Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors

OBJECTIVE: To describe rates and concordance of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in adolescent childhood cancer survivors and their mothers and fathers. METHOD: Participants were 150 adolescent survivors of childhood cancer, 146 mothers, and 103 fathers who completed the Impact of Events Scale-Revised, the Posttraumatic Stress Disorder Reaction Index, and the PTSD module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. RESULTS: PTSS are common in families of childhood cancer survivors. Parents reported more symptomatology than former patients. Mothers and fathers had relatively equal rates of current PTSD and levels of PTSS. Nearly 30% of mothers met diagnostic criteria since their child's diagnosis, with 13.7% currently experiencing PTSD. Nearly 20% of families had at least one parent with current PTSD. Ninety-nine percent of the sample had at least one family member reexperiencing symptoms. CONCLUSIONS: Both PTSD and PTSS help in understanding the experience of adolescent cancer survivors and their families. Within families of childhood cancer survivors, it is likely that some member may be experiencing treatable bothersome memories, arousal, or avoidance specific to the cancer experience.     

A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents

Recent years have witnessed a rapid acceleration in the recognition and documentation of posttraumatic stress disorder (PTSD) and posttraumatic stress symptomatology (PTSS) in childhood cancer survivors and their parents. However, applicability of PTSD both diagnostically and conceptually to cancer-related traumatic responses remains poorly articulated within the current literature. Following an outline of childhood cancer and PTSD, this paper critically examines the applicability of such a diagnosis to this clinical population. It then systematically reviews the current evidence base (24 studies) on PTSD and PTSS in childhood cancer survivors and their parents. Prevalence of PTSD and PTSS, as well as associated predictors, in this clinical population varies widely. Findings are considered in the light of a number of contemporary theories of PTSD. Limitations within current conceptualizations of PTSD are highlighted with respect to the nature of cancer as a traumatic event and the specific features of traumatic stress manifestations in childhood cancer survivors and their parents. Finally, a number of pertinent research areas are elucidated which are argued to warrant further investigation.     

Secondary traumatization and attachment among wives of former POWs: a longitudinal study

The aim of the present study was to examine the directionality of the association between post-traumatic stress symptoms (PTSS) and attachment insecurities across time among indirect trauma survivors. Wives of former prisoners of war (ex-POWs), with and without post-traumatic stress disorder (PTSD), and comparable controls were assessed 30 (T1) and 38 (T2) years after the Yom Kippur War. As expected, wives of ex-POWs endorsed higher PTSS compared to wives of controls. Wives of ex-POWs with PTSD endorsed higher PTSS and higher attachment avoidance compared to wives of ex-POWs without PTSD and controls. There were significant associations between PTSS and attachment insecurities. Contrary to the hypothesis, the relationship between PTSS and attachment insecurities among wives of ex-POWs was unidirectional, with attachment anxiety at T1 predicting PTSS at T2, and not vice versa. Results indicate that attachment anxiety might act as a risk factor for secondary traumatic reactions.     

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

Objective To examine posttraumatic stress symptoms (PTSS) inparents of children with cancer as a function of time sincediagnosis, treatment status, and relapse history, and as comparedto parents of healthy children. Method Participants includedparents of 199 children with cancer, comprising a cross-sectionalsample of diagnoses and treatment phases, ranging from currentlyon therapy to long-term survivors, and 108 parents of healthychildren obtained via acquaintance control methods. Parentscompleted a standardized self-report measure of PTSS. ResultsWithin the cancer group, parental report of PTSS differed asa function of treatment status and time since diagnosis. Parentsof children on active treatment endorsed similar levels of PTSSas control parents, whereas parents of children off treatmentreported significantly lower levels of PTSS than did controls.Similarly, parents of long-term survivors reported significantlylower levels of PTSS than did controls, while parents of recentlydiagnosed children did not differ from controls on PTSS. Incontrast, parents of children who had suffered a relapse reportedsignificantly higher levels of PTSS, and were much more likelyto be identified as a posttraumatic stress disorder (PTSD) case.Conclusions As a group, parents of children with cancer didnot demonstrate any evidence of increased PTSS relative to parentsof healthy children. Time since diagnosis, child treatment status,and relapse history are significant determinants of parent PTSS.Only parents of children who experienced a relapse appear tobe at increased risk of PTSD. The current results appear discrepantfrom the existing literature, and possible explanations forthese discrepancies are examined.     

Posttraumatic stress and related impairment in survivors of childhood cancer in early adulthood compared to healthy peers

OBJECTIVE: To compare rates of posttraumatic stress disorder (PTSD) and related impairment between childhood cancer survivors in early adulthood and healthy peers. METHODS: Cancer survivors (n = 57) and comparison group (n = 83) completed measures of PTSD, depression, health-related quality of life (HRQOL), mood, and satisfaction with life (SWL). RESULTS: The cancer survivor group was more likely to have PTSD than the control group (odds ratio = 4.67, p < .05) but was not more likely to experience subclinical PTSD symptoms. The groups differed on physical HRQOL, F(1, 140) = 15.02, p < .001, and positive affect, F(1, 140) = 7.03, p < .01, but did not differ on depression, SWL, psychosocial HRQOL, and negative mood. Those in the survivor group with PTSD (n = 10) experienced more depression and negative affect, worse HRQOL and SWL, perceived their cancer to impact developmental tasks more, and were older at the time of diagnosis compared with those without PTSD (n = 47). CONCLUSIONS: Although most are well adjusted, childhood cancer survivors in early adulthood are more likely to have PTSD and to experience significant impairment compared with healthy peers.     

Brief report: the impact of maternal posttraumatic stress disorder symptoms and child gender on risk for persistent posttraumatic stress disorder symptoms in child trauma victims

OBJECTIVE: To longitudinally examine the impact of maternal posttraumatic stress disorder symptoms (PTSS) on child adjustment following a child's traumatic injury, focusing on child gender differences. METHODS: Forty-one child traumatic injury victims aged 8-18 years and their biological mothers were interviewed over two follow-ups (6 weeks and 7 months). Children were administered the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale for Children and Adolescents (CAPS-CA), whereas mothers completed the CAPS. RESULTS: Six weeks post trauma, maternal PTSS were significantly related to PTSS in boys but not in girls. However, at 7 months, maternal PTSS were strongly related to child PTSS in both boys and girls. Significant 6-week maternal distress-child gender interactions suggested that maternal PTSS, especially avoidance, predicted greater 7-month PTSS but that this was primarily because of a significant relationship in females. CONCLUSIONS: Maternal distress was found to negatively impact subsequent child adjustment, particularly in females. These results underscore the importance of considering family-centered interventions for child PTSD, especially in girls.     

Posttraumatic growth in adolescent survivors of cancer and their mothers and fathers

OBJECTIVE: To describe posttraumatic growth (PTG) following childhood cancer survival and its association with demographic and disease/treatment variables, perceived treatment severity and life threat, and posttraumatic stress symptoms (PTSS). METHOD: Adolescent survivors of cancer (N = 150, ages 11-19), at least 1 year after treatment, and their mothers (N = 146) and fathers (N = 107) completed self-report measures of perceived treatment intensity and PTSS and a semistructured interview designed to identify posttraumatic responses and indicators of PTG including perceived positive changes for self, relationships, and life goals. RESULTS: A majority of adolescents and their mothers and fathers reported PTG. Greater perceived treatment severity and life threat, but not objective disease severity, was associated with PTG. PTG and PTSS were positively associated for the adolescent cancer survivors. Diagnosis after age 5 resulted in more perceived benefit and greater PTSS for adolescent survivors. CONCLUSION: Clarification of the concept and measurement of PTG after childhood cancer is warranted, as are prospective studies of the association of PTG and PTSS and the role of demographic variables and illness-specific appraisals.     

Post-traumatic stress symptoms in an elite unit of Brazilian police officers: prevalence and impact on psychosocial functioning and on physical and mental health

BACKGROUND: Frequent exposure to traumatic situations put police officers under an increased risk for developing post-traumatic stress disorder (PTSD). The goals of this study were to determine the current prevalence of post-traumatic stress symptoms (PTSS) in Brazilian police officers and to compare groups with and without PTSS in terms of associated morbidity. METHODS: Police officers from an elite unit (n=157) were asked to fill out a socio-demographic questionnaire, the 12-item General Health Questionnaire and the Post-Traumatic Stress Disorder Checklist-Civilian Version. The latter's scores were used to establish the diagnoses of "full PTSD" and of "partial PTSD". RESULTS: Prevalence rates of "full PTSD" and "partial PTSD" were 8.9% and 16%, respectively. Compared with the "no PTSD" group, police officers with "full PTSD" were five times more likely to be divorced (21.6% vs. 4.3%, p=0.008), felt that their physical health was poorer (64.3% vs. 6%, p<0.001), had more medical consultations during the last 12 months [2.00 (+/-1.62) vs. 1.09 (+/-1.42), p=0.03] and reported more often lifetime suicidal ideation (35.7% vs. 5.2%, p=0.002). LIMITATIONS: The sample was relatively small. A screening tool was employed instead of a semi-structured interview. The cross-sectional design is unsuitable for ascertaining cause-effect relations. CONCLUSIONS: PTSD prevalence in our sample was comparable to those reported for North American and Dutch policemen. The presence of "full PTSD" was associated with evidences of considerable morbidity. These findings may contribute to the development of effective policies aimed at the prevention and treatment of PTSD in law enforcement agents.     

PTSD after traumatic injury: an investigation of the impact of injury severity and peritraumatic moderators

Presence of injury is often examined as a risk factor for posttraumatic stress disorder (PTSD); however, results have been mixed regarding the relationship between injury severity and PTSD symptoms (PTSS). The present study examined subjective and objective injury severity ratings in traumatic injury victims to determine if they differentially predict PTSS. Results demonstrated that subjective, not objective, injury severity predicted PTSS at six weeks and three months post-trauma. The moderating impact of peritraumatic factors was also examined. Peritraumatic dissociation moderated the impact of subjective injury severity on PTSS. Findings indicate that subjective injury severity should be incorporated into early screeners for PTSD risk.     

Identity in adolescent survivors of childhood cancer

OBJECTIVE: To investigate identify formation among adolescent survivors of childhood cancer. Family functioning, perceived emotional support from family and peers, life stress, and anxiety produced by the cancer experience also were examined as they influenced identity development. METHOD: Participants were 52 adolescent survivors and their mothers recruited from a medical center and 42 healthy adolescent counterparts and their mothers recruited from the community. RESULTS: A greater frequency of survivors than their healthy peers was found within the foreclosed identity status. Factors associated with the foreclosed identity status included the cancer diagnosis, symptoms of posttraumatic stress disorder (PTSD), and family functioning characterized by greater levels of conflict. CONCLUSIONS: Data were interpreted to suggest that the foreclosed identity status may serve a protective function in assisting survivors to cope with the stressors of the cancer experience.     

Trait anxiety as an independent predictor of poor health‐related quality of life and post‐traumatic stress symptoms in rectal cancer

Objectives To determine the influence of trait anxiety on patient reports of health‐related quality of life (HRQoL) and post‐traumatic stress symptoms (PTSS) in a sample of rectal cancer survivors. Design Eighty patients who had been diagnosed with rectal cancer were assessed at two points in time in a longitudinal study. Methods At Time 1, soon after initial treatment, participants completed the State‐Trait Anxiety Inventory and the Temperament and Character Inventory Harm Avoidance scale, which were combined into a composite measure of trait anxiety. At Time 2, 2–5 years following Time 1, participants were assessed for HRQoL using the Functional Assessment of Cancer Therapy‐Colorectal scale (FACT‐C) and for PTSS using the Impact of Event Scale‐Revised (IES‐R). Results HRQoL and PTSS were generally favourable on average, although many of the patients reported faring poorly. Higher levels of trait anxiety were predictive of poorer scores on all of the FACT‐C and the IES‐R total and subscale measures. More severe faecal incontinence was associated with poorer scores on the FACT Emotional well‐being subscale, the FACT‐Colorectal Cancer Scale, and all of the IES‐R scales. Males were more likely than females to have poorer scores on the FACT Social well‐being subscale, and those patients who were further out from active treatment had more favourable scores on the FACT‐Colorectal Cancer Scale. The presence of a colostomy did not impact HRQoL or PTSS. Conclusion Trait anxiety had a significant influence on HRQoL and PTSS several years following diagnosis and treatment of rectal cancer.     

Patterns of appraisal and coping across different stressor conditions among former prisoners of war with and without posttraumatic stress disorder

Little is known about how survivors of extreme events cope with traumatic memories and subsequent negative life experiences. The present study compared (a) repatriated prisoners of war (RPWs) from World War II (WW II) with chronic posttraumatic stress disorder (PTSD), (b) RPWs without PTSD, and (c) noncombat veterans on measures of general psychological functioning, appraisal, and coping. Appraisal and coping were assessed under 2 stressor conditions: memories of war/captivity and recent negative life events. RPWs with PTSD reported poorer general psychological functioning; significantly less control over memories of WW II: and more frequent use of self-isolation, wishful thinking, self-blame, and social support in an effort to cope with these memories than did the 2 comparison groups. Fewer between-groups differences were found for the recent stressor condition. Findings are discussed in terms of factors that may explain the perseverance of coping difficulties associated with PTSD.     

Derealization and self‐harm strategies are used to regulate disgust,fear, and sadness in adult survivors of childhood sexual abuse

Emotion regulation (ER) difficulties have been identified as an important target for clinical intervention in the treatment of post‐traumatic stress disorder (PTSD) symptoms in survivors of childhood sexual abuse (CSA). However, there is limited research regarding the use of specific strategies to regulate specific emotions following exposure to traumatic events. The aim of the current study was to investigate the indirect effects of four trauma‐related emotions (anger, sadness, disgust, and fear) on PTSD severity via two mediators: derealization and self‐harm. In particular, we tested that if the two hypothetical mediators operate sequentially, derealization precedes self‐harm and/or self‐harm precedes derealization. A predominate female clinical sample (N = 109) of CSA survivors completed measures of experience of emotions, ER, and post‐traumatic stress. Bivariate and serial mediation analyses were conducted to test the direct and indirect effects of trauma‐related emotions on PTSD severity. Serial mediation analyses indicated that there were significant total effects of all trauma‐related emotions on PTSD severity. Three trauma‐related emotions (sadness, disgust, and fear) were indirectly associated to PTSD severity via derealization and self‐harm and via self‐harm and derealization. Results indicate that difficulties in regulating the emotions of sadness, disgust, and fear may result in more severe derealization and self‐harm as coping strategies, which in turn lead to greater PTSD severity. The sequence of mediators does not hold great importance in these pathways. Overall, our findings suggest that therapeutically targeting derealization and self‐harm might enable the reduction of PTSD among CSA survivors.     

Structure of orbitofrontal cortex and its longitudinal course in cancer-related post-traumatic stress disorder

The neurobiological basis of cancer-related post-traumatic stress disorder (PTSD) has never been studied. We investigated brain structural alterations and the longitudinal courses in patients with cancer-related PTSD. Baseline scans using magnetic resonance imaging were performed in 14 cancer survivors with PTSD, 100 without PTSD, and 70 healthy subjects. Follow-up scans were performed 2 years later in 76 cancer survivors (PTSD, n=9; non-PTSD, n=67). Using voxel-based morphometry, the gray matter volume (GMV) of the cancer survivors with PTSD was compared with the GMVs of those without PTSD and of the healthy subjects. The effects of the interactions between the diagnosis and the timing of the GMV measurements were examined. The GMV of the right orbitofrontal cortex (OFC) was significantly smaller in cancer survivors with PTSD than in those without PTSD or healthy subjects. The interaction between the diagnosis and the timing of the right OFC's GMV measurement was not significant. The OFC, which is thought to be involved in the extinction of fear conditioning and the retrieval of emotional memory, might play an important role in the pathophysiology of PTSD. Moreover, the OFC's GMV may remain constant after the development of cancer-related PTSD.     

Identification of traumatic stress reactions in women at increased risk for breast cancer

It has been shown that the diagnosis and treatment of cancer may constitute a traumatic event that generates in patients and some of their family members traumatic reactions that are consistent with the symptom profile of posttraumatic stress disorder (PTSD). The present study was conducted to establish the degree to which women at increased familial risk for breast cancer showed such traumatic reactions and to establish which demographic or psychological variables may contribute to the experience of such traumatic reactions in at-risk individuals. Seventy-three women from the Revlon UCLA Breast Center High Risk Clinic were assessed for traumatic reactions that might be consistent with the DSM-IV criteria for PTSD. The results showed that women at increased risk for breast cancer exhibited traumatic responses similar to those reported by cancer patients. When the authors used a self-report instrument that maps onto DSM-IV criteria, 4% of the study subjects reported symptoms consistent with criteria for a potential diagnosis of PTSD, and an additional 7% of the subjects reported symptoms consistent with potentially subclinical levels of PTSD, according to DSM-IV criteria.     

Delayed-onset PTSD: a prospective study of injury survivors

BACKGROUND: Recent studies have indicated that delayed-onset posttraumatic stress disorder (PTSD) (i.e., the development of PTSD more than 6 months posttrauma) is generally characterised by subsyndromal diagnoses within the first 6 months. This study sought to examine the relationship between sub-clinical levels of PTSD symptoms at 3 months posttrauma and delayed onset PTSD at 12 months in a large sample of traumatic injury survivors. METHODS: Three hundred and one consecutively admitted injury survivors were assessed at 3 and 12 months posttrauma. PTSD was diagnosed according to DSM-IV criteria, while partial and subsyndromal diagnoses were based on recent definitions developed by Mylle and Maes [Mylle, J., Maes, M., 2004. Partial posttraumatic stress disorder revisited. J. Affect. Disord. 78, 37-48]. RESULTS: Eight percent of participants was diagnosed with 3-month PTSD while 10% was diagnosed with 12-month PTSD. Nearly half (47%) of 12-month PTSD cases were of delayed onset. The majority of those with delayed-onset were diagnosed with partial or subsyndromal PTSD at 3 months. Ten percent of delayed onset cases did not meet partial or subsyndromal criteria. LIMITATIONS: As symptoms were not assessed at 6 months (the DSM cut-off for delayed PTSD), it could not be conclusively determined that delayed-onset cases had not developed PTSD between 3 and 6 months posttrauma. CONCLUSION: A considerable proportion of 12-month PTSD diagnoses was delayed in onset. While most demonstrated 3-month morbidity in the form of partial and subsyndromal diagnoses, a minority did not. Thus, clinicians should consider subthreshold diagnoses as potential risk factors for delayed-onset PTSD. Future research is required to identify factors that may predict delayed-onset PTSD in trauma survivors without evidence of prior PTSD pathology.     

特大爆炸事故幸存者创伤后应激障碍的初步研究

目的 :了解特大意外爆炸事故对幸存者心理健康水平、PTSD的发生、PTSD的临床特征及其相关因素的影响。方法 :在爆炸事故后 3 -5个月期间 ,调查事故幸存者 ( 2 8例 ,研究组 )的一般情况、创伤经历、受伤程度及对善后处理的满意程度 ,采用创伤后应激反应症状清单、事件影响量表 (IES)、SCL -90、康奈尔医学指数 (CMI)、SDS、SAS评定 ,并与对照 ( 3 0例 )进行比较 ,分析PTSD诊断的相关因素。结果 :研究组IES、SDS、SAS、CMI、总分、CMIMR和SCL -90各统计指标与对照组的差异极其显著 (P <0 0 1)。诊断为PTSD者 78 6% ,PTSD的诊断与IES总分、现场暴露程度和对善后处理的满意程度相关。结论 :特大爆炸事故可导致暴露者出现不同程度的心理痛苦 ,PTSD的发生与创伤事件的暴露程度和对善后处理的满意程度相关。     

Sleep complaints are not corroborated by objective sleep measures in post-traumatic stress disorder: a 1-year prospective study in survivors of motor vehicle crashes

Disturbed sleep is a common complaint among patients with post-traumatic stress disorder (PTSD). However, laboratory studies of sleep in PTSD have provided inconsistent evidence of objective sleep disturbances. A major shortcoming of most previous studies is the fact that they were performed retrospectively in patients with chronic PTSD, often complicated by comorbid psychiatric disorders and drug abuse. Thus, little is known about the development of sleep disturbances in recently traumatized subjects. In this study, 102 motor vehicle collision (MVC) survivors were followed from the time of collision throughout 1 year. Nineteen subjects hospitalized for elective surgery served as a comparison group. Subjective quality of sleep was assessed using the mini-Sleep Questionnaire and the Sleep Habit Questionnaire. In addition, a 48-h actigraphic recording was obtained 1 week, 3 and 12 months after the collision. At 12 months, a structured clinical interview (SCID) was administered to reach a formal diagnosis of PTSD. Twenty-six of the MVC survivors, but none of the comparison subjects, met the diagnostic criteria for PTSD. While MVC survivors with PTSD reported markedly poorer sleep as reflected by significantly higher scores on the mini-Sleep Questionnaire, there were no significant differences between the three groups on the actigraphic measures that were largely normal. These results, which were obtained in subjects with no evidence of active psychiatric symptoms at the time of trauma and free of psychotropic or hypnotic medications, further support previous polysomnographic (PSG) studies suggesting that altered sleep perception, rather than sleep disturbance per se, may be the key problem in PTSD.     

A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator

BACKGROUND: Brief interventions are needed in dealing with traumatic stress problems in large survivor populations after devastating earthquakes. The present study examined the effectiveness of a single session of exposure to simulated tremors in an earthquake simulator and self-exposure instructions in reducing post-traumatic stress disorder (PTSD). METHOD: Participants were consecutively recruited from among survivors screened during field surveys in the disaster region in Turkey. Thirty-one earthquake survivors with PTSD were assigned either to a single session of behavioural treatment (n=16) or to repeated assessments (RA; n=15). Assessments in the treatment group were at 4, 8, 12, 24 weeks and 1-2 years post-treatment. The RA cases were assessed at baseline and 4 and 8 weeks after trial entry, after which they received the same treatment and were followed up at 4, 12, 24 weeks and 1-2 years. RESULTS: Between-group treatment effects at week 8 were significant on measures of fear, PTSD and self- and assessor-rated global improvement. Improvement rates were 40% at week 4, 72% at week 12, 80% at week 24, and 80% at 1-2-years' follow-up, with large effect sizes on fear and PTSD measures. Post-session reduction in fear of earthquakes and increased sense of control over fear at follow-up related to improvement in PTSD. CONCLUSION: The study provided further evidence of the effectiveness of a single session of behavioural treatment in reducing fear and PTSD in earthquake survivors. Future research needs to examine the usefulness of earthquake simulators in increasing psychological preparedness for earthquakes.     

Post-traumatic stress disorder and major depression among Italian Nazi concentration camp survivors: a controlled study 50 years later

BACKGROUND: The study aimed to assess the current and lifetime rates of post-traumatic stress disorder (PTSD) and major depression (MDD) among Nazi concentration camps survivors. METHODS: We investigated 51 Italian political deportees and 47 Resistance Movement veterans who reported traumatic experiences during active service. The Structured Clinical Interview for DSM-IV was used to assess the presence of PTSD and MDD. The Dissociative Experiences Scale and the shorter version of the Hopkins Symptoms Checklist were also administered. RESULTS: The lifetime rates of PTSD and MDD were 35.3% and 45.1% respectively among deportees and 4.3% and 6.4% among former partisans. The current rates for PTSD and MDD were 25.5% and 33.3% among deportees and 4.3% and 4.3% among former partisans. Dissociative symptoms were more severe among deportees than among Resistance movement veterans. CONCLUSIONS: Concentration camp internment, even for political reasons, appears to have severe long-term psychiatric consequences.