Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients

OBJECTIVE: Prior research suggests that the diagnosis and treatment of cancer can result in the development of symptoms of posttraumatic stress disorder (PTSD). Based on Lazarus and Folkman's model of stress, the current study examined whether trauma appraisals, coping, social support, and social constraint were associated with the severity of PTSD symptoms in cancer patients who had undergone bone marrow transplantation (BMT). METHODS: Participants were 23 males and 79 females treated with BMT an average of 20 months previously (range = 3-62 months). Past and current psychiatric diagnoses were assessed through a structured clinical interview. PTSD symptomatology and other psychological variables were assessed using standardized self-report measures. RESULTS: Results indicated that 5% of participants met diagnostic criteria for current PTSD. Participants reported an average of three to four symptoms of PTSD (range = 0-16). Univariate analyses confirmed predictions that increased PTSD symptomatology would be associated with more negative appraisals of the BMT experience, greater use of avoidance-based coping strategies, lower levels of social support, and greater social constraint (p < .05). Regression analyses indicated that each of these variables accounted for significant (p < .05) variability in PTSD symptomatology above and beyond relevant demographic and medical variables. CONCLUSIONS: Results of the present study confirm and extend prior research regarding the prevalence of PTSD and PTSD symptoms among patients treated for cancer. In addition, the study identified a set of theoretically derived psychological characteristics that seem to place patients at risk for greater PTSD symptomatology after BMT.     

Trajectories of adjustment in mothers of children with newly diagnosed cancer: a natural history investigation

OBJECTIVES: The objectives of this study were (a) to assess negative affectivity and posttraumatic symptomatology in mothers following the diagnosis of cancer in their children; (b) to examine sociodemographic and psychosocial variables associated with change in distress over time; and (c) to identify distinct subgroups of mothers whose patterns and trajectories of adjustment can be distinguished according to available predictor data. METHODS: Two hundred and twelve mothers at seven sites were assessed just following their child's diagnosis, and again 3 months and 6 months later. Primary outcomes included measures of mood disturbance, depressive symptoms, and symptoms of posttraumatic stress. RESULTS: Overall, mothers demonstrated a pattern of mildly elevated negative affectivity and posttraumatic symptomatology initially, with steady improvements evident at 3- and 6-month follow-up. Distinct adjustment trajectories were evident within the sample as a whole, indicating subgroups of mothers with high-declining, moderate-stable, and low-stable distress levels. CONCLUSIONS: These findings highlight considerable resilience among mothers facing the stress of childhood cancer. Intervention efforts aimed at reducing maternal distress might best be targeted towards the subgroup of mothers who may be predicted to exhibit the highest level of distress.     

Brief report: the risk of posttraumatic stress disorder in mothers of children diagnosed with pediatric cancer and type I diabetes

OBJECTIVE: To evaluate the risk of and predictors of enduring and late-onset posttraumatic stress disorder (PTSD) among mothers of children diagnosed with type I diabetes and cancer. METHOD: Mothers (N = 99) of children diagnosed with cancer or diabetes for at least 12 months completed a structured clinical interview for PTSD and self-report measures of PTSD, depression, anxiety, and stressful life events. RESULTS: There was no significant difference in the rate of PTSD between the two groups. Overall, fewer mothers (7%) met criteria for PTSD on the structured clinical interview than those on a self-report measure of PTSD (17%). Mothers who reported more depressive symptoms, anxiety, and stressful life events tended to report significantly more PTSD symptoms. CONCLUSIONS: The findings extend prior research regarding the prevalence rate and predictors of PTSD and PTSD symptoms in pediatric populations. It is recommended that clinicians exercise caution when interpreting prevalence rates for PTSD that are derived from self-report measures.     

Posttraumatic stress symptoms in parents of children with acute burns

OBJECTIVE: To develop a model of risk factors for posttraumatic stress disorder (PTSD) symptoms in parents of children with burns. METHODS: Immediately following the burn and 3 months later, parents reported on their children's and their own psychological functioning and traumatic stress responses. RESULTS: Approximately 47% of the parents reported experiencing significant posttraumatic stress symptoms 3 months after the burn. Our model indicates three independent pathways to PTSD symptoms (i.e., parent-child conflict, parents' dissociation, and children's PTSD symptoms). Additionally, parents' anxiety predicted increased parent-child conflict, conflict with extended family and size of the burn predicted parents' dissociation, and size of the burn and children's dissociation predicted children's PTSD symptoms. CONCLUSIONS: This study suggests that many parents of children with burns suffer from posttraumatic stress symptoms. Interventions that target factors such as family conflict, children's symptoms, and parents' acute anxiety and dissociation may diminish the risk for PTSD.     

Part 1: Children's Psychological Responses to Disasters

Reviews children's psychological responses to disasters and puts relevant work in historical perspective. Common responses include specific fears, separation difficulties, sleep problems, and symptoms associated with posttraumatic stress disorder (PTSD). After severe exposure, diagnosable PTSD, anxiety, and depression may occur. Factors influencing responses include disaster characteristics (exposure severity, extent of bereavement and other losses, separation from significant others), children's age and sex, and characteristics of family and community. Symptoms typically decrease rapidly, and recovery generally is complete by 18 months to 3 years except after severe life-threat or long-term family and community disruption.     

Psychosocial predictors of distress in parents of children undergoing stem cell or bone marrow transplantation

OBJECTIVE: To examine psychosocial predictors of distress (mood disturbance, perceived stress, caregiver burden) in parents of children undergoing stem cell or bone marrow transplantation (BMT). METHOD: Measures of prior illness experiences, premorbid child behavior problems, family environment, social support, and parental coping behavior were obtained from the resident parents of 151 children prior to the children's admission for BMT. Parents subsequently completed assessments of their mood disturbance, perceived stress, and caregiving burden on a weekly basis through week +6 post-BMT, and then monthly through month +6 post-BMT. RESULTS: Significant changes were observed in parental distress across the course of BMT. After correcting for demographic and medical factors, several significant predictors of parental distress trajectories were identified, including prior parent and patient illness-related distress, premorbid child internalizing behavior problems, the family relationship dimensions of the family environment, and parental avoidant coping behaviors. Multivariable models were developed using a hierarchical modeling approach. The best-fit model accounted for approximately 50% of the variance in parental global distress. CONCLUSIONS: Subgroups of parents at higher risk for increased distress during the acute phase of transplant have been identified. These findings can help target parents who may be in greater need of intervention aimed at reducing transplant-related distress.     

Posttraumatic stress disorder in parents of children with newly diagnosed type 1 diabetes

OBJECTIVE: To determine rates of posttraumatic stress disorder (PTSD) and symptoms in mothers and fathers of children with newly diagnosed type 1 diabetes. METHODS: Parents of 38 children with newly diagnosed type 1 diabetes were assessed with the Posttraumatic Diagnostic Scale 6 weeks after diagnosis. RESULTS: Twenty-four percent of the mothers and 22% of the fathers met full diagnostic criteria for current PTSD. In addition, 51% of the mothers and 41% of the fathers met criteria for partial or subclinical PTSD. Co-occurence of PTSD in couples was very low. Posttraumatic stress symptomatology did not correlate with age and gender of the child, socioeconomic status, family structure, or length of hospital stay. CONCLUSIONS: The findings support applicability of a posttraumatic stress model for investigating the psychological impact of type 1 diabetes on parents.     

Posttraumatic stress and behavior problems in infants and toddlers with burns

This study assessed posttraumatic stress disorder (PTSD) and behavior problems in young children with burns and examined individual, injury-related, and family-related determinants. Seventy-six children, aged 12-49 months, were assessed at an average of 15 months after their burn injury, using parents as informants on the posttraumatic stress disorder semi-structured interview and observational record for infants and young children and the child behavior checklist. Ten children (13.2%) met the alternative criteria for PTSD proposed by Scheeringa et al. Number of PTSD symptoms were associated with family-related variables (maternal PTSD, quality of family relations). Compared to community norms, children with burns showed less externalizing behavior problems, and internalizing behavior problems were within the normal range. Overall, behavioral adjustment was associated with the quality of family relations (cohesion, expressiveness, conflicts). Whereas behavior was found to be normal in young children with burns, this study provides evidence for a substantial prevalence of PTSD.     

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.     

Screening for preschool posttraumatic stress disorder with the Child Behavior Checklist

OBJECTIVE: To examine the psychometric properties and utility of a Child Behavior Checklist-Posttraumatic Stress Disorder (CBCL-PTSD) Scale to screen for posttraumatic stress disorder (PTSD) in traumatized preschool children. METHOD: Data for this study were drawn from a study of young child trauma and consisted of 62 traumatized children, 23 months through 6 years of age. The children's mothers were interviewed about PTSD symptoms and then completed the Child Behavior Checklist (CBCL). RESULTS: The modified CBCL-PTSD correlated highly with the number of PTSD symptoms from the interview (r = 0.66). The CBCL-PTSD scale predicted PTSD symptoms above and beyond the internalizing and externalizing scales of the CBCL. A cutoff score of nine on this scale possessed the best sensitivity and specificity in classifying those traumatized children who met diagnostic criteria for PTSD. CONCLUSION: The modified CBCL-PTSD scale could be a useful cost-effective tool to screen for PTSD in traumatized, preschool-age children.     

The role of negative interpretations of intrusive memories in depression

BACKGROUND: Recent investigations have shown that intrusive memories of negative past events, the hallmark symptom of posttraumatic stress disorder (PTSD), are also commonly experienced in depression. This study explored whether Ehlers and Steil's [Ehlers, A., Steil, R., 1995. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Behavioural and Cognitive Psychotherapy, 23, 217-249] model of PTSD maintenance, which focuses on the role played by negative interpretations of intrusive symptoms in the persistence of PTSD, also describes processes that operate in depression. METHODS: Eighty-four undergraduate students were interviewed to identify the presence of intrusive memories in the previous week. Participants who reported an intrusive memory were administered self-report questionnaires that indexed cognitive and affective responses to the memory. RESULTS: Negative interpretations of intrusive memories were significantly correlated with cognitive avoidance (particularly rumination) and depression severity, after controlling for intrusion frequency and severity of memory content. Negative meaning was the strongest predictor of depression, explaining variance over and above intrusion frequency. Ruminative responses to intrusions were highly correlated with depression. LIMITATIONS: The use of an unselected student sample. CONCLUSIONS: The demonstrated utility of Ehlers and Steil's [Ehlers, A., Steil, R., 1995. Maintenance of intrusive memories in posttraumatic stress disorder: A cognitive approach. Behavioural and Cognitive Psychotherapy, 23, 217-249] model of PTSD to account for one aspect of depression maintenance supports recent commentaries [Harvey, A.G., Watkins, E., Mansell, W., Shafran, R., 2004. Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. New York: Oxford University Press] that call for a transdiagnostic approach to understanding the cognitive and behavioural processes that underpin psychological disorders.     

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.     

Caregiver traumatization adversely impacts young children's mental representations on the MacArthur Story Stem Battery

The aim of our study was to investigate the impact of maternal exposure to family violence, maltreatment, and related posttraumatic stress disorder (PTSD) on young children's mental representations of self and caregivers. Participant mothers (n=24) and children (n=25) were recruited from a referred sample when they were 4-7 years old. Maternal report and child story stem narratives were used. Mother's experience of domestic violence and severity of violence-related PTSD symptoms robustly predicted more dysregulated aggression, attentional bias to danger and distress, as well as more avoidance of and withdrawal from conflicts presented in the children's story stems. Less narrative coherence was also noted. Traumatized mothers experience and symptoms prior to their child's turning 4 years old adversely affected their child's mental representations from 4-7 years.     

Peritraumatic Dissociation and Emotions as Predictors of PTSD Symptoms Following Childbirth

ABSTRACT

The current study investigated the contributive role of perinatal dissociative and perinatal emotional responses to the development of PTSD symptoms following childbirth. Method: Using a prospective, longitudinal design, 140 women were studied who were followed from the first week after delivery to three months postpartum. Results: Three women (2.1%) met criteria for PTSD and 21.4% reported a traumatic childbirth experience. Both perinatal negative emotional reactions and perinatal dissociative reactions were the predictors of PTSD symptoms at three months postpartum. The effect of perinatal dissociation, however, was partially mediated by perinatal emotional reactions. Conclusion: Posttraumatic stress disorder can be a consequence of the experience of childbirth. Women who reported high levels of negative emotions during and shortly after childbirth were more likely to develop PTSD symptoms than women who did not. Women who experienced an instrumental delivery and also reported higher levels of psychoform perinatal dissociation, were at higher risk than women who reported higher levels of perinatal dissociation during a spontaneous delivery. These findings add to the growing body of literature regarding traumatic childbirth and indicate that perinatal dissociative and emotional phenomena are associated with posttraumatic stress.     

Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling

Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.     

A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder

This study tested a family-based skills-building intervention in veterans with chronic combat-related posttraumatic stress disorder (PTSD). Veterans and a family member were randomly assigned to 1 of 3 conditions: (a) waiting list, (b) 18 sessions of twice-weekly exposure therapy, or (c) 18 sessions of twice-weekly exposure therapy followed by 16 sessions of behavioral family therapy (BFT). Participation in exposure therapy reduced PTSD positive symptoms (e.g., reexperiencing and hyperarousal) but not PTSD negative symptoms. Positive symptom gains were maintained at 6-month follow-up. However, participation in BFT had no additional impact on PTSD symptoms.     

Posttraumatic stress disorder and depression among new mothers at 8?months later of the 2008 Sichuan earthquake in China

On May 12, 2008, a magnitude 8.0 earthquake struck China's southwestern Sichuan province. Recent studies have identified mental health problems among the survivors, but little is known about the impact of the Sichuan earthquake on the mental health of new mothers in the area. The main objective was to assess the impact of the Sichuan earthquake on the posttraumatic stress disorders (PTSD) and depression of new mothers. A total of 317 new mothers were interviewed in the hospital from January 2009 to March 2009. Symptoms of PTSD were measured using the impact of event scale-revised, and symptoms of postpartum depression were measured using the Center for Epidemiologic Studies Depression scale. The prevalence rates of PTSD and postpartum depression were 19.9% and 29.0%, respectively. Women with high earthquake exposure had higher risks of PTSD (odds ratio (OR), 5.91; 95% confidence interval (CI), 1.75–19.97; P < 0.001) and postpartum depression (OR, 7.28; 95% CI, 2.51–21.08; P < 0.001) than women without earthquake experience. In addition, women with low monthly family income and farm workers had a higher risk of having PTSD; women who were unemployed or with lower monthly family income and poor sleep had a higher risk of having depression. Earthquake experience increased the risks of having PTSD and depression among new mothers at 8 months later of the earthquake.     

Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder

The authors report on changes in cognitions related to posttraumatic stress disorder (PTSD) among 54 female survivors of sexual and nonsexual assault with chronic PTSD who completed either prolonged exposure alone or in combination with cognitive restructuring. Treatment included 9-12 weekly sessions, and assessment was conducted at pretreatment, posttreatment, and a modal 12-month follow-up. As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttraumatic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported. Reductions in these negative cognitions were significantly related to reductions in PTSD symptoms. The addition of cognitive restructuring did not significantly augment the cognitive changes. Theoretical implications of the results are discussed.     

Elevated blood levels of dehydroepiandrosterone sulphate vary with symptom load in posttraumatic stress disorder: findings from a longitudinal study of refugees in Sweden

BACKGROUND: The present study is part of a longitudinal study of recently resettled refugees with the aim of learning which factors in their daily life influence health as measured by self-report and stress-responsive hormones. METHODS: In a group of recently resettled refugees with a high incidence of posttraumatic stress disorder (PTSD), diagnosed by structured interview, self-rated symptoms of PTSD were followed three times over a period of 9 months after inclusion in the study. Eighty-six individuals were included in the study and 58 subjects (67.4%) completed it. Blood samples were drawn at each examination for assessment of hormone levels. RESULTS: After adjustment for age, dehydroepiandrosterone sulphate (DHEA-s) was observed to be higher in non-depressed PTSD cases than in non-PTSD without depression. There was an interaction between PTSD and depression regarding DHEA-s levels. DHEA-s correlated significantly with changes in self-rated symptoms of PTSD at last follow-up; the greater the increase in PTSD symptoms, the greater the increase in plasma DHEA-s. The variation of DHEA-s levels in relation to changes in self-rated health in non-PTSD showed the opposite pattern, although not reaching significance. CONCLUSIONS: The finding of changes in DHEA-s should encourage further studies of the role of altered steroid metabolism in PTSD.     

Central and peripheral psychophysiological responses to trauma-related cues in subclinical posttraumatic stress disorder: a pilot study

This study examined verbal-subjective, peripheral and central physiological responses of motor vehicle accident (MVA) survivors with subclinical posttraumatic stress disorder (PTSD), without PTSD symptoms as well as healthy controls. Seven persons of each group were exposed to positive, neutral, accident-related and negative, non-accident-related slides. The verbal-subjective ratings of the slides did not differ between the groups. In contrast to the verbal ratings of the trauma-related materials, the behavioral and physiological responses showed a remarkable dissociation from these reports. The startle responses were enhanced to accident-related slides only in the PTSD group and MVA survivors with PTSD had a significantly lower response to the neutral slides than MVA survivors without PTSD. P200 was lower to positive, neutral and negative slides in the PTSD group compared to both other groups. The late positive complex showed no group-related effects. The data suggest that traumatized persons with PTSD show exaggerated emotional responses to trauma-related stimuli and reduced cognitive responses to several types of stimuli that may interfere with the extinction of the emotional trauma memory.