSH higher, among adolescents with more exposure. Depressive symptoms were negatively correlated with baseline cortisol and positively with TSH. Mean GH, TSH, and cortisol levels in both groups fell within normal limits. The pre- to postexercise increase in GH, TSH, and cortisol suggests that exercise challenge may be useful in the field investigation of neurohormonal activity among traumatized individuals.     

Borderline traits and symptoms of post‐traumatic stress in a sample of female victims of intimate partner violence

Research has shown that symptoms of a post‐traumatic stress disorder (PTSD) are prevalent among victims of intimate partner violence (IPV). Furthermore, positive correlations have been reported between IPV victimization and borderline traits, and borderline traits and PTSD symptomatology. Although there is some evidence that individuals with a borderline disorder are vulnerable to developing PTSD after experiencing trauma, to our knowledge, this has never been studied empirically among a sample of victims of IPV in specific. However, the presence of borderline traits might place these victims at higher risk for developing PTSD symptoms as well. In the current study, associations between PTSD symptoms and borderline traits were examined in a Dutch sample of female help‐seeking victims of IPV (n = 120). As hypothesized, it was found that borderline traits significantly add to the vulnerability for development of PTSD in IPV victims, above and beyond the severity of IPV. Results are discussed in the light of practical implications like an early screening for borderline traits in treatment of victims of IPV. Copyright © 2010 John Wiley & Sons, Ltd.     

PTSD symptoms and partner abuse: low income women at risk

Aspects of partner abuse (types, severity, chronicity, treatment of injury, fear, etc.) were addressed with low income community women, half of whom scored above the cutoff on the Crime Related PTSD scale. Using this cutoff, 47% of women who sustained moderate violence were high in CR-PTSD symptoms. If their partner also raped them, the rate (63%) was similar to women who sustained severe violence (65%) or severe violence and rape (71%). No ethnic differences were found for rates or severity of CR-PTSD symptoms. A MANCOVA by ethnicity (African Americans, Euro-Americans, Mexican Americans) and CR-PTSD symptoms (low vs. high) identified ethnic differences only on total sexual aggression and recent threats of violence. The high symptom group reported more abuse on all measures. Results from the CR-PTSD and the general lack of ethnic differences support the notion that SES contributes more to women's vulnerability to abuse and stress symptoms than does ethnicity.     

Cross-cultural response to trauma: A study of traumatic experiences and posttraumatic symptoms in Cambodian refugees

Despite a growing literature of cross-cultural research on mental illness, little is known about the universality of most psychiatric disorders. This study was designed to determine whether people from a very different culture have the same symptoms in response to traumatic experiences as do trauma survivors in the United States. We were also interested to find out if the severity of the current symptoms is related to the amount of trauma experienced. Furthermore, we gathered information about the perceived severity of traumatic experiences among refugees. Fifty Cambodian refugees living in the U.S. were asked about their traumatic experiences and their current symptoms of posttraumatic stress, dissociation, depression, and anxiety. High levels of all symptoms were found along with statistically significant relationships between each symptom measure and the amount of trauma experienced. We conclude that the basic symptom picture in this group was similar to that observed in U.S. trauma survivors.     

Multivariate analysis of liver regenerative capacity after hepatectomy in humans

Many factors affect liver regeneration after partial hepatectomy; however, those factors that are essential for regulation of liver regeneration in humans are not known. Using multiple regression analysis we conducted a study to determine essential factors involved in the speed of liver regeneration after hepatectomy. The subjects were 59 patients who underwent hepatic resection between January 1980 and December 1991. A regression equation for predicting regeneration speed (Y; cm³/day) during the 1st postoperative month was obtained by stepwise forward multiple regression analysis, using 11 explanatory parameters (Xi). The regeneration speed and the resection ratio (%; indicating the magnitude of resection) were calculated based on a computed tomography (CT) scan volumetric study. The degree of liver fibrosis, expressed as the fibrotic index (%), was morphometrically determined in Azan-Mallory stained sections. Of the 11 explanatory parameters, the resection ratio and the fibrotic index had a significant simple correlation with Y. The following regression equation was obtained: Y (cm³/day)=–1.1+3.7 × resection ratio –5.4 × alkaline phosphatase –3.7 × fibrotic index +1.2× total bilirubin –2.6 × glutamic pyruvic transaminase (multiple correlation coefficient, 0.82). We found that the extent of resection and the degree of fibrosis, as well as alkaline phosphatase, total bilirubin, and glutamic pyruvic transaminase, contributed to the speed of regeneration after partial hepatectomy.     

War-related trauma and symptoms of posttraumatic stress disorder among adult Kosovar refugees

Since 1999, almost 16,000 Kosovar refugees have entered the United States. Few studies have investigated trauma and symptoms of posttraumatic stress disorder (PTSD) in this population. We conducted a caseworker-assisted survey of 129 Kosovar refugees (aged 18 to 79 years, 55% male). Of these individuals, 78 (60.5%) showed the likely presence of PTSD. The mean number of war-related traumatic events reported was 15 (SD = 4.5). Higher PTSD scores were associated with more traumatic events and female gender.     

Psychological symptoms and psychiatric diagnoses in operation desert storm troops serving graves registration duty

This clinical report describes symptoms of psychological and physical distress and psychiatric disorders in 24 Army Reservists who served war zone graves registration duty in support of Operation Desert Storm. Troops underwent comprehensive assessment for evidence of psychopathology that might be associated with war zone duty as one component of a debriefing protocol scheduled during regular drill exercises eight months after their return to the United States. Troops endorsed items suggestive of high war zone stress exposure, common symptoms of anxiety, anger, and depression, and multiple health and somatic concerns. Almost half of the sample met criteria for post-traumatic stress disorder, and diagnosis of this disorder was strongly associated with evidence of depressive and substance abuse disorders. The gruesome aspects of body recovery and identification in a war zone setting were cited as stressor elements of significant negative impact.     

Attachment insecurity, responses to critical incident distress, and current emotional symptoms in ambulance workers

Ambulance workers are exposed to critical incidents that may evoke intense distress and can result in long-term impairment. Individuals who can regulate distress may experience briefer post-incident distress and fewer long-term emotional difficulties. Attachment research has contributed to our understanding of individual differences in stress regulation, suggesting that secure attachment is associated with effective support-seeking and coping strategies, and fewer long-term difficulties. We tested the effect of attachment insecurity on emotional distress in ambulance workers, hypothesizing that (1) insecure attachment is associated with symptoms of current distress and (2) prolonged recovery from acute post-critical incident distress, coping strategies and supportive contact mediate this relationship. We measured (1) attachment insecurity, (2) acute distress, coping and social contact following an index critical incident and (3) current symptoms of post-traumatic stress, depression, somatization and burnout and tested the hypothesized associations. Fearful-avoidant insecure attachment was associated with all current symptoms, most strongly with depression (R=0.38, p<0.001). Fearful-avoidant attachment insecurity was also associated with maladaptive coping, reduced social support and slower recovery from social withdrawal and physical arousal following the critical incident, but these processes did not mediate the relationship between attachment insecurity and current symptoms. These findings are relevant for optimizing post-incident support for ambulance workers.     

Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms

Seventy-seven civilian employees who were victims of robbery were randomly assigned to either an immediate (<10 hr) or delayed (>48 hr) debriefing group, using the J. Mitchell (1983) CISD protocol. Scores on the Posttraumatic Stress Diagnostic Scale were obtained at 4 time intervals: debrief, 2 and 4 days postdebrief, and 2 weeks postrobbery. The number and severity of symptoms did not differ at debrief, but were lower for the immediate than for the delayed group at each subsequent time interval. The number and severity of symptoms declined across time intervals; however, although this reduction was pronounced for the immediate group it was minimal for the delayed group. The results supported use of immediate debriefing with this type of incident and victim.     

Factor analysis of treatment response in posttraumatic stress disorder

Factor analysis is applied to the symptoms of posttraumatic stress disorder (PTSD) to reduce the multidimensional symptom space to 2 dimensions; 1 dimension strongly correlated with depressive symptoms and 1 independent dimension weakly correlated with depressive symptoms. These factors are used to assess whether the effectiveness of an antidepressant medication is due to its antidepressant effect. The treatment is shown to be effective in both dimensions. The factor analysis sheds light on the symptom structure of PTSD, supports PTSD as a distinct psychiatric disorder, and supports the current diagnostic criteria.