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.     

Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women

Symptoms of depression and posttraumatic stress disorder (PTSD) were examined for their association with health status in a sample of sexual assault victims. Hypotheses were that symptoms of each disorder would account for unique variance in health status among individuals exposed to traumatic stressors. Fifty-seven sexually assaulted college women were assessed for prior victimization history, assault characteristics, and depressive and PTSD symptoms. When prior history of sexual victimization, assault severity, and physical reactions during the assault were controlled, hierarchical multiple regression models indicated that symptoms of PTSD and depression were significantly associated with global health perceptions and severity of self-reported health symptoms. Only PTSD symptoms were significantly associated with reproductive health symptoms. The results suggest that both symptoms of PTSD and depression account for the relationship between exposure and health impairment among sexual assault victims.     

Posttraumatic stress disorder symptoms during the first six months after traumatic brain injury

Controversy exists regarding the rate and risk factors for posttraumatic stress disorder (PTSD) following traumatic brain injury (TBI). The authors determined the rate and phenomenology of PTSD symptoms in the 6 months after TBI by conducting a prospective cohort study of 124 subjects who completed the PTSD Checklist-Civilian Version. The cumulative incidence of meeting PTSD symptom criteria at 6 months was 11% and full criteria 5.6%. Prevalence peaked at 1 month (10%). Eighty-six percent had another psychiatric disorder and 29% a history of PTSD. Symptoms were associated with not completing high school, assault, recalling being terrified or helpless, and positive toxicology. PTSD after TBI is rare and the relation to risk factors and comorbidities must be examined.     

Traumatic events and posttraumatic stress disorder in an urban population of young adults

To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population.     

Assault characteristics and posttraumatic stress disorder in rape victims

A diagnosis of posttraumatic stress disorder (PTSD) encompasses several of the symptoms associated with the response to rape. The object of this study was to determine the incidence of PTSD among 51 rape victims and to compare the groups with and without PTSD with respect to the characteristics of the assaults. The results showed that 70% of the victims had PTSD and further suggested that PTSD was likely to be a long-term problem for these women. The results supported the view that psychological treatment approaches to rape victims should take into account the posttraumatic nature of the response. The incidence of rapes by strangers, of physical force being used, of weapons being displayed and of injuries being sustained by the victim were all higher in the group of women who had PTSD. These are all features that can be readily identified in the initial assessment of the rape victim and may help to identify the victims at risk of developing long-term psychological sequelae after rape. Appropriate therapeutic action taken early may influence the prognosis for a significant proportion of rape victims.     

Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001

Objective

This study examined the association of lifetime traumatic stress with psychiatric diagnostic status and symptom severity in veterans serving in the US military after 9/11/01.

Method

Data from 356 US military veterans were analyzed. Measures included a standardized clinical interview measure of psychiatric disorders, and paper-and-pencil assessments of trauma history, demographic variables, intellectual functioning, posttraumatic stress disorder (PTSD) symptoms, depression, alcohol misuse, and global distress.

Results

Ninety-four percent of respondents reported at least one traumatic stressor meeting DSM-IV criterion A for PTSD (i.e., life threatening event to which the person responded with fear, helplessness or horror), with a mean of four criterion A traumas. Seventy-one percent reported serving in a war-zone, with 50% reporting occurrence of an event meeting criterion A. The rate of current psychiatric disorder in this sample was: 30% PTSD, 20% major depressive disorder, 6% substance abuse or dependence and 10% for the presence of other Axis I psychiatric disorders. After accounting for demographic covariates and combat exposure, childhood physical assault and accident/disasters were most consistently associated with increased likelihood of PTSD. However, PTSD with no comorbid major depressive disorder or substance use disorder was predicted only by combat exposure and adult physical assault. Medical/unexpected-death trauma and adult physical assault were most consistently associated with more severe symptomatology.

Conclusions

Particular categories of trauma were differentially associated with the risk of psychiatric diagnosis and current symptom severity. These findings underscore the importance of conducting thorough assessment of multiple trauma exposures when evaluating recently post-deployed veterans.     

Panic following trauma: the etiology of acute posttraumatic arousal

Two studies examined the contributing factors for panic symptoms following trauma. In Study 1, survivors of sexual and nonsexual assaults (N=105) were assessed at 2 weeks postcrime. Prior trauma, psychiatric history, crime characteristics, and peritraumatic dissociation were assessed. Posttraumatic panic was modestly predicted by childhood sexual abuse (CSA) experiences, a history of Anxiety and Depression, and peritraumatic dissociation. Childhood physical abuse (CPA), Adult Victimization, crime variables, and a prior history of Substance Use disorders and posttraumatic stress disorder (PTSD) were not implicated. In Study 2, the role of peritraumatic panic in predicting later arousal was also examined in a similar sample who were assessed within 6 weeks of their trauma (N=93). Presence of significant arousal during trauma predicted frequency of posttrauma panic attacks, but not its severity. In contrast to Study 1, prior history of PTSD, perception of life threat, and the index trauma being a sexual assault all predicted posttrauma panic, whereas prior trauma exposure and depression did not. These findings are discussed in terms of cognitive and arousal factors that may influence posttrauma panic.     

Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology

OBJECTIVE: This study examined whether trauma exposure before, during, and/or after military service contributed to current levels of post-traumatic stress disorder (PTSD) and adjustment. Further, we investigated whether trauma exposure before military service was mediated or moderated by military trauma in its effects on current PTSD and adjustment. METHOD: In this retrospective study, archival data from the medical records of 422 male veterans diagnosed with PTSD between December 2001 and July 2004 at a Veterans Administration Medical Center PTSD clinic were analyzed. Measures included the Clinician-Administered PTSD Scale interview as well as self-report measures assessing trauma history, health problems, and general psychopathology (including PTSD). RESULTS: Findings indicated that nonmilitary-related trauma was prevalent in this sample (90%). Regression analyses for PTSD symptom severity revealed that age, greater combat exposure, and a history of physical assault after military service were significantly associated with more severe PTSD symptoms. Childhood physical abuse, adult sexual trauma, and a history of being physically assaulted during military service were also significantly associated with PTSD symptom severity. Mediational analyses indicated that childhood trauma was associated with both adult trauma and increased symptomatology on various outcome measures. Moderational analyses indicated that adult trauma exposure moderated the effect of childhood trauma exposure on health complaints. CONCLUSIONS: Results suggest that several variables, including age, greater combat exposure, and premilitary and postmilitary traumas, are associated with increased PTSD symptomatology. This finding underscores the importance of conducting a thorough assessment of trauma when diagnosing PTSD.     

Effects of adolescent trauma exposure on risky behavior in college women

Individuals with sexual assault or abuse histories are likely to engage in risky sexual and other self-destructive behaviors. Studies of these behaviors, however, have focused on target traumatic events without accounting for other events in the participant's history, recency of the events, and/or developmental level at time of occurrence. The present study addressed some of these confounds by creating groups with unique and non-overlapping trauma histories among adolescent participants whose first trauma occurred at age 12 or older. Sophomore women from six regional campuses were screened in a two-stage procedure, and 209 of 363 final interviewees were included in the present report. These were assigned to a no trauma group, or to one of five groups with a unique trauma history: a single traumatic loss, a single physical assault, a single sexual assault, ongoing sexual or physical abuse, or multiple single traumas. Risky sexual behavior, suicidal ideation, and elevated perpetration of violence were most prominent among those with ongoing abuse exposure, although a single exposure to interpersonal violence during adolescence was sufficient for some risky behaviors. Major depression (MDD) and posttraumatic stress disorder (PTSD) were associated with many of the behaviors, and may serve to heighten risk.     

Investigation of telomere length and psychological stress in rape victims

Background: Women are at an increased risk of depression and other mental health problems following rape. Various etiological factors for depression, including predisposing genetic factors, have been identified. Telomeres are repetitive nucleoprotein structures located at chromosomal ends that protect them from premature degradation. Telomeres reduce in length with each cell division, resulting in cellular senescence and apoptosis. Methods: Relative quantification of telomeric repeats using qPCR was performed to investigate whether shorter relative leukocyte telomere length (LTL) in a cohort of 64 rape victims was associated with resilience, the development of rape trauma‐related major depressive disorder (MDD) or the development of posttraumatic stress disorder (PTSD) after 3 months. Results: Out of the 64 participants, 23 participants were diagnosed with MDD at baseline and 31 after 3 months. Nine participants were diagnosed with PTSD (MDD and PTSD specifically related to the trauma). No significant associations were observed between relative LTL and resilience or the development of MDD at either baseline or after 3 months in this cohort. However, a marginally significant association was evident between relative LTL and PTSD status. Conclusions: The significant association between relative LTL and PTSD suggests that shorter relative LTL might have acted as a predisposing factor in the development of PTSD after a severely traumatic event. The results of this study indicate that telomere shortening may be an important marker of PTSD risk, with implications for early intervention and timely treatment, and as such warrant replication in a larger cohort. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.     

Trauma, traumatic stress and depression following an airline catastrophy]

OBJECTIVES: Acute stress responses following a trauma indicate a sensitivity to posttraumatic stress disorder (PTSD), and is often comorbid with depression. Earlier exposure to a traumatic event can be an additional risk factor in PTSD development. METHOD: Eight injured patients hospitalized after a major air disaster were monitored and assessed for a month. The symptoms of acute stress response (ASR), PTSD, and depression were assessed using DSM-IV criteria immediately following the accident, then each week thereafter. The Impact of Event Scale (IES) was completed on the 30th day (D30). RESULTS: Four patients presented with an ASR, and 3 of them had a PTSD at D30. Of those 3 patients with PTSD, 2 presented with an associated depression. These 2 patients had been exposed to a traumatic event before the disaster; and a significant relation was found between the history of the earlier trauma and the PTSD associated with depression. CONCLUSION: The traumatized victims with a history of earlier traumas seem more susceptible to developing a PTSD associated with depression.     

Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime.

OBJECTIVE: To compare the relation between peritraumatic dissociation and acute stress and the early development of posttraumatic stress disorder (PTSD) in victims of general crime. METHOD: A total of 48 subjects were assessed within 24 hours of the trauma, using the Peritraumatic Dissociative Experiences Questionnaire Self-Report Version (PDEQ-SRV). They were followed longitudinally to assess acute stress (2 weeks after the assault,) using the Standford Acute Stress Reaction Questionnaire (SASRQ), and posttraumatic stress (at 5 weeks), using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES). RESULTS: Among PTSD subjects mean PDEQ scores were significantly higher (mean 3, SD 0.9) than in those without PTSD (mean 2.3, SD 0.7) (t = 2.78, df 46, P = 0.007). Among PTSD subjects, mean SASRQ scores were significantly higher (mean 97.9, SD 29.2) than in those without PTSD (mean 54.8, SD 28.2) (t = 4.9, df 46, P = 0.00007). CONCLUSIONS: High levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute reexperiencing can help the clinician identify subjects at highest risk.     

Posttraumatic stress disorder and depression in battle-injured soldiers

OBJECTIVE: This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. METHOD: The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed. RESULTS: At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length. CONCLUSIONS: Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.     

Bureaucratic Structure and Impersonal Experience in Mental Hospitals

Abstract

Individuals with sexual assault or abuse histories are likely to engage in risky sexual and other self—destructive behaviors. Studies of these behaviors, however, have focused on target traumatic events without accounting for other events in the participant's history, recency of the events, and/or developmental level at time of occurrence. The present study addressed some of these confounds by creating groups with unique and non—overlapping trauma histories among adolescent participants whose first trauma occurred at age 12 or older. Sophomore women from six regional campuses were screened in a two—stage procedure, and 209 of 363 final interviewees were included in the present report. These were assigned to a no trauma group, or to one of five groups with a unique trauma history: a single traumatic loss, a single physical assault, a single sexual assault, ongoing sexual or physical abuse, or multiple single traumas. Risky sexual behavior, suicidal ideation, and elevated perpetration of violence were most prominent among those with ongoing abuse exposure, although a single exposure to interpersonal violence during adolescence was sufficient for some risky behaviors. Major depression (MDD) and posttraumatic stress disorder (PTSD) were associated with many of the behaviors, and may serve to heighten risk.     

Potential risk factors for rape in three ethnic groups

This article describes the frequency of possible risk factors that emerged during a cross-cultural study of psychosocial response to sexual assault among African-American, Hispanic, and non-Hispanic white women presenting for treatment at a major urban rape treatment center. Of 881 victims screened, 51% had no observable risk factors while 49% fell into categories of variables that previous research has associated with increased vulnerability. Included were mental disability (psychiatric or developmental), a prior history of rape or incest, tourist or visitor status (site unfamiliarity), and homelessness. Ethnic groups differed significantly in these categories, suggesting socioeconomic and cultural variables that may affect rape statistics and that should be taken into account in rape prevention programs in the community.     

A twin registry study of familial and individual risk factors for trauma exposure and posttraumatic stress disorder

This study examines the association of individual and familial risk factors with exposure to trauma and posttraumatic stress disorder (PTSD) in male twins (N = 6744) from the Vietnam Era Twin Registry. Independent reports of familial psychopathology from co-twins were used to avoid the potential biases of the family history method. Risk for exposure to traumatic events was increased by service in Southeast Asia, preexisting conduct disorder, preexisting substance dependence, and a family history of mood disorders whose effects appear to be partly genetic. Preexisting mood disorders in the individual were associated with decreased odds of traumatic exposure. Risk of developing PTSD following exposure was increased by an earlier age at first trauma, exposure to multiple traumas, paternal depression, less than high school education at entry into the military, service in Southeast Asia, and preexisting conduct disorder, panic disorder or generalized anxiety disorder, and major depression. Results suggest the association of familial psychopathology and PTSD may be mediated by increased risk of traumatic exposure and by preexisting psychopathology.     

Associations between Pittsburgh Sleep Quality Index factors and health outcomes in women with posttraumatic stress disorder

ObjectiveThe Pittsburgh Sleep Quality Index (PSQI) is a widely used measure of subjective sleep disturbance in clinical populations, including individuals with posttraumatic stress disorder (PTSD). Although the severity of sleep disturbance is generally represented by a global symptom score, recent factor analytic studies suggest that the PSQI is better characterized by a two- or three-factor model than a one-factor model. This study examined the replicability of two- and three-factor models of the PSQI, as well as the relationship between PSQI factors and health outcomes, in a female sample with PTSD.MethodsThe PSQI was administered to 319 women with PTSD related to sexual or physical assault. Confirmatory factor analyses tested the relative fit of one-, two-, and three-factor solutions. Bivariate correlations were performed to examine the shared variance between PSQI sleep factors and measures of PTSD, depression, anger, and physical symptoms.ResultsConfirmatory factor analyses supported a three-factor model with Sleep Efficiency, Perceived Sleep Quality, and Daily Disturbances as separate indices of sleep quality. The severity of symptoms represented by the PSQI factors was positively associated with the severity of PTSD, depression, and physical symptoms. However, these health outcomes correlated as much or more with the global PSQI score as with PSQI factor scores.ConclusionsThese results support the multidimensional structure of the PSQI. Despite this, the global PSQI score has as much or more explanatory power as individual PSQI factors in predicting health outcomes.     

Posttraumatic stress disorder and associated risk factors in Canadian peacekeeping veterans with health-related disabilities.

OBJECTIVES: This study investigates posttraumatic stress disorder (PTSD) and its associated risk factors in a random, national, Canadian sample of United Nations peacekeeping veterans with service-related disabilities. METHODS: Participants included 1016 male veterans (age < 65 years) who served in the Canadian Forces from 1990 to 1999 and were selected from a larger random sample of 1968 veterans who voluntarily and anonymously completed a general health survey conducted by Veterans Affairs Canada in 1999. Survey instruments included the PTSD Checklist-Military Version (PCL-M), Center for Epidemiological Studies-Depression Scale (CES-D), and questionnaires regarding life events during the past year, current stressors, sociodemographic characteristics, and military history. RESULTS: We found that rates of probable PTSD (PCL-M score > 50) among veterans were 10.92% for veterans deployed once and 14.84% for those deployed more than once. The rates of probable clinical depression (CES-D score > 16) were 30.35% for veterans deployed once and 32.62% for those deployed more than once. We found that, in multivariate analyses, probable PTSD rates and PTSD severity were associated with younger age, single marital status, and deployment frequency. CONCLUSIONS: PTSD is an important health concern in the veteran population. Understanding such risk factors as younger age and unmarried status can help predict morbidity among trauma-exposed veterans.     

Acute psychological reactions in assault victims of non-domestic violence: Peritraumatic dissociation,post-traumatic stress disorder,anxiety and depression

The aims of this study were to investigate acute and subacute post-traumatic reactions in victims of physical non-domestic violence. A Norwegian sample of 138 physically assaulted victims was interviewed and a questionnaire was completed. The following areas were examined: the frequency and intensity of acute and subacute psychological reactions such as peritraumatic dissociation (PD), post-traumatic stress disorder (PTSD) and anxiety and depression; the relationship between several psychological reactions; the relationship between psychological reactions and level of physical injury, perceived life threat, and potential of severe physical injury, and the relationship between psychological reactions and socio-demographic variables. The following distress reactions were measured retrospectively: PD, PTSD, and anxiety and depression. Thirty-three per cent of the victims scored as probable PTSD cases according to the Post Traumatic Symptoms Scale 10 (PTSS-10); the corresponding Impact of Event Scale-15 (IES-15) score identified prevalence of 34% respectively. Forty-four per cent scored as cases with probable anxiety and depression, according to the Hopkins Symptom Check List 25 (HSCL-25). Severity of perceived threat predicted higher scores on all measures of psychological reactions. There were no statistically significant differences between acute and subacute groups on PD, PTSS-10, IES-15, IES-22 and HSCL-25 according to measured means (and standard deviations) and occurrence of probable cases and risk level cases. The results showed no connection between severity of physical injury and caseness. The acute psychological impairment that results from assault violence may have a deleterious effect on the mental health of victims.     

Posttraumatic stress disorder and depression following trauma: understanding comorbidity

OBJECTIVE: Posttraumatic stress disorder (PTSD) and major depression occur frequently following traumatic exposure, both as separate disorders and concurrently. This raises the question of whether PTSD and depression are separate disorders in the aftermath of trauma or part of a single general traumatic stress construct. This study aimed to explore the relationships among PTSD, depression, and comorbid PTSD/depression following traumatic injury. METHOD: A group of 363 injury survivors was assessed just prior to discharge from hospital and 3 and 12 months postinjury. Canonical correlations were used to examine the relationship between PTSD and depression symptom severity and a set of predictor variables. Multinomial logistic regression was used to identify whether the diagnostic categories of PTSD, depression, and comorbid PTSD/depression were associated with different groups of predictors. RESULTS: The majority of psychopathology in the aftermath of trauma was best conceptualized as a general traumatic stress factor, suggesting that when PTSD and depression occur together, they reflect a shared vulnerability with similar predictive variables. However, there was also evidence that in a minority of cases at 3 months, depression occurs independently from PTSD and was predicted by a different combination of variables. CONCLUSIONS: While PTSD and comorbid PTSD/depression are indistinguishable, the findings support the existence of depression as a separate construct in the acute, but not the chronic, aftermath of trauma.