Suicidal Behavior After Severe Trauma. Part 2: The Association Between Methods of Torture and of Suicidal Ideation in Posttraumatic Stress Disotrder

The study reports on 65 refugees with diagnoses of posttraumatic stress disorder (PTSD) and manifest suicidal behavior (40% had suicide attempts; 29% detailed suicide plan; 31% recurrent suicidal thoughts). Our hypothesis was that the predominant kind of stressful experience in PTSD patients might be reflected in their choice of method when pondering or attempting suicide. Relationships were found to exist between the main stressors and the respective subjects' preference for suicide method. Particularly among PTSD patients with a history of torture, an association was found between the torture methods that the victim had been exposed to, and the suicide method used in ideation or attempts. Blunt force applied to the head and body was associated with jumping from a height or in front of trains, water torture with drowning, or sharp force torture with methods involving self-inflicted stabbing or cutting. Relationships between main stressors and content of suicidal ideation are discussed.     

Thematic Resolution, PTSD, and Complex PTSD: The Relationship Between Meaning and Trauma-Related Diagnoses

The role of modifying schemas in trauma-focused psychotherapy has received theoretical and clinical attention. However, the relationship of schematic processing to posttraumatic stress disorder (PTSD) diagnosis has not been examined empirically. The current study compared measures of thematic disruption among individuals with PTSD alone, PTSD with concurrent complex PTSD, and no PTSD. Eighty two participants were interviewed to assess PTSD status, complex PTSD status, traumatic life events, and trauma-related thematic processing. Results indicated that variables quantifying thematic disruption and thematic resolution significantly distinguished those individuals with concurrent PTSD plus complex PTSD from the other two groups. Exploratory analyses indicated that PTSD symptom severity and the interpersonal nature of the trauma were related to thematic disruption.     

An Examination of Antecedent Traumas and Psychiatric Comorbidity Among Male Inmates with PTSD

Despite substantially higher rates of posttraumatic stress disorder (PTSD) among male inmates than among men in the general population, there is a dearth of research on PTSD among incarcerated men. The current study addresses traumatic events that precede PTSD and psychiatric disorders that are comorbid with PTSD in an inmate sample. Seeing someone seriously injured or killed, being sexually abused, and being physically assaulted were the three most commonly reported antecedent traumas to PTSD. Lifetime and current rates of mood disorders, anxiety disorders, and antisocial personality disorder were elevated among inmates with a diagnosis of PTSD. Two hundred and thirteen inmates participated in the study. Sixty-nine participants (33%) met lifetime DSM–III–R criteria for PTSD, and 45 (21%) met current criteria. The findings are compared with general population samples, and implications of the findings are discussed.     

CBT for Vietnamese Refugees with Treatment-Resistant PTSD and Panic Attacks: A Pilot Study

We examined the feasibility, acceptability, and therapeutic efficacy of a culturally adapted cognitive-behavior therapy (CBT) for twelve Vietnamese refugees with treatment-resistant posttraumatic stress disorder (PTSD) and panic attacks. These patients were treated in two separate cohorts of six with staggered onset of treatment. Repeated measures Group x Time ANOVAs and between-group comparisons indicated significant improvements, with large effect sizes (Cohen's d) for all outcome measures: Harvard Trauma Questionnaire (HTQ; d = 2.5); Anxiety Sensitivity Index (ASI: d = 4.3); Hopkins Symptom Checklist-25 (HSCL-25), anxiety subscale (d = 2.2); and Hopkins Symptom Checklist-25, depression subscale (d = 2.0) scores. Likewise, the severity of (culturally related) headache-and orthostasis-cued panic attacks improved significantly across treatment     

Race, Combat, and PTSD in a Community Sample of New Zealand Vietnam War Veterans

The association between posttraumatic stress disorder (PTSD), combat exposure, and race was examined in a New Zealand community sample of 756 Vietnam War veterans. Maori veterans reported higher levels of PTSD than their non-Maori counterparts. However, the race effect was shown to be mediated by combat exposure level, rank, and combat role. These findings support differential experience explanations for the relationship between postwar adjustment and race, suggesting that higher levels of psychological symptoms reported by minority group veterans can be accounted for by their experience of higher levels of combat stressors.     

Cross-cultural care for PTSD: Research,training, and service needs for the future

Treating the consequences of violence in refugees, immigrants, and other minority groups is complicated by several factors. One of these factors involves the treatment of such problems, which are often related to both past violence as well as to current adverse conditions or precipitants. Another factor relates to cross-cultural assessment and treatment, which requires special education, experience, and supervision. Thirdly, there is usually the matter of concurrent acculturation, which may be undermined by biopsychosocial maladjustment due to past violence and which may in turn precipitate psychiatric syndromes that are related to previous violence. The future implications of these factors for research, training, and service needs are reviewed in this paper.This is a revised version of a paper prepared for a conference on Long-Term Effects of Mass Violence: Cross-Cultural Treatment and Research Issues in PTSD, for National Institutes of Mental Health April 1986.     

Prolonged Trauma and Subsequent Suicidal Behavior: Child Abuse and Combat Trauma Reviewed

Stressful events have long been acknowledged as important risk factors for suicidal behavior. Although suicide research has generally focused on less severe stressful events, a long-standing vulnerability for suicidal behavior may be a sequela of prolonged traumatic stressors. The present paper discusses the relationship between prolonged traumatic stress and subsequent suicidality by reviewing studies that have examined suicidal behavior in relationship to child abuse and combat trauma. Traumatic stress is conceptualized according to a person-environment interactional paradigm, and this paradigm is used to discuss the characteristics of traumatic events, recovery environments, and individuals that may contribute to subsequent suicidality.     

A new development in PTSD and the law: the case of Fairfax County v. Mottram

The decision of the Virginia Supreme Court in Fairfax County Fire & Rescue Department v. Mottram (2002) has important implications for Workers' Compensation claims for posttraumatic stress disorder, particularly those involving emergency services personnel. A firefighter/paramedic who developed chronic, disabling PTSD after responding to a fatal fire was denied benefits because he had previously reported symptoms of the disorder, whereas the statute recognized a single traumatic incident only. The court held that PTSD resulting from multiple traumatic stressors may be considered a compensable occupational disease analogous to dermatitis developed by a flower shop employee with chronic exposure to irritating stimuli. The decision, which constitutes legal recognition of work-related cumulative PTSD in rescue workers, provides benefits for treatment and encourages earlier treatment of traumatic stress in this group.     

The psychobiology of PTSD: Perspectives and reflections on the past,present, and future

This article reviews historic, clinical, therapeutic, and research work regarding psychopathological responses to massive emotional stress. From these emerge the suggestion that post-traumatic stress disorder represents a physioneurosis. Psychophysiological and neuroendocrine investigations of the last decade are summarized, as well as the neuropsychological hypothesis the author has derived therefrom about the etiologic development of post-traumatic stress disorders. Lines of future research are suggested.Based on an address given as the recipient of the Pioneer Award, sponsored by Upjohn Company, International Society for Traumatic Stress Studies, Washington, D.C., October 24, 1991.     

Multidimensional assessment of combat-related PTSD: Phenomenological,psychometric, and psychophysiological considerations

The literature on assessment of PTSD in combat veterans is discussed as it relates to several major diagnostic issues. Studies bearing on the validity of the PTSD diagnosis are presented. Additionally, a multidimensional assessment of PTSD is described in detail. The major assessment instruments currently used are discussed and the research supporting the selection of each of the assessment tools is presented.     

The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: examination of comorbidity with anxiety and depression

Previous research has indicated a relationship between posttraumatic stress disorder (PTSD) and somatic complaints. We examined whether this relationship is a result of shared comorbidity with anxiety and depression. Local doctors interviewed a random, community sample of 526 tortured and 526 nontortured Bhutanese refugees living in U.N. refugee camps in Nepal. The interview covered demographics, torture, somatic complaints, and PTSD, depression, and anxiety measures. Number of PTSD symptoms, independent of depression and anxiety, predicted both number of reported somatic complaints and number of organ systems involving such complaints. Physicians need to screen for PTSD when survivors of extreme stressors present nonspecific somatic complaints.     

PTSD Scale of the Child Behavior Checklist: Concurrent and Discriminant Validity with Non-Clinic-Referred Sexually Abused Children

Several assessment instruments include measures that are purported to assess characteristics of posttraumatic stress disorder (PTSD). Although these measures are used often by researchers and clinicians, few are supported by extensive validity data. The PTSD scale of the Child Behavior Checklist (CBCL) is one that has not yet encountered significant challenges to its validity. We examine the concurrent and discriminant validity of the CBCL-PTSD scale. Participants included 63 non-clinic-referred sexually abused (SA) children, 60 non-SA psychiatric outpatient children, and 61 non-SA, non-clinic-referred schoolchildren. Results revealed questionable concurrent validity for this scale, and suggest poor discriminant validity between SA children and non-SA psychiatric outpatients.     

Partner Abuse and Posttraumatic Stress Disorder as Risk Factors for Suicide Attempts in a Sample of Low-Income, Inner-City Women

This study examined partner abuse and posttraumatic stress disorder (PTSD) as risk factors for suicidal behavior among women, and whether or not PTSD mediated the partner abuse-suicidal behavior association. Attempters (n = 119) were approximately three times more likely to be above clinical cut-points for physical partner abuse, nonphysical abuse, and PTSD than nonattempters (n = 85). Physical partner abuse, but not nonphysical partner abuse, was associated with an increased risk for PTSD. Further, PTSD mediated the link between physical partner abuse and suicidality, such that when PTSD was statistically controlled, the association between physical partner abuse and suicide attempt status was reduced to nonsignificance. Implications of findings for interventions for female victims of partner abuse, and women who make nonfatal suicide attempts are discussed.     

The Relationship Among Personality Variables, Exposure to Traumatic Events, and Severity of Posttraumatic Stress Symptoms

In examining predictors of posttraumatic stress, researchers have focused on trauma intensity and devoted less attention to other variables. This study examined how personality and demographic variables are related to the likelihood of experiencing a trauma, and to the severity of posttraumatic symptoms in a sample of 402 college students reporting a wide range of trauma. Elevations in antisocial and borderline traits were significant predictors of retraumatization, accounting for 12% of the variance. Personality variables and trauma intensity were significant predictors of PTSD severity, accounting for 43% of the variance. Neuroticism interacted with trauma intensity in predicting Posttraumatic Stress Disorder (PTSD) severity. Among persons low in Neuroticism, there was a modest trauma intensity–PTSD relationship, whereas among persons high in neuroticism there was a strong relationship.     

Trauma Symptoms in Bone Marrow Transplant Survivors: The Role of Nonmedical Life Events

This cross-sectional study investigated the association of trauma-related symptomatology and recent life events in cancer survivors following bone marrow transplantation (BMT). One hundred adults averaging 4.4 years post-BMT were interviewed. Participants reported their trauma-related symptomatology regarding cancer and its treatment as well as the number and valence of recent life events. Results indicated that the more negative life events a person experienced, the greater his/her trauma-related symptomatology. The association of trauma-related symptomatology with positive events varied by the individuals' level of physical functioning. For individuals with poorer physical functioning, higher levels of trauma-related symptomatology were associated with a greater number of positive events, suggesting the greater vulnerability of these individuals to any type of change in their life.     

Characteristics and Content of Intrusive Memories in PTSD and Their Changes With Treatment

Although intrusive reexperiencing is a core symptom of postraumatic stress disorder (PTSD), relatively little is known about its phenomenology. The present study assessed the characteristics and content of intrusive trauma memories in 22 patients with PTSD, and followed their changes in the course of cognitive behavioral treatment. Patients had a small number of different intrusive memories (1-4, M = 2.2) that occurred in an invariable, repetitive way. The intrusions were distressing and had a vivid perceptual content. They appeared to the patient to be happening in the "here and now." With therapy, the frequency, vividness, distress, and nowness of the intrusions faded gradually. There was no exacerbation with imaginal reliving. The content of intrusions was classified by raters to test A. Ehlers et al.'s (2002) hypothesis that intrusive memories are usually of warning stimuli that signalled the moments with the greatest emotional impact. The results were consistent with this hypothesis.     

Western conceptualizations and Eastern experience: a cross-cultural study of traumatic stress reactions among Tibetan refugees in India

This study investigated the nature and impact of traumatic experiences among Tibetan refugees in India. It explored the applicability of western conceptualizations of reactions to traumatic events among this cultural group. A randomly selected sample of refugee camp students was assessed on measures of psychological and physical complaints, and on impact as well as severity of traumatic experiences. Respondents had experienced multiple traumatic events. The majority reported ongoing health problems. More than half demonstrated symptoms of intrusion–avoidance. Those with more traumatic experiences reported more symptoms of anxiety and depression (psychologically and, particularly, somatically manifested). Cultural differences in types of experienced traumatic events and manifestations of distress are discussed, as are implications for cross-cultural trauma research using western conceptualizations and instruments.     

Spirituality, Resilience, and Anger in Survivors of Violent Trauma: A Community Survey

This study evaluates the relationship between spirituality, resilience, anger and health status, and posttraumatic symptom severity in trauma survivors. A community sample (N = 1,200) completed an online survey that included measures of resilience, spirituality (general beliefs and reincarnation), anger, forgiveness, and hatred. In survivors of violent trauma (n = 648), these measures were evaluated with respect to their relationship to physical and mental health, trauma-related distress, and posttraumatic symptom severity. Using multivariate regression models, general spiritual beliefs and anger emerged in association with each outcome, whereas resilience was associated with health status and posttraumatic symptom severity only. Forgiveness, hatred, and beliefs in reincarnation were not associated with outcome. The importance of these findings to treating trauma survivors is discussed.     

Relationships Among Trauma Exposure,Chronic Posttraumatic Stress Disorder Symptoms,and Self-Reported Health in Women: Replication and Extension

Fifty-two women who served during the Vietnam era were assessed for war-zone exposure, traumatic life events, posttraumatic stress disorder (PTSD), and self-reported health status. Symptoms of PTSD were examined as mediators in the relationship between traumatic exposure and subsequent reports of health problems. Results showed that PTSD symptoms accounted significantly for variance in health problems reported by women with prior traumatic stressor exposure. When the cardinal symptom domains of PTSD (reexperiencing, numbing, avoidance, hyperarousal) were analyzed separately, the symptom cluster representing hyperarousal accounted uniquely for the variance associated with health complaints, beyond that contributed by other symptom clusters. Discussion of the results focuses on mechanisms underlying the relationship between specific symptoms of PTSD and self-reported health. Implications for intervention within the medical system are also considered.     

Complex posttraumatic sStress disorder: An exploratory investigation of PTSD and DES NOS among Dutch war veterans

The recently developed concept Disorder of Extreme Stress Not Otherwise Specified (DES NOS) or complex posttraumatic stress disorder (complex PTSD) is designed to encompass long-standing symptoms not present in PTSD. An exploratory investigation of PTSD and DES NOS was performed with the Structured Clinical Interview for PTSD and for DES NOS in a small sample of Dutch war veterans with combat experience. Both PTSD and DES NOS symptoms were frequently reported. About 67% of the veterans met criteria for PTSD and 38% met criteria for DES NOS. DES NOS appeared to be associated with PTSD. Several DES NOS subcategories proved more important than others for distinguishing simple PTSD from complex PTSD.