Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities

Purpose

To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities.

Method

Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and “trauma to close others” categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type.

Results

Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories.

Conclusions

Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.     

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.     

Adverse race-related events as a risk factor for posttraumatic stress disorder in Asian American Vietnam veterans

Few studies have explored the relationship between exposure to adverse race-related events and posttraumatic stress disorder (PTSD). This study examined whether adverse race-related events can give rise to symptoms that meet the criteria for a PTSD diagnosis as specified in the DSM-IV. Three hundred Asian American Vietnam veterans were administered a Mississippi Scale and a questionnaire that assessed exposure to adverse race-related events in the military and associated PTSD symptoms. A subsample was administered the Clinician-Administered PTSD Scale. A majority of the participants (77%) reported exposure to adverse race-related events. Depending on the number of events to which they were exposed, between 13% and 36% reported symptoms consistent with meeting full criteria for PTSD. Mississippi Scale scores increased significantly as a function of frequency of exposure to adverse race-related events. These results converge with the Clinician-Administered PTSD Scale findings to demonstrate that adverse race-related events can be traumatic and associated with PTSD. These findings support the construct and convergent validity of race-related PTSD.     

Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder

Prior research has indicated a seemingly unique relation between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) that appears to relate to negative treatment outcome for OCD. However, to date, the prevalence of trauma and PTSD in individuals seeking treatment for OCD is unclear. To begin to address this gap, this study assessed history of traumatic experiences and current PTSD in individuals seeking treatment for treatment-resistant OCD. Trauma predictors of PTSD severity also were examined in this sample. Participants included 104 individuals diagnosed with treatment-resistant OCD who sought treatment over the course of 1 year from OCD specialty treatment facilities. Data were collected via naturalistic retrospective chart reviews of pre-treatment clinical intake files. Findings revealed that 82% of participants reported a history of trauma. Over 39% of the overall sample met criteria for PTSD, whereas almost 50% of individuals with a trauma history met criteria for PTSD. Interpersonal traumas and greater frequency of traumas were most predictive of PTSD severity, and individuals diagnosed with OCD and additional major depressive disorder (MDD) or borderline personality disorder (BPD) appeared at particular risk for a comorbid PTSD diagnosis. PTSD may be relatively common in individuals diagnosed with treatment-resistant OCD; and interpersonal traumas, MDD, and BPD may play a relatively strong predictive role in PTSD diagnosis and severity in such OCD patients.     

Assessing dissociation as a risk factor for posttraumatic stress disorder: a study of adult offspring of holocaust survivors

Dissociative symptoms are frequently present in trauma survivors with posttraumatic stress disorder (PTSD). However, the possibility that dissociative symptoms may comprise a risk factor for the development of PTSD has not been examined. The current research investigates this possibility by evaluating dissociative symptoms in a group of adult offspring of Holocaust survivors, whom we have previously shown to be at increased risk of PTSD. Eighty-seven Holocaust survivor offspring and 39 comparison participants completed the Dissociative Experiences Scale, and assessments of trauma exposure, psychopathology, and parental PTSD. Dissociative symptoms were elevated in individuals with current PTSD, but not in those with past PTSD or with the risk factor of parental PTSD. Dissociative symptoms were also associated with forms of psychopathology other than PTSD. The results suggest that dissociative symptoms are related to current psychiatric symptomatology, including PTSD, rather than representing an enduring trait or preexisting risk factor for the development of PTSD.     

Cognitive-behavioral treatment for posttraumatic stress disorder in children and adolescents

Several cognitive-behavioral therapy (CBT) approaches are available for treating child and adolescent posttraumatic stress disorder (PTSD). These treatments include common elements (eg, psychoeducation, gradual exposure, relaxation). This review (1) delineates common elements in CBT approaches for treating child and adolescent PTSD; (2) provides a detailed review of three CBT approaches with substantial evidence of effectiveness; and (3) describes promising practices in the area of CBT approaches to treating child and adolescent PTSD. Cultural and implementation considerations are also included.     

Symptom structure of posttraumatic stress disorder in a nationally representative sample

Diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) for posttraumatic stress disorder (PTSD) posit three symptom clusters including reexperiencing, avoidance/numbing, and hyperarousal. Factor analytic studies have suggested several alternative models of PTSD symptomatology. It is uncertain whether these new models are widely generalizable as most studies have relied on relatively select treatment seeking samples (e.g., combat veterans). To address this limitation, confirmatory factor analysis was applied to symptom data from National Comorbidity Survey respondents with a lifetime history of PTSD (n = 429). Several models were tested. The model comprised of four intercorrelated factors (reexperiencing, avoidance, numbing, and hyperarousal) received the strongest support, but did not meet all the goodness-of-fit criteria. A follow-up principal-components analysis yielded a four-factor solution, with factors representing dysphoria, cued reexperiencing and avoidance, uncued reexperiencing and hyperarousal, and trauma-related rumination. The theoretical and clinical implications of these findings are discussed.     

Approach–avoidance coping conflict in a sample of burn patients at risk for posttraumatic stress disorder

Background: Following an acute burn injury, higher distress is consistently observed among individuals exhibiting a conflict between approach coping (e.g., processing) and avoidance coping (e.g., suppression) relative to those individuals who use only one of these methods. Study objectives were to determine if contradictory coping messages would lead to such approach–avoidance coping conflict and to determine if experiment‐induced coping conflict is also associated with higher distress. Methods: Participants (n=59 adults hospitalized with acute burn injuries) were assigned randomly to experimental conditions differing in the order in which training was provided in two ways of coping with posttrauma re‐experiencing symptoms (i.e., process‐then‐suppress versus suppress‐then‐process). The primary dependent variable was coping behavior during the 24‐hr posttraining period. Coping behavior was categorized as approach coping (processing), avoidance coping (suppressing), or approach–avoidance coping conflict (both) on the basis of median splits on subscales assessing these behaviors. Secondary analyses examined the relationship between this experiment‐induced coping conflict and re‐experiencing symptoms. Results: Results indicated that participants in the process‐then‐suppress condition, relative to the suppress‐then‐process condition, were significantly more likely to exhibit approach–avoidance coping conflict (i.e., above median split on both processing and suppressing) during the next 24 hr. Furthermore, approach–avoidance coping conflict was associated with greater re‐experiencing symptoms assessed via self‐report and by blinded coding of recorded speech. Conclusions: It is concluded that the order of coping skill training can influence treatment outcome, success of coping methods, and overall levels of distress. therefore, training in stabilizing and calming methods should precede training in active processing following stressful life events. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Gender differences in the factor structure of posttraumatic stress disorder symptoms in war-exposed adolescents

DSM-IV's three-factor model of posttraumatic stress disorder (PTSD) is rarely empirically supported, whereas other four-factor models ( [King et al., 1998] and [Simms et al., 2002]) have proven to be better representations of PTSD's latent structure. To date, a clear consensus as to which model provides the best representation of PTSD's underlying dimensions has yet to be reached. The current study investigated whether gender is associated with factor structure differences using the King et al. (1998) model of reexperiencing, avoidance, numbing, and hyperarousal PTSD symptoms. Participants were war-exposed Bosnian secondary/high school boys and girls (N = 1572) assessed nearly two years after the 1992-1995 Bosnian conflict. Confirmatory factor analytic tests of measurement invariance across PTSD model parameters revealed many significant sex-linked differences. Implications regarding the potential role of gender as a moderator of the King et al. (1998) model's factor structure are discussed.     

Trauma and posttraumatic stress disorder symptomatology: patterns among American Indian adolescents in substance abuse treatment

In this study the authors examined the prevalence and correlates of posttraumatic stress disorder (PTSD) and trauma symptomatology among a sample of 89 American Indian adolescents in a residential substance abuse treatment program. These youths reported an average of 4.1 lifetime traumas, with threat of injury and witnessing injury being most common; molestation, rape, and sexual attack were least common. Approximately 10% of participants met the Diagnostic and Statistical Manual IV Text Revision (DSM-IV-TR) criteria for full PTSD, and about 14% met the criteria for subthreshold PTSD. Molestation (including rape and sexual attack), experiencing 6 or more traumas, and a diagnosis of abuse of or dependence on stimulants were significantly associated with PTSD. Findings indicated that trauma was a pervasive phenomenon among this population, with sexual traumas being particularly stigmatizing, resulting in high rates of posttraumatic symptomatology, specifically PTSD.     

Attention-deficit/hyperactivity disorder comorbidity in a sample of veterans with posttraumatic stress disorder

This study examined attention-deficit/hyperactivity disorder (ADHD) comorbidity in military veterans with a high prevalence of posttraumatic stress disorder (PTSD) and evaluated the relationships between the 2 disorders and exposure to traumatic events. The sample included 222 male and female military veterans who were administered structured clinical interviews based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Results show that 54.5% met the criteria for current PTSD, 11.5% of whom also met the criteria for current adult ADHD. Level of trauma exposure and ADHD severity were significant predictors of current PTSD severity. Evaluation of the underlying structure of symptoms of PTSD and ADHD using confirmatory factor analysis yielded a best-fitting measurement model that comprised 4 PTSD factors and 3 ADHD factors. Standardized estimates of the correlations among PTSD and ADHD factors suggested that the largest proportion of shared variance underlying PTSD-ADHD comorbidity is related to problems with modulating arousal levels that are common to both disorders (ie, hyperarousal and hypoarousal).     

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample.

Research has indicated significant comorbid psychopathology with chronic posttraumatic stress disorder (PTSD) in samples of war veterans. The present paper examines the issue of comorbidity in a disaster sample to learn whether findings from veterans generalized to this event. A total of 193 subjects exposed to the Buffalo Creek dam collapse of 1972 were examined 14 years later using diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Past and present PTSD was found in a significant portion of the sample. Major depression was the next most common diagnosis and was highly related to PTSD. Anxiety disorders were also common. The overlap with other diagnoses was quite similar to that found in a sample of Vietnam veterans we studied earlier, except that the disaster sample had fewer dysthymic disorders, substance abusers, and antisocial personality disorders. Possible explanations for comorbidity in chronic PTSD were discussed and it was suggested that the morphology of PTSD may be quite stable in at least some other nonveteran trauma populations.     

Predicting posttraumatic stress symptoms longitudinally in a representative sample of hospitalized injured adolescents

OBJECTIVE: Adolescents constitute a high-risk population for traumatic physical injury, yet few longitudinal investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms over time in representative samples. METHOD: Between July 2002 and August 2003, 108 randomly selected injured adolescent patients ages 12 to 18 and their parents were interviewed at baseline and again 2, 5, and 12 months postinjury. Initially, participants were screened for PTSD symptoms with the PTSD Reaction Index (PTSD-RI) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale, as well as preinjury trauma. Random-coefficient regression was used to assess the association between baseline clinical, injury, and demographic characteristics and the development and maintenance of PTSD symptoms longitudinally. RESULTS: Between 19% and 32% of adolescents screened positive for PTSD (i.e., had PTSD-RI scores of > or =38) during the course of the 12 months after the injury. Higher initial adolescent PTSD and depressive symptoms, higher emergency department heart rate, greater objective event severity, and greater parental preinjury trauma were significant independent predictors of higher adolescent PTSD symptoms. CONCLUSIONS: For a substantive minority of hospitalized adolescents, high PTSD symptom levels persist during the 12 months after injury. Clinical characteristics readily identifiable after the acute injury predict the development of PTSD symptoms over time. Real-world clinical trials that test screening and intervention procedures for representative samples of at-risk youths are warranted.     

Trauma exposure,posttraumatic stress disorder and risk for alcohol,nicotine, and marijuana dependence in Israel

Background

Substance dependence is more common among trauma-exposed individuals; however, most studies suggest that Posttraumatic Stress Disorder (PTSD) accounts for the link between trauma exposure (TE) and substance dependence.

Objectives

This study examined associations between TE and substance dependence (alcohol, nicotine, and marijuana), and whether PTSD accounted for this association.

Method

1317 Jewish Israeli household residents completed in-person structured interviews assessing TE, PTSD, and substance (alcohol, nicotine, marijuana) dependence between 2007 and 2009. Regression analyses examined associations among TE, PTSD, and substance dependence.

Results

In the full sample, mean number of traumatic events was 2.7 (sd = 2.2), with 83.7% experiencing at least one event. In the full sample, mean number of PTSD symptoms was 2.5 (sd = 3.4), with 13.5% meeting PTSD diagnostic criteria. Prevalence of alcohol dependence was 13.4%; nicotine dependence 52.8%; and marijuana dependence 12.1%. Number of traumatic events was associated with increased odds of alcohol (OR = 1.3; 95% CI = 1.2–1.4) and nicotine (OR = 1.2; 95% CI = 1.1–1.3) dependence. Similarly, any traumatic event exposure was associated with increased odds of alcohol (OR = 3.1; 95% CI = 1.6–6.0) and nicotine (OR = 1.9; 95% CI = 1.2–2.9) dependence. PTSD symptoms were associated with increased odds of alcohol (OR = 1.2; 95% CI = 1.1–1.3), nicotine (OR = 1.1; 95% CI = 1.1–1.2), and marijuana (OR = 1.1; 95% CI = 1.04–1.2) dependence; similarly, a PTSD diagnosis was associated with increased odds of alcohol (OR = 3.4; 95% CI = 2.1–5.5), nicotine (OR = 2.2; 95% CI = 1.4–3.4), and marijuana (OR = 2.6; 95% CI = 1.2–5.9) dependence. PTSD symptoms accounted for a sizeable proportion of the TE effect on alcohol (46%) and nicotine dependence (31%).

Conclusion

Individuals with more traumatic events had heightened risk for alcohol and nicotine dependence, and PTSD symptoms partially accounted for this risk. However, marijuana dependence was only significantly related to PTSD symptoms. Clinicians and researchers should separately assess different types of dependence among trauma-exposed individuals both with and without PTSD symptoms.     

Symptoms of posttraumatic stress disorder in a community sample of low-income pregnant women

OBJECTIVE: The purpose of this study was to examine symptoms of posttraumatic stress disorder (PTSD) in a community sample of low-income pregnant women who met the DSM-IV diagnostic criteria for the disorder. METHOD: Pregnant women (N=948) were screened for trauma, PTSD, depression, and co-occurring illicit substance use. PTSD symptoms were compared in traumatized pregnant women and a sample of nonpregnant traumatized women from the National Comorbidity Survey. RESULTS: Suicidal thoughts and a high degree of psychiatric comorbidity were common in pregnant women with PTSD. Pregnant women were selectively and significantly less likely to endorse reexperiencing symptoms of PTSD (29.5%, N=82), compared to nonpregnant women (79.4%, N=464). CONCLUSIONS: PTSD in pregnancy was associated with comorbidity, poor health behaviors, and lower recall of memory-related PTSD symptoms. Further prospective study is needed.     

Clinical correlates of bipolar disorder in a large, referred sample of children and adolescents

OBJECTIVE:To compare the prevalence, clinical correlates, and comorbidity among children and adolescents with bipolar disorder (BPD) assessed in the early 1990s (first cohort) with those evaluated over the last 7 years (second cohort). METHODS: Subjects were consecutively referred children (N=108) and adolescents (N=197) with a DSM-III-R BPD diagnosis, referred to a child psychiatry service and evaluated with identical structured assessment methods. RESULTS: Mania was identified in 16% of referred youth in both age groups and cohorts; in both age groups and cohorts, the clinical picture was predominantly irritable and mixed, and the course was chronic. Youth with BPD in both age groups and cohorts frequently had comorbidity with ADHD, psychosis and anxiety disorders. They also had high rates of psychiatric hospitalization and evidence of severely impaired psychosocial functioning. CONCLUSIONS: The consistency of clinical features of bipolar disorder seen across age groups (children vs. adolescents) and cohorts (early and late cohorts) over the past decade supports the hypothesis that BPD in the young is a severe condition afflicting a sizeable minority of referred youth. These findings replicate and extend our previous characterization of an early onset mania, which may represent a developmental subtype of BPD.