Posttraumatic stress disorder and psychiatric co-morbidity following stroke: the role of alexithymia

More research is needed to further our understanding of posttraumatic stress disorder symptoms (PTSD) and psychiatric co-morbidity following stroke, especially the trajectories of such symptoms over time. Previous studies suggest that exposure to a traumatic experience such as stroke is not sufficient to explain the etiology of PTSD. Alexithymia may be involved, but its relationships with PTSD and psychiatric co-morbidity following stroke remains unclear. This study aims to address these knowledge gaps. While in hospital, stroke patients (n = 90) completed questionnaires assessing PTSD symptoms, psychiatric co-morbidity, alexithymia and physical disability. PTSD symptoms and psychiatric co-morbidity were re-assessed approximately 3 months post-stroke (n = 78). The severity of post-stroke PTSD did not change significantly over time, while psychiatric co-morbidity reduced significantly. Alexithymia, in particular difficulty in identifying feelings, was associated with severity of post-stroke PTSD and psychiatric co-morbidity at baseline, but after adjusting for these, there was no significance 3 months post-stroke. We suggest that patients' difficulty in identifying feelings had a role to play in influencing relatively short-term rather than long-term PTSD and co-morbid psychiatric symptoms. Alternatively, PTSD could be interpreted as driving the alexithymic characteristics.     

Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review

Although video-EEG monitoring has revolutionized the diagnosis of psychogenic nonepileptic seizure (PNES), the etiology of this condition remains poorly understood. This article is a critical review of studies on the prevalence of traumatic events, abuse, and/or posttraumatic stress disorder (PTSD) in patients with PNES. Searches carried out on MEDLINE (1966-2004) and Web of Science (1945-2004) identified 17 relevant studies. PNES samples showed very high rates of trauma (44-100%) and abuse (23-77%), which were 15-40% higher than those found in control groups. This suggests that traumatic experiences may be a potential risk factor for PNES. PNES samples also showed a higher prevalence of PTSD than control groups, raising the possibility that PNES may arise as a clinical expression of a hypothetical PTSD subtype the core symptoms of which are dissociative. Methodological limitations do not permit the confirmation of these hypotheses. Stronger research designs are needed, such as prospective and case-control studies in both hospital and community settings.     

Treatment outcome of posttraumatic stress disorder: A white matter tract analysis

Despite the development of empirically supported treatments for posttraumatic stress disorder (PTSD), many individuals remain symptomatic following therapy or dropout prematurely. Neuroimaging studies examining PTSD treatment outcome may offer valuable insights into possible mechanisms that may impact treatment efficacy. To date, few studies of PTSD have used neuroimaging to examine symptom change following completed treatment, and most have focused on gray matter. Studies of white matter are equally important, as changes in white matter integrity (WMI) are connected to a host of detrimental outcomes. The current study examined symptom change of 21 women with PTSD as a result of interpersonal violence who received baseline diffusion tensor imaging (DTI) scans and completed 12 weeks of Cognitive Processing Therapy (CPT). After controlling for baseline PTSD severity, fractional anisotropy (FA) in the left internal capsule, posterior limb of the internal capsule, left cingulate gyrus, superior longitudinal fasciculus, and splenium of the corpus callosum was predicted by PTSD symptom change. Results contribute to understanding neural changes within therapy and may assist in predicting individual treatment response. Namely, by identifying areas potentially impacted by PTSD treatment, future studies may be able to connect the function of these white matter areas to better predict patient PTSD treatment outcome.     

Family psychiatric history, peritraumatic reactivity, and posttraumatic stress symptoms: A prospective study of police

Background

Family history of psychiatric and substance use disorders has been associated with posttraumatic stress disorder (PTSD) in cross-sectional studies.

Method

Using a prospective design, we examined the relationships of family history of psychiatric and substance use disorders to posttraumatic stress symptoms in 278 healthy police recruits. During academy training, recruits were interviewed on family and personal psychopathology, prior cumulative civilian trauma exposure, and completed self-report questionnaires on nonspecific symptoms of distress and alcohol use. Twelve months after commencement of active duty, participants completed questionnaires on critical incident exposure over the previous year, peritraumatic distress to the worst critical incident during this time, and posttraumatic stress symptoms.

Results

A path model indicated: (1) family loading for mood and anxiety disorders had an indirect effect on posttraumatic stress symptoms at 12 months that was mediated through peritraumatic distress to the officer’s self-identified worst critical incident, (2) family loading for substance use disorders also predicted posttraumatic stress symptoms at 12 months and this relationship was mediated through peritraumatic distress.

Conclusion

These findings support a model in which family histories of psychopathology and substance abuse are pre-existing vulnerability factors for experiencing greater peritraumatic distress to critical incident exposure which, in turn, increases the risk for development of symptoms of posttraumatic stress disorder. Replication in other first responders, military and civilians will be important to determine generalizability of these findings.     

Psychological trauma,posttraumatic stress disorder and trauma-related depression: A mini-review

There are various types of traumatic stimuli, such as catastrophic events like wars, natural calamities like earthquakes, and personal trauma from physical and psychological neglect or abuse and sexual abuse. Traumatic events can be divided into type I and type II trauma, and their impacts on individuals depend not only on the severity and duration of the traumas but also on individuals’ self-evaluation of the traumatic events. Individual stress reactions to trauma include posttraumatic stress disorder (PTSD), complex PTSD and trauma-related depression. Trauma-related depression is a reactive depression with unclear pathology, and depression occurring due to trauma in the childhood has gained increasing attention, because it has persisted for a long time and does not respond to conventional antidepressants but shows good or partial response to psychotherapy, which is similar to the pattern observed for PTSD. Because trauma-related depression is associated with high risk of suicide and is chronic with a propensity to relapse, it is necessary to explore its pathogenesis and therapeutic strategy.     

Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder

Objectives

The objectives of the present study were (1) to assess the impact of cognitive-behavior therapy (CBT) for posttraumatic stress disorder (PTSD) on associated sleep disturbances and (2) to explore the correlates of persistent sleep difficulties in terms of anxiety and depression symptoms and perceived health.

Method

Fifty-five individuals with PTSD were administered a series of assessments designed to evaluate sleep, PTSD symptoms, symptoms of anxiety and depression, and perceived health before and after individual CBT for PTSD and at 6-month follow-up.

Results

Significant improvements were observed on sleep quality, sleep onset latency, sleep efficiency, and sleep disturbances. These changes were not fully maintained after 6 months, and 70% of people who reported baseline sleep difficulties (Pittsburgh Sleep Quality Index >5) still reported significant problems with sleep after treatment. Persistent sleep difficulties were associated with more severe posttraumatic, anxious, and depressive symptoms as well as poorer health.

Conclusion

Although CBT for PTSD had a favorable impact on sleep, the majority of participants suffered from residual sleep difficulties. Individuals with persistent sleep difficulties posttreatment may experience more residual posttraumatic, depression, and anxiety symptoms and poorer mental and physical health than those who do not report sleep problems posttreatment. Further research in this area will allow clinicians to treat sleep problems in these individuals more effectively.     

Hippocampal volume in borderline personality disorder with and without comorbid posttraumatic stress disorder: A meta-analysis

Background

Several studies have found a reduction in hippocampal volume in borderline personality disorder (BPD) patients.

Methods

In order to investigate the degree to which comorbid posttraumatic stress disorder (PTSD) could account for reduction in hippocampal volume in these patients, we conducted a systematic review and meta-analysis of studies that compared hippocampal volume in BPD patients with and without PTSD relative to healthy controls.

Results

Seven articles, involving 124 patients and 147 controls, were included. We found a statistically significant reduction for the left and right hippocampus. Data from the four studies that discriminated BPD patients with and without PTSD indicate that hippocampal volumes were reduced bilaterally in BPD patients with PTSD, relative to healthy controls, but that results were mixed for BPD patients without PTSD, relative to healthy controls.

Conclusions

Results from this meta-analysis suggest that hippocampal volumes are reduced in patients with BPD, relative to healthy controls, but particularly in cases in which patients are diagnosed with comorbid PTSD.     

Time, before, and after time: temporal self and social appraisals in posttraumatic stress disorder

Background and objectives

In the aftermath of a traumatic event, individuals may engage in a series of comparisons in which they appraise their current functioning in relation to how they functioned prior to the traumatic event, as well as how they anticipate functioning in the future. In addition, trauma-exposed individuals may also appraise their functioning in relation to other individuals exposed to the same or similar types of traumatic events. We examine whether PTSD and non-PTSD classified individuals differ in temporal self and social appraisals.

Methods

Operation Enduring/Iraqi Freedom (OEF/OIF) combat-veterans with and without PTSD appraised their own past, current, and anticipated future functioning, as well as hypothetical other OEF/OIF veterans functioning across the same three temporal points.

Results

Individuals without PTSD appraised their own functioning as progressively improving across time. In contrast, individuals with PTSD viewed their current pre-trauma current self more favorably than their current or anticipated future self. Both groups appraised hypothetical other OEF/OIF veterans improving with time, yet individuals with PTSD evaluated other OEF/OIF veterans more favorably than those without PTSD.

Limitations

Limitations of the study include a cross-sectional design, precluding causality; the lack of a non-trauma exposed group, relatively small sample, and all-male gender of participants limit the generalizability to other populations.

Conclusions

PTSD and non-PTSD individuals differ in self and social appraisals when asked to evaluate past, present, and future functioning. Further research needs to better understand the extent to which these differences are associated with resilience to or maintenance of PTSD symptoms.     

An analysis of inhibitory functioning in individuals with chronic posttraumatic stress disorder

Cognitive abnormalities in posttraumatic stress disorder (PTSD) may be a function of underlying inhibitory deficits. Prepulse inhibition (PPI) and attentional blink (AB) are paradigms thought to assess inhibition. Using a sample of 28 individuals with PTSD compared to 20 trauma-exposed and 19 healthy individuals, PPI was examined using white noise that was preceded by a tone, and AB was examined using a presentation of letters in a stream of numbers. Relative to the control group, the PTSD and trauma-exposed groups did not follow the u-shaped pattern in AB, suggesting trauma-exposure and subsequent PTSD are associated with similar impairment in attention. Individuals with PTSD showed reduced PPI compared to trauma-exposed and healthy individuals, suggesting individuals with PTSD exhibit faulty automatic processing. For individuals with PTSD, PTSD severity was associated with a decline in PPI. These findings suggest a general faulty inhibitory mechanism associated with trauma exposure and PTSD.     

The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war

The aims of this study were to assess: (1) the relationship between PTSD and impairment, (2) whether there is a threshold in the association of PTSD score and impairment, and (3) whether any of the PTSD criteria are more strongly associated with impairment. We studied 10,069 service personnel from a representative sample of the British Armed Forces to assess the effects of the Iraq war. Participants completed the PTSD checklist (PCL), the general health questionnaire-12 (GHQ-12), the alcohol use disorder identification test (AUDIT) and five questions to assess impairment. 78% of those with a PCL-score of 50 or more endorsed at least one impairment item in comparison to 27% of those with a score below 50. The odds ratio (OR) of impairment in the PCL group with a score of 50 or more was 16.7 (95% CI 12.9-21.6). There was an increasing risk of impairment with an increasing category of PCL-score without a noticeable threshold. For each PTSD subscale: intrusiveness, avoidance/numbing and hyper-arousal, divided into four score categories, there was an increased association with impairment, but the association of avoidance/numbing with impairment was the greatest and independent of the other two criteria (OR 7.2 (95% CI 4.8-10.9). Having a good relationship with a partner had minimal effect on the level of association between PTSD and impairment. Functional impairment is a serious problem for those with PTSD. The impairment is not confined to those with the highest PCL-score. Avoidance/numbing is the criterion which makes the greatest independent contribution to impairment     

A longitudinal investigation of posttraumatic stress disorder in patients with ovarian cancer

Introduction

Exposure to the aggressive and life-threatening nature of ovarian cancer and its treatment is potentially traumatic. However, little is known about the occurrence of posttraumatic stress disorder (PTSD) in these patients.

Methods

A total of 121 women newly diagnosed with ovarian cancer were recruited into a prospective longitudinal study of the course of PTSD and the factors that predict its development and persistence. Between 82 and 111 were assessed at each of the four time points subsequent to their diagnosis, and 63 women provided complete data from the beginning of chemotherapy treatment, midtreatment, end of treatment and 3-months follow-up on PTSD.

Results

Between 36% and 45% of the total sample experienced PTSD at some point, with a nonsignificant but progressive increase in prevalence over time. Of those women with complete data, only 30% never experienced PTSD at any time. Most of the women were intermittent cases of PTSD (57%, n=36), while 13% (n=8) were persistent cases. Younger women were at higher risk of experiencing PTSD.

Discussion

The prevalence of women newly diagnosed with ovarian cancer with persistent PTSD is relatively low (13%); however, our findings highlight that the trajectory of the illness and its associated stressors may constitute an enormous challenge and may be perceived as traumatic and stressful for most of the women in our sample at least once. Repetitive screening for PTSD and the provision of psychological treatments could ameliorate PTSD symptoms.     

Clinically significant avoidance of public transport following the London bombings: Travel phobia or subthreshold posttraumatic stress disorder?

Following the London bombings of 7 July 2005 a “screen and treat” program was set up with the aim of providing rapid treatment for psychological responses in individuals directly affected. The present study found that 45% of the 596 respondents to the screening program reported phobic fear of public transport in a screening questionnaire. The screening program identified 255 bombing survivors who needed treatment for a psychological disorder. Of these, 20 (8%) suffered from clinically significant travel phobia. However, many of these individuals also reported symptoms of posttraumatic stress disorder [PTSD]. Comparisons between the travel phobia group and a sex-matched group of bombing survivors with PTSD showed that the travel phobic group reported fewer re-experiencing and arousal symptoms on the Trauma Screening Questionnaire (Brewin et al., 2002). The only PTSD symptoms that differentiated the groups were anger problems and feeling upset by reminders of the bombings. There was no difference between the groups in the reported severity of trauma or in presence of daily transport difficulties. Implications of these results for future trauma response are discussed.     

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.     

Posttraumatic stress disorder, dissociation, and sexual abuse history in epileptic and nonepileptic seizure patients

Rates of posttraumatic stress disorder (PTSD), dissociative symptoms, and childhood sexual abuse (CSA) are believed to be higher among patients with nonepileptic seizures (NES) than those with epileptic seizures (ES). However, women have higher rates of CSA and sexual assault than men. Comparisons of seizure type controlling for gender may produce different results. Data from an opportunity sample of 34 patients with ES and 17 with NES evaluated during or following phase 1 video-EEG monitoring demonstrated that patients with NES had statistically higher rates of PTSD and CSA and higher Dissociative Experiences Scale (DES) scores than patients with ES. No differences were found between women with NES and ES for histories of PTSD or CSA. Mean between-group DES score differences remained. Results indicated that PTSD, dissociation, and CSA may be common among women presenting to a tertiary epilepsy referral center for both ES and NES. Neither a positive history of CSA nor a history of PTSD was evidence against epilepsy.     

Prevalence and features of panic disorder and comparison to posttraumatic stress disorder in VA primary care

Objective

Although panic disorder (PD) is a highly prevalent condition in both community and community primary care settings, little is known about PD in veteran populations, especially in comparison to posttraumatic stress disorder (PTSD). The present study investigated prevalence, comorbidity, physical and mental health impairment, and health care utilization of veterans with PD and PTSD.

Method

A total of 884 veterans participated in a cross-sectional investigation in primary care clinics in four Veteran Affairs Medical Centers (VAMCs). Participants completed diagnostic interviews and self-report questionnaires, and a chart review was completed to assess their VAMC health care utilization.

Results

A large number of veterans (8.3%) met the diagnostic criteria for PD and reported significantly more severe physical health impairment (pain, general health), mental health impairment (emotional well-being, role limitations) and social functioning than veterans without PD. Veterans with PD also had increased health care utilization for mental health. Further, PD was highly comorbid with PTSD, with similar symptoms across all measures.

Conclusions

These findings demonstrate the high prevalence and severe impairment associated with PD in veterans and highlight the need for improved recognition, assessment and specialized treatments for PD in VAMCs and other care settings.     

Comorbid posttraumatic stress disorder and major depressive disorder: The usefulness of a sequential treatment approach within a randomised design

Cognitive Processing Therapy (CPT) and Behavioural Activation Therapy (BA) were used to treat individuals with comorbid posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Fifty-two individuals (48 women, 4 men) were randomized to CPT alone (n = 18), CPT then BA for MDD (n = 17), or BA then CPT (n = 17). Presenting trauma was primarily interpersonal (87 %). Participants were assessed at pre-, posttreatment, and 6-month follow-up. PTSD and MDD symptoms were the main outcome of interest; trauma cognitions, rumination, and emotional numbing were secondary outcomes. All groups showed sizeable reductions in PTSD and depression (effect sizes at follow-up ranging between 1.02–2.54). A pattern of findings indicated CPT/BA showed better outcomes in terms of larger effect sizes and loss of diagnoses relative to CPT alone and BA/CPT. At follow-up greater numbers of the CPT/BA group were estimated to have achieved good end-state for remission of both PTSD and depression (49 %, CI₉₅ [.26, .73]) relative to CPT alone (18 %, CI₉₅ [.03, .38]) and BA/CPT (11 %, CI₉₅ [.01, .29]). Although tempered by the modest sample size, the findings suggest that individuals with comorbid PTSD and MDD may benefit from having PTSD targeted first before remaining MDD symptoms are addressed.     

The role of high-density lipoprotein cholesterol in risk for posttraumatic stress disorder: Taking a nutritional approach toward universal prevention

Several cross-sectional studies, but no prospective studies, have reported an association between an abnormal lipid profile and posttraumatic stress disorder (PTSD). We hypothesized that an abnormal lipid profile might predict risk for developing PTSD. In this prospective study, we analyzed data from 237 antidepressant-naïve severely injured patients who participated in the Tachikawa Cohort of Motor Vehicle Accident Study. High-density lipoprotein cholesterol (HDL-C) levels at baseline were significantly lower in patients with PTSD than those without PTSD at 6 months after motor vehicle accident (MVA) and were inversely associated with risk for PTSD. In contrast, triglycerides (TG) at baseline were significantly higher in patients with PTSD than in those without PTSD at 6 months post-MVA and were positively associated with risk for PTSD. There was no clear association between low-density lipoprotein cholesterol or total cholesterol and risk for PTSD. In conclusion, low HDL-C and high TG may be risk factors for PTSD. Determining lipid profiles might help identify those at risk for PTSD after experiencing trauma.     

The potential role of atypical antipsychotics for the treatment of posttraumatic stress disorder

Despite the fact that the majority of currently available treatment guidelines propose antidepressants as the first-line pharmacological therapy for posttraumatic stress disorder (PTSD), a substantial portion of patients fail to show an adequate response following this type of treatment. In this context, a number of small, open-label studies and randomized controlled clinical trials (RCTs) have found atypical antipsychotics (AAs) to be a beneficial treatment for patients with PTSD. Thus, the present meta-analysis was conducted to enhance the sample size power and further the current understanding of the role of AAs for the treatment of PTSD. An extensive search of several databases identified 12 appropriate RCTs and available data from 9 of these (n = 497) were included in the final meta-analysis. AAs may have potential benefits for the treatment of PTSD as indicated by changes from baseline of the total score on the Clinician Administered PTSD Scale (CAPS; standardized mean difference [SMD] = −0.289, 95% confidence intervals [CIs] = −0.471, −0.106), P = 0.002). Additionally, AAs were found to be significantly more effective (P < 0.0001) than a placebo in terms of change from baseline for the intrusion sub-score on the CAPS (SMD = −0.373, 95% CIs = −0.568, −0.178) but there were no significant reductions for the avoidance and hyperarousal sub-symptoms. The responder rate and rate of improvement of depressive symptoms were also significantly higher in the AA group than the placebo group (P = 0.004 and P < 0.0001, respectively). However, the present results should be interpreted carefully and be translated into clinical practice only with due consideration of the limited quality and quantity of existing RCTs included in this analysis.     

Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population

While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD–BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD–BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.     

Dissemination and implementation of prolonged exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a highly prevalent, often chronic and disabling psychiatric disorder that is associated with significant adverse health and life consequences. Although several evidence-based treatments (EBTs), including Prolonged Exposure therapy (PE), have been found effective and efficacious in reducing PTSD symptomology, the majority of individuals with this disorder receive treatments of unknown efficacy. Thus, it is imperative that EBTs such as PE be made available to PTSD sufferers through widespread dissemination and implementation. We will review some of the efforts to increase the availability of PE and the common barriers to successful dissemination and implementation. We also discuss novel dissemination strategies that are harnessing technology to overcome barriers to dissemination.