Posttraumatic stress disorder in victims of sexual assault--related to depression or physical symptoms]

To clarify the clinical characteristics of mental disorders in sexual assault victims, we investigated the victims focusing on PTSD, depression, physical symptoms, and their relationships. SUBJECTS: Participants were 46 treatment-seeking female victims of sexual assault who consulted four hospitals, one clinic and one psychological services center, between February 2000 and April 2001. The mean +/- SD age of the participants was 28.0 +/- 8.9 years, the mean +/- SD period from the traumatic event was 94.5 +/- 88.0 months. PTSD was diagnosed and evaluated using a structured interview (Clinician-Administered PTSD Scale for DSM-IV: CAPS). Depressive symptoms were assessed using Self-rating Depression Scales (SDS). Physical symptoms were assessed using the Physical symptom scale developed by the authors. RESULTS: Thirty-two participants (69.6%) met the criteria for PTSD in their current diagnosis, and 41 (89.1%) had the disorder at some point during their lives. SDS score and Physical symptom scale score of the PTSD group were significantly higher than those scores of the non-PTSD group. The SDS score correlated with the Avoidant-numbing score. The Physical symptoms scale score correlated with the Intrusion score and Hyperarousal score. We think that the PTSD group had the co-existing depression secondary to PTSD. Although previous studies have discussed the relationship between physical symptoms and Hyperarousal symptoms, this study suggested that physical symptoms were related to Intrusion symptoms as much as Hyperarousal symptoms. We found 2 patterns when PTSD patients reported physical symptoms related to Intrusion symptoms. The patterns were caused (1) by physiological reactivity on exposure to internal or external cues that symbolize an aspect of the traumatic event, and caused (2) by somatic reenactment symptoms. CONCLUSION: We discuss the importance for clinicians to distinguish Intrusion symptoms from physical symptoms as well as Avoidant-numbing symptoms from depressive symptoms on PTSD diagnosis. Because sexual assault victims have difficulty in talking about the traumatic experience, clinicians should pay attention to these findings in developing therapeutic plans for the victims.     

Convergent validity of measures of PTSD in Vietnam combat veterans

The authors evaluated the convergent validity of several widely used psychometric tests of posttraumatic stress disorder (PTSD) symptoms against DSM-III-R criteria for PTSD in 130 Vietnam combat veterans. Significant positive correlations were found between these instruments and the number of DSM-III-R symptoms endorsed, supporting the validity of psychometric instruments as continuous measures of PTSD symptom severity. The various psychometric measures also correlated moderately with one another, suggesting that they assess related but somewhat separate PTSD phenomena. Finally, predicted relationships between stressors and symptoms were supported by significant correlations between degree of traumatic combat exposure and DSM-III-R and psychometric indexes of PTSD.     

A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions

Although efforts to prevent posttraumatic stress disorder (PTSD) have met with relatively limited success, theoretically driven preventive approaches with promising efficacy are emerging. The current article critically reviews investigations of PTSD prevention programs that target persons at risk for being exposed to a traumatic event or who have been exposed to a traumatic event. This review uniquely extends prior reviews in this area by using theories of PTSD to suggest future directions in the area of PTSD prevention. The authors first discuss the primary mechanisms of action believed to account for the failure for PTSD symptoms to remit among a substantial minority of traumatic event-exposed individuals. Second, empirical progress in PTSD prevention efforts is reviewed. Third, the authors consider how existing prevention programs target these mechanisms of action. Finally, the authors consider directions for future research in the area of targeted PTSD prevention.     

Elevated cerebrospinal fluid substance p concentrations in posttraumatic stress disorder and major depression

OBJECTIVE: The authors tested the hypothesis that concentrations of the pain-transmitting neuropeptide substance P are elevated in the CSF of patients with major depression or posttraumatic stress disorder (PTSD), which have overlapping symptoms. The authors also sought to determine if CNS substance P concentrations change on provocation of symptoms in PTSD patients. METHOD: The authors measured CSF substance P concentrations in medication-free patients with either major depression or PTSD and in healthy comparison subjects. Next, using a within-subject, crossover design, the authors sampled CSF for 6 hours through an indwelling subarachnoid catheter in PTSD patients before, during, and after exposure to a 60-minute traumatic or neutral videotape stimulus. RESULTS: Both depressed and PTSD patients had significantly elevated basal CSF substance P concentrations. In the challenge study, marked increases in CSF substance P concentrations were found only after precipitation of PTSD symptoms. CSF substance P concentrations increased by 169% and 90.6% of baseline levels at 10 and 70 minutes, respectively, after the start of the traumatic videotape but changed by only 1.1% and -8.1% of baseline levels 10 and 70 minutes after the start of the neutral videotape. CONCLUSIONS: These results suggest that elevated CNS substance P concentrations are involved in both major depression and PTSD. The marked increase in CSF substance P concentrations during and after the symptom-provoking stimulus, but not after the neutral stimulus, implicates CNS release of substance P in the mechanism of acute PTSD symptoms. These data also reveal that CNS substance P responds acutely to psychological stress in humans.     

The trauma of first episode psychosis: the role of cognitive mediation

OBJECTIVE: First episode psychosis can be a distressing and traumatic event which has been linked to comorbid symptomatology, including anxiety, depression and PTSD symptoms (intrusions, avoidance, etc.). However, the link between events surrounding a first episode psychosis (i.e. police involvement, admission, use of Mental Health Act, etc.) and PTSD symptoms remains unproven. In the PTSD literature, attention has now turned to the patient's appraisal of the traumatic event as a key mediator. In this study we aim to evaluate the diagnostic status of first episode psychosis as a PTSD-triggering event and to determine the extent to which cognitive factors such as appraisals and coping mechanisms can mediate the expression of PTSD (traumatic) symptomatology. METHOD: Approximately 1.5 years after their first episode of psychosis, patients were assessed for traumatic symptoms, conformity to DSM-IV criteria for posttraumatic stress disorder (PTSD), and their appraisals of the traumatic events and coping strategies. Psychotic symptomatology was also measured. RESULTS: 31% of the sample of 35 patients who agreed to participate reported symptoms consistent with a diagnosis of PTSD. Although no relationship was found between PTSD (traumatic) symptoms and potentially traumatic aspects of the first episode (including place of treatment, detention under the MHA etc.), intrusions and avoidance were positively related to retrospective appraisals of stressfulness of the ward (i.e. the more stressful they rated it the greater the number of PTSD symptoms) and the patient's coping style (sealers were less likely to report intrusive re-experiencing but more likely to report avoidance). CONCLUSIONS: The results call into question whether it is possible to make claims for a simple causal link between psychosis and PTSD. Instead patients' appraisals of potentially traumatic events and their coping styles may mediate the traumatic impact of a first episode of psychosis.     

Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: a twin study

OBJECTIVE: Posttraumatic stress disorder (PTSD) develops in only a subset of persons exposed to traumatic stress, suggesting the existence of stressor and individual differences that influence risk. In this study the authors examined the heritability of trauma exposure and PTSD symptoms in male and female twin pairs of nonveteran volunteers. METHOD: Scores on a traumatic events inventory and a DSM-IV PTSD symptom inventory were examined in 222 monozygotic and 184 dizygotic twin pairs. Biometrical model fitting was conducted by using standard statistical methods. RESULTS: Additive genetic, common environmental, and unique environmental effects best explained the variance in exposure to assaultive trauma (e.g., robbery, sexual assault), whereas exposure to nonassaultive trauma (e.g., motor vehicle accident, natural disaster) was best explained by common and unique environmental influences. PTSD symptoms were moderately heritable, and the remaining variance was accounted for by unique environmental experiences. Correlations between genetic effects on assaultive trauma exposure and on PTSD symptoms were high. CONCLUSIONS: Genetic factors can influence the risk of exposure to some forms of trauma, perhaps through individual differences in personality that influence environmental choices. Consistent with symptoms in combat veterans, PTSD symptoms after noncombat trauma are also moderately heritable. Moreover, many of the same genes that influence exposure to assaultive trauma appear to influence susceptibility to PTSD symptoms in their wake.     

Hippocampal volume in adult burn patients with and without posttraumatic stress disorder

OBJECTIVE: Increasing evidence suggests that posttraumatic stress disorder (PTSD) is associated with small hippocampal size. The authors compared trauma-exposed subjects with PTSD and trauma-exposed subjects without PTSD to clarify whether small hippocampal size is related to PTSD or to mere trauma exposure. METHOD: Three-dimensional structural magnetic resonance imaging was used to assess hippocampal volumes in 30 men who had recently been exposed to a severe burn trauma and 15 matched healthy comparison subjects. RESULTS: Relative to the comparison subjects, the trauma-exposed subjects with PTSD (N=15) as well as the trauma-exposed subjects without PTSD (N=15) had significantly smaller volumes of the right hippocampus (subjects with PTSD: -12%; subjects without PTSD: -13%). Larger total areas of burned body surface were significantly related to smaller left hippocampal volumes. Use of analgesic/sedative treatment with the N-methyl-d-aspartic acid (NMDA) antagonist ketamine was significantly related to larger right hippocampal volumes and to stronger PTSD symptoms. CONCLUSIONS: PTSD is not a necessary condition for small hippocampal size in trauma-exposed individuals. Rather, the results provide evidence that smaller hippocampal size in trauma-exposed individuals is a result of traumatic stress. The posttraumatic application of NMDA antagonists may protect against hippocampal damage induced by traumatic stressors but increases the patient's risk of developing PTSD symptoms.     

Characteristics of the traumatic stressors experienced by rural first responders

First responders routinely experience work-related events that meet the definition of a traumatic stressor. Despite the high exposure to traumatic events, prevalence rates of posttraumatic stress disorder (PTSD) are relatively low. This discrepancy points to the potential value of identifying factors that distinguish those traumatic stressors that produce ongoing traumatic stress symptoms from those that do not. The present study surveyed 181 first responders from rural settings. A repeated-measures design was used to compare characteristics of traumatic stressors that were or were not associated with ongoing PTSD symptoms. A factor analysis revealed that distressing events were characterized by chaos and resource limitations. Consistent with contemporary models, two mediational analyses revealed that each event characteristic predicted peritraumatic dissociation and posttraumatic cognitions, which in turn predicted PTSD symptoms. Moreover, the effect of each event characteristic on PTSD symptoms was partially mediated by these cognitive processes.     

Validity of PTSD in a sample of refugee children: can a separate diagnostic entity be justified?

The objective of this study was to examine the construct validity of PTSD in a sample of refugee children from the Middle East – more specifically, to assess whether associations between traumatic events and specific PTSD symptoms were more outspoken than (1) the associations of PTSD symptoms with non‐traumatic exposures, and (2) the associations of violent exposures with symptoms other than PTSD‐symptoms. Parents of 311 refugee children from the Middle East were interviewed concerning their children's traumatic experiences and mental health symptoms. The specific PTSD symptoms did not cluster in a factor analysis. The PTSD symptom complex was significantly predicted not only by violent exposures (mother tortured, OR 8.2, p < 0.005; father disappeared OR 3.2, p < 0.05) but also by indicators of family interaction and parents' occupational situation. The two identified violent exposures had significant independent associations with a series of symptoms including symptoms other than those of PTSD (r_s ranging from 0.25 to 0.44, p < 0.001). Thus it does not seem sufficient to focus solely on PTSD symptomatology when assessing the mental health needs of refugee children. Copyright © 2006 John Wiley & Sons, Ltd.     

Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity.

OBJECTIVE: Despite progress in epidemiologic research on posttraumatic stress disorder (PTSD), little is known about factors that distinguish chronic from nonchronic PTSD. In a previous report, the authors identified a set of personal predispositions associated with PTSD following traumatic events in a general population sample of young adults. The purpose of this analysis was to identify characteristics of chronic PTSD and examine whether any of the suspected risk factors for PTSD was associated specifically with chronic PTSD. METHOD: A random sample of 1,007 21- to 30-year-old members of a large health maintenance organization in the Detroit area was interviewed, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS), revised for DSM-III-R. The analysis was performed on data from 394 respondents who reported traumatic events, of whom 93 met criteria for PTSD. Chronic PTSD was defined as duration of symptoms for 1 year or more. RESULTS: Persons with chronic PTSD (N = 53) had, on the average, a significantly higher total number of PTSD symptoms and higher rates of overreactivity to stimuli that symbolized the stressor and interpersonal numbing than persons with nonchronic PTSD. The rates of one or more additional anxiety or affective disorders and a variety of medical conditions were higher in persons with chronic than nonchronic PTSD. Family history of antisocial behavior and female sex were associated specifically with chronic PTSD. CONCLUSIONS: The findings suggest that chronic PTSD may be associated with specific risk factors and clinical features. Longitudinal data on the course of PTSD are needed to determine whether the distinct features and the medical and psychiatric histories of persons with chronic PTSD are complications attendant on a chronic course or coexisting disturbances that inhibit recovery.     

Treatment of acute posttraumatic stress disorder with brief cognitive behavioral therapy: a randomized controlled trial

OBJECTIVE: The purpose of this study was to evaluate the efficacy of brief cognitive behavioral therapy for patients with acute posttraumatic stress disorder (PTSD) resulting from various types of psychological trauma. METHOD: The authors randomly assigned 143 patients with acute PTSD (irrespective of the time criterion), within 3 months after experiencing a traumatic incident, to either brief cognitive behavioral therapy (N=79) or a waiting list comparison group (N=64). Cognitive behavioral therapy consisted of four weekly sessions containing education, relaxation exercises, imaginal exposure, in vivo exposure, and cognitive restructuring. Main outcome measure was PTSD score measured by structured interview; secondary outcomes were anxiety and depression measured by questionnaire. Assessments took place before the intervention and 1 week and 4 months after the intervention. RESULTS: Symptoms of PTSD, anxiety, and depression decreased in both groups over time. One week after the intervention, the cognitive behavioral therapy group had significantly fewer symptoms of PTSD than the comparison group, but this difference was smaller and no longer significant 4 months after the intervention. Similar results were found for anxiety and depression scores. Subgroup analyses showed that cognitive behavioral therapy led to significantly lower PTSD scores at 4 months in patients with baseline comorbid major depression and in patients who were included within the first month after the traumatic incident both at 1 week and at 4 months. CONCLUSIONS: Brief early cognitive behavioral therapy accelerated recovery from symptoms of acute PTSD but did not influence long-term results. Brief early cognitive behavioral therapy showed enhanced efficacy in patients with baseline comorbid depression and patients who were included within 1 month after their traumatic experience.     

Group psychotherapy for adolescent survivors of homicide victims: a pilot study.

OBJECTIVE: To conduct an exploratory study designed to evaluate the effectiveness of a time-limited psychotherapy group model to decrease traumatic symptoms among adolescent survivors of homicide victims. METHOD: Forty-five inner-city adolescents between the ages of 11 and 19 years participated in community-based, time-limited therapy groups that were specifically designed for youths who had a loved one die because of violence. The therapy groups were based on a 10-week treatment model for adolescent survivors of homicide victims with the goals of providing grief education, facilitating thoughts and feelings about grief, and reducing traumatic symptoms. RESULTS: On completion of group therapy, the adolescent participants reported an overall significant decrease in traumatic symptoms on an index of posttraumatic stress, especially in the areas of reexperiencing and avoidance symptoms. The mean difference between pre- and posttest was a 10.03 decrease in the sum of the Child PTSD Reaction Index scores (sig = .001). CONCLUSION: The results of this pilot study indicate that group therapy may be helpful in reducing PTSD symptoms among inner-city, African-American adolescent survivors of homicide victims. Although validity is limited by the lack of a comparison group, the authors suggest that such a brief trauma/grief psychotherapy group may be applicable for suburban and rural adolescent survivors of homicide victims as well. .     

PTSD reactions and functioning of American Airlines flight attendants in the wake of September 11

The authors explore the psychological reactions and functional coping responses of American Airlines (AA) flight attendants, a unique at-risk group of people in the war on terrorism, in the aftermath of the September 11 attacks. Demographic characteristics and standardized questionnaires, including the Posttraumatic Stress Disorder Checklist and the Psychotherapy Outcome Assessment and Monitoring System--Trauma Version, were sent in June 2002 to approximately 26,000 AA flight attendants. Of the 2050 respondents, 18.2% reported symptoms consistent with probable posttraumatic stress disorder (PTSD). Those living alone were 1.48 times more likely to have a probable PTSD diagnosis than those living with someone else. Age or years of service as a flight attendant did not predict probable PTSD; however, marital status did. Substance abuse was not endorsed as a coping strategy. Given the traumatic events experienced by AA flight attendants, and persistent threats of future terrorist attacks, these results reveal that additional assessment and treatment interventions for stress-related symptoms in this population seem warranted.     

PTSD symptoms and cognitive performance in recent trauma survivors

Chronic post-traumatic stress disorder (PTSD) has been associated with cognitive impairments involving memory and attention. The association between cognitive impairment and early PTSD symptoms is unknown, yet such association may lead to poorer processing of traumatic memories and thereby contribute to subsequent PTSD. This study evaluated the relationship between PTSD symptoms and cognitive functioning within 10 days of traumatic events. Forty-eight survivors were assessed for symptoms of PTSD, anxiety, depression and dissociation and for immediate and delayed verbal and figural memory, attention, learning and IQ. Survivors with high levels of PTSD symptoms showed impaired attention and immediate recall for figural information and lower IQ. They did not show, however, an impairment of verbal recall and learning. The observed difference was not explained by anxiety or dissociation. It disappeared, however, when the effect of depressive symptoms was controlled for. Lower IQ and impaired attention are associated with early PTSD and depressive symptoms. Poorer attention may have a role in shaping traumatic memories.     

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.     

DSM-III-R criteria for posttraumatic stress disorder

The authors describe the changes in DSM-III criteria for posttraumatic stress disorder (PTSD) that have been included in DSM-III-R. DSM-III-R includes specification of generic characteristics of traumatic stressors, clearer organization of symptoms around three dimensions of stress response (reexperiencing, avoidance and numbing, and physiological arousal), inclusion of symptoms specific to children, and specification of onset and duration of the disorder. The importance of these changes in the evolution of the diagnosis of PTSD is discussed.     

Low-dose cortisol for symptoms of posttraumatic stress disorder

OBJECTIVE: Because elevated cortisol levels inhibit memory retrieval in healthy human subjects, the present study investigated whether cortisol administration might also reduce excessive retrieval of traumatic memories and related symptoms in patients with chronic posttraumatic stress disorder (PTSD). METHOD: During a 3-month observation period, low-dose cortisol (10 mg/day) was administered orally for 1 month to three patients with chronic PTSD in a double-blind, placebo-controlled, crossover design. RESULTS: In each patient investigated, there was a significant treatment effect, with cortisol-related reductions of at least 38% in one of the daily rated symptoms of traumatic memories, as assessed by self-administered rating scales. In accordance, Clinician-Administered PTSD Scale ratings assessed after each month showed cortisol-related improvements for reexperiencing symptoms and, additionally, in one patient for avoidance symptoms. CONCLUSIONS: The results of this pilot study indicate that low-dose cortisol treatment reduces the cardinal symptoms of PTSD.     

Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults

OBJECTIVE: Few studies have focused on the natural course of posttraumatic stress disorder (PTSD) and its determinants in samples of the general population. The authors examined determinants of remission and chronicity of PTSD and associations with other disorders in a prospective community sample. METHOD: The data were drawn from a prospective, longitudinal epidemiological study of adolescents and young adults (age 14-24 years) in Munich, Germany (N=2,548). The course of PTSD from baseline to follow-up 34-50 months later was studied in 125 respondents with DSM-IV PTSD or subthreshold PTSD at baseline. RESULTS: Although 52% of the PTSD cases remitted during the follow-up period, 48% showed no significant remission of PTSD symptoms. Respondents with a chronic course were more likely to experience new traumatic event(s) during follow-up (odds ratio=5.21, 95% confidence interval [CI]=1.95-13.92), to have higher rates of avoidant symptoms at baseline (odds ratio=10.16, 95% CI=1.73-59.51), and to report more help seeking (odds ratio=5.50, 95% CI=1.04-29.05), compared to respondents with remission. Rates of incident somatoform disorder (odds ratio=4.24, 95% CI=1.60-11.19) and other anxiety disorders (odds ratio=4.07, 95% CI=1.15-14.37) were also significantly associated with a chronic course. CONCLUSIONS: PTSD is often a persistent and chronic disorder. Specific symptom clusters--especially avoidant symptoms--might be associated with the course of PTSD. In addition, the occurrence of new traumatic events differentiates PTSD cases with a chronic course from those with remission.     

Dissociation and posttraumatic stress disorder in Vietnam combat veterans.

OBJECTIVE: This study compared current dissociative symptoms and dissociation at the time of specific traumatic events in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and Vietnam combat veterans without PTSD. METHOD: Vietnam combat veterans who sought treatment for PTSD (N = 53) were compared to Vietnam combat veterans without PTSD (N = 32) who sought treatment for medical problems. Dissociative symptoms were evaluated with the Dissociative Experiences Scale. Dissociation at the time of a combat-related traumatic event was evaluated retrospectively with the modified Dissociative Experiences Questionnaire. The Combat Exposure Scale was used to measure level of combat exposure. RESULTS: There was a significantly higher level of dissociative symptoms, as measured by the Dissociative Experiences Scale, in patients with PTSD (mean = 27.0, SD = 18.0) than in patients without PTSD (mean = 13.7, SD = 16.0). This difference persisted when the difference in level of combat exposure was controlled with analysis of covariance. PTSD patients also reported more dissociative symptoms at the time of combat trauma, as measured retrospectively by the Dissociative Experiences Questionnaire (mean = 11.5, SD = 1.6) than non-PTSD patients (mean = 1.8, SD = 2.1). CONCLUSIONS: Dissociative symptoms are an important element of the long-term psychopathological response to trauma.