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.     

Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder

OBJECTIVE: The authors examined the relationship between posttraumatic stress disorder (PTSD), trauma, and self-reported nonpsychiatric medical conditions in a sample of 502 primary care patients with one or more anxiety disorders. METHODS: Primary care patients with one or more DSM-IV anxiety disorders were assessed for comorbid psychiatric and substance use problems and for a history of trauma. These individuals also completed a self-report measure of current and lifetime medical conditions, lifetime tobacco use, and current regular exercise. RESULTS: Of 502 participants with at least one anxiety disorder, 84 (17 percent) reported no history of trauma, 233 (46 percent) had a history of trauma but no PTSD, and 185 (37 percent) met DSM-IV criteria for PTSD. Patients with PTSD reported a significantly greater number of current and lifetime medical conditions than did participants with other anxiety disorders but without PTSD. Primary care patients with PTSD were more likely to have had a number of specific medical problems, including anemia, arthritis, asthma, back pain, diabetes, eczema, kidney disease, lung disease, and ulcer. Possible explanations for the greater rates of medical conditions among participants with PTSD were examined as predictors in multiple regression. PTSD was found to be a stronger predictor of reported number of medical problems than trauma history, physical injury, lifestyle factors, or comorbid depression. CONCLUSIONS: These findings suggest that PTSD is associated with a higher rate of general medical complaints.     

Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial

OBJECTIVE: To evaluate the efficacy of individual trauma-focused cognitive-behavioral therapy (CBT) for treating posttraumatic stress disorder (PTSD) in children and young people. METHOD: Following a 4-week symptom-monitoring baseline period, 24 children and young people (8-18 years old) who met full DSM-IV PTSD diagnostic criteria after experiencing single-incident traumatic events (motor vehicle accidents, interpersonal violence, or witnessing violence) were randomly allocated to a 10-week course of individual CBT or to placement on a waitlist (WL) for 10 weeks. RESULTS: Compared to the WL group, participants who received CBT showed significantly greater improvement in symptoms of PTSD, depression, and anxiety, with significantly better functioning. After CBT, 92% of participants no longer met criteria for PTSD; after WL, 42% of participants no longer met criteria. CBT gains were maintained at 6-month follow-up. Effects of CBT were partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD. CONCLUSIONS: Individual trauma-focused CBT is an effective treatment for PTSD in children and young people.     

Posttraumatic stress disorder in hospitalized adolescents: psychiatric comorbidity and clinical correlates

OBJECTIVE: To describe the diagnostic comorbidity and clinical correlates of posttraumatic stress disorder (PTSD) in adolescent psychiatric inpatients. METHOD: Seventy-four adolescent inpatients were given a structured diagnostic interview, the revised version of the Diagnostic Interview for Children and Adolescents, and a battery of standard self-report measures to assess general trauma exposure, posttraumatic stress symptoms, suicidal behavior, dissociation, and depression. RESULTS: Ninety-three percent of subjects reported exposure to at least one traumatic event such as being a witness/victim of community violence, witnessing family violence, or being the victim of physical/sexual abuse. Thirty-two percent of subjects met diagnostic criteria for current PTSD, with sexual abuse cited as the most common traumatic stressor in 69% of PTSD cases. Girls were significantly more likely to develop PTSD than boys, although the total number of types of trauma did not differ by gender. Compared with psychiatric controls, male youngsters with PTSD were significantly more likely to have comorbid diagnoses of eating disorders, other anxiety disorders, and somatization disorder. Furthermore, male and female youngsters with PTSD were significantly more likely to have attempted suicide and report greater depressive and dissociative symptoms. CONCLUSION: In clinical populations of hospitalized adolescents exposed to multiple forms of trauma, PTSD is a common, but highly comorbid disorder. Specific multimodal assessments and treatments targeted to both PTSD and its comorbidity profile are warranted.     

The impact of endorsing Spitzer's proposed criteria for PTSD in the forthcoming DSM-V on male and female Veterans

This study explored differences between Spitzer's proposed model of posttraumatic stress disorder (PTSD) and the current DSM-IV diagnostic classification scheme in 353 Veterans. The majority of Veterans (89%) diagnosed with PTSD as specified in the DSM-IV also met Spitzer's proposed criteria. Veterans who met both DSM-IV and Spitzer's proposed criteria had significantly higher Clinician Administered PTSD Scale severity scores than Veterans only meeting DSM-IV criteria. Logistic regression indicated that being African American and having no comorbid diagnosis of major depressive disorder or history of a substance use disorder were found to predict those Veterans who met current, but not proposed criteria. These findings have important implications regarding proposed changes to the diagnostic classification criteria for PTSD in the forthcoming DSM-V.     

On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice

BACKGROUND: Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients. METHOD: 1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder. RESULTS: No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion. CONCLUSION: In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.     

Post-traumatic stress disorder

BACKGROUND: The study is aimed at investigating the influence of trauma type, pre-existing psychiatric disorders with an onset before trauma, and gender on post-traumatic stress disorder (PTSD). METHODS: Traumas, PTSD and psychiatric disorders were assessed in a representative sample of 4075 adults aged 18-64 years using the Composite International Diagnostic Interview. Pre-existing DSM-IV diagnoses of anxiety disorders, depressive disorders, somatoform disorders, alcohol abuse and dependence, nicotine dependence, gender, and the type of trauma were analysed with logistic regressions to estimate the influence of these factors on the risk for developing PTSD. RESULTS: The lifetime prevalence of exposure to any trauma did not vary by gender. The conditional probability of PTSD after exposure to trauma was higher in women (11.1% SE = 1.58) than men (2.9% SE = 0.83). Univariate analyses showed that pre-existing anxiety disorders, somatoform disorders and depressive disorders significantly increase the risk of PTSD. Multivariate analyses revealed that specific types of trauma, especially rape and sexual abuse, pre-existing anxiety disorders and somatoform disorders are predictors of an increased risk of PTSD, while gender and depressive disorder were not found to be independent risk factors. CONCLUSION: Women do not have a higher vulnerability for PTSD in general. However, especially sexually motivated violence and pre-existing anxiety disorders are the main reasons for higher prevalences of PTSD in women.     

Gender differences in patients with posttraumatic stress disorder in a general psychiatric practice.

OBJECTIVE: This report examined gender differences in the clinical manifestations of current posttraumatic stress disorder (PTSD) in treatment-seeking patients. METHOD: Outpatients with PTSD (N=138) were interviewed with the Structured Clinical Interview for DSM-IV. RESULTS: Compared with male patients, female patients experienced more reexperiencing symptoms and were more likely to meet criteria for current PTSD and to report sexual trauma as their index trauma. Men with PTSD were more likely than women with PTSD to meet criteria for a substance use disorder and for antisocial personality disorder. No gender differences were found in the frequency of other types of comorbid disorders, the number of comorbid disorders, or the presence of PTSD as a primary disorder. CONCLUSIONS: Overall, male and female patients with current PTSD present with fairly comparable clinical profiles.     

Symptoms of posttraumatic stress disorder in adolescents with conduct disorder: sex differences and onset patterns.

OBJECTIVE: To examine sex differences in the rate and symptoms of posttraumatic stress disorder (PTSD), trauma exposure, and onset patterns in youth with conduct disorder (CD). METHOD: Youth admitted to a clinical facility for severe behaviour problems completed the Diagnostic Interview for Children and Adolescents--Revised (DICA-R) to assess the presence of CD and PTSD. RESULTS: Over one-half of CD youth reported exposure to trauma, yet only 17% met criteria for PTSD. PTSD was more frequent in CD girls (28%) than in boys (10%), and girls experienced greater symptom intensity and anhedonia, difficulty feeling love or affection, and disturbance of sleep and concentration. Girls more frequently reported sexual assault, while boys were more likely to report accidents, physical assaults, and witnessing the death of a loved one. Retrospective reports indicated that PTSD tended to develop subsequent to CD. CONCLUSIONS: Exposure to trauma is common among CD youth; however, diagnostic procedures should be adapted for increased sensitivity to PTSD. The development of CD may increase the risk for PTSD, particularly in girls, by exposing youth to situations in which they are traumatized. The role of trauma in CD should be routinely examined by clinicians and warrants further research.     

Is PTSD caused by traumatic stress?

Sequential subjects (N=103) presenting for pharmacologic treatment of major depression were examined prior to treatment for history of traumatic experiences. Subjects were also examined for symptoms of posttraumatic stress disorder (PTSD). Two blinded raters subsequently judged whether subjects' experiences met DSM-IV criteria for trauma (criterion A of PTSD). Among 54 subjects scored by both raters as having experienced trauma, 42 (78%) met all other DSM-IV criteria for PTSD. Among 36 subjects scored by both raters as not having experienced trauma, 28 displayed all other DSM-IV criteria for PTSD--also a rate of 78%. This equivalence suggests that in a treatment-seeking population, caution should be exercised in attributing the PTSD syndrome to trauma.     

Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events

OBJECTIVE: The aim of the present study was to isolate the unique contribution of physical injury to the subsequent development of posttraumatic stress disorder (PTSD). METHOD: Participants were 60 injured soldiers and a comparison group of 40 soldiers (matched by rank, military role, and length of service) who took part in the same combat situations but were not injured. Current and lifetime diagnoses were determined by using the Structured Clinical Interview for DSM-IV. In addition, an extensive battery of self-report questionnaires was given to assess severity of PTSD, anxiety, depression, and dissociative symptoms. The average time that elapsed between the injury and the interview was 15.5 months (SD=7.3). RESULTS: Ten (16.7%) of the 60 injured survivors but only one (2.5%) of the 40 comparison soldiers met diagnostic criteria for PTSD at the time of the interview (odds ratio=8.6, 95% confidence interval=1.1-394.3). Moreover, wounded participants had significantly higher scores than their noninjured counterparts on all clinical measures. Finally, presence of PTSD was not related to severity of injury or severity of the trauma. CONCLUSIONS: The findings clearly indicate that bodily injury is a major risk factor-rather than a protective one-for PTSD. While supporting the notion that bodily injury contributes to the appraisal of the traumatic event as more dangerous, the data also suggest that this heightened level of perceived threat is not a simple, straightforward function of the severity of injury or of the traumatic event.     

A pilot study of interpersonal psychotherapy for posttraumatic stress disorder

OBJECTIVE: This article describes pilot testing of interpersonal psychotherapy adapted for posttraumatic stress disorder (PTSD). Unlike most psychotherapies for PTSD, interpersonal psychotherapy is not exposure-based, focusing instead on interpersonal sequelae of trauma. METHOD: Fourteen consecutively enrolled subjects with chronic PTSD (DSM-IV) from various traumas received an open, 14-week interpersonal psychotherapy trial. RESULTS: Treatment was well tolerated: 13 subjects (93%) completed therapy. After 14 weeks, 12 of 14 subjects no longer met diagnostic criteria for PTSD, 69% responded (50% Clinician Administered PTSD Scale score decrement), and 36% remitted (score < or =20). Thirteen subjects reported declines in PTSD symptoms across all three symptom clusters. Depressive symptoms, anger reactions, and interpersonal functioning also improved. CONCLUSIONS: Treating interpersonal sequelae of PTSD appears to improve other symptom clusters. Interpersonal psychotherapy may be an efficacious alternative for patients who refuse repeated exposure to past trauma. This represents an exciting extension of interpersonal psychotherapy to an anxiety disorder.     

Traumatic events and posttraumatic stress in childhood

CONTEXT: Traumatic events are common and are related to psychiatric impairment in childhood. Little is known about the risk for posttraumatic stress disorder (PTSD) across different types of trauma exposure in children. OBJECTIVE: To examine the developmental epidemiology of potential trauma and posttraumatic stress (PTS) in a longitudinal community sample of children. METHODS: A representative population sample of 1420 children aged 9, 11, and 13 years at intake were followed up annually through 16 years of age. Main Outcome Measure Traumatic events and PTS were assessed from child and parent reports annually to 16 years of age. Risk factors and DSM-IV disorders were also assessed. RESULTS: More than two thirds of children reported at least 1 traumatic event by 16 years of age, with 13.4% of those children developing some PTS symptoms. Few PTS symptoms or psychiatric disorders were observed for individuals experiencing their first event, and any effects were short-lived. Less than 0.5% of children met the criteria for full-blown DSM-IV PTSD. Violent or sexual trauma were associated with the highest rates of symptoms. The PTS symptoms were predicted by previous exposure to multiple traumas, anxiety disorders, and family adversity. Lifetime co-occurrence of other psychiatric disorders with traumatic events and PTS symptoms was high, with the highest rates for anxiety and depressive disorders. CONCLUSIONS: In the general population of children, potentially traumatic events are fairly common and do not often result in PTS symptoms, except after multiple traumas or a history of anxiety. The prognosis after the first lifetime trauma exposure was generally favorable. Apart from PTSD, traumatic events are related to many forms of psychopathology, with the strongest links being with anxiety and depressive disorders.     

Implications of childhood sexual abuse for adult borderline personality disorder and complex posttraumatic stress disorder

OBJECTIVE: This study examined whether women with a history of early-onset sexual abuse or those with late-onset sexual abuse were more likely to meet diagnostic criteria for both borderline personality disorder and complex posttraumatic stress disorder (PTSD). METHOD: The Revised Diagnostic Interview for Borderlines and the Trauma Assessment Package were administered to 65 women from three outpatient clinics in a metropolitan area. Thirty-eight subjects met criteria for early-onset abuse, while 27 subjects met criteria for late-onset abuse. RESULTS: The diagnoses of both borderline personality disorder and complex PTSD were significantly higher in women reporting early-onset abuse than in those with late-onset abuse. The trauma variables sexual abuse and paternal incest were significant predictors of both diagnoses. CONCLUSIONS: In contrast to those with comorbid diagnoses, some women with a history of childhood sexual abuse may be extricated from the diagnosis of borderline personality disorder and subsumed under that of complex PTSD.     

Posttraumatic stress disorder among African Americans in an inner city mental health clinic

This study examined 184 African-American outpatients in a mental health clinic in the inner city to define the rate of occurrence of traumatic experience and posttraumatic stress disorder (PTSD). This population experienced a high rate of severe trauma. Forty-three percent were found to have PTSD, as measured by the PTSD Symptom Scale. Finally, a chart review of 72 participants found that only 11 percent of participants who met DSM-IV criteria for PTSD also had a chart diagnosis of PTSD. PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.     

Mental Hygiene in Industry†

Objective: Approximately 30 million Americans present to acute care medical settings annually after incurring traumatic injuries. Posttraumatic stress disorder (PTSD) and depressive symptoms are endemic among injury survivors. Our article is a replication and extension of a previous report documenting a pattern of multiple traumatic life events across patients admitted to Level I trauma centers for an alcohol-related injury. Method: This study is a secondary analysis of a nationwide 20-site randomized trial of an alcohol brief intervention with 660 traumatically injured inpatients. Pre-injury trauma history was assessed using the National Comorbidity Survey trauma history screen at the six-month time point. Results: Most common traumatic events experienced by our population of alcohol-positive trauma survivors were having had someone close unexpectedly die, followed by having seen someone badly beaten or injured. Of particular note, there is high reported prevalence of rape/sexual assault, and childhood abuse and neglect among physically injured trauma survivors. Additional trauma histories are increasingly common among alcohol-positive patients admitted for a traumatic injury. Conclusions: Due to the high rate of experienced multiple traumatic events among acutely injured inpatients, the trauma history screen could be productively integrated into screening and brief intervention procedures developed for acute care settings.     

The relationship of gender and trauma characteristics to posttraumatic stress disorder in a community sample of traumatized northern plains American Indian adolescents and young adults

OBJECTIVE: Previous studies have identified a high prevalence (25%-80%) of trauma among American Indian and non-American Indian adolescents and adults. However, only a fraction of traumatized individuals develop posttraumatic stress disorder (PTSD). This article examines the relationships of gender and trauma characteristics to a diagnosis of PTSD among a community sample of traumatized American Indian adolescents and young adults. METHOD: Complete data were collected from 349 American Indians aged 15 to 24 years who participated in a cross-sectional community-based study from July 1997 to December 1999 and reported experiencing at least 1 traumatic event. Traumatic events and PTSD were assessed using a version of the Composite International Diagnostic Interview. Logistic regression determined the relationships of gender, trauma type, age at first trauma, and number of traumas to the development of PTSD. RESULTS: Forty-two participants (12.0% of those who experienced a traumatic event) met criteria for lifetime PTSD. While all 4 of the independent variables noted above demonstrated univariate associations with PTSD, multivariate logistic regression analyses indicated that only experiencing a sexual trauma (odds ratio [OR] = 4.45, 95% confidence interval [CI] = 1.76 to 11.28) and having experienced 6 or more traumas (OR = 2.53, 95% CI = 1.06 to 6.04) were independent predictors of meeting criteria for PTSD. CONCLUSION: American Indian children and adolescents who experience sexual trauma and multiple traumatic experiences may be at particularly high risk for developing PTSD.     

Posttraumatic stress disorder in a psychosomatic outpatient clinic. Gender effects, psychosocial functioning, sense of coherence, and service utilization

BACKGROUND: The lifetime prevalence of DSM-IV traumatic events and posttraumatic stress disorder (PTSD) was assessed in outpatients of a tertiary referral mental health center; differences in psychopathology and service utilization between PTSD and non-PTSD patients were evaluated. METHODS: Five hundred eighty-three outpatients (35.3 years, S.D.=12.5; 74.3% women and 25.7% men), who had been initially examined by clinically experienced medical and psychological psychotherapists, were investigated by means of standardized trauma-specific questionnaires. RESULTS: Of the patients, 61.1% reported at least one traumatic event during their lifetime, but only 34.3% of the total sample met the DSM-IV (A1 and A2) criteria. The lifetime prevalence of PTSD-positive screening was 10.1%. In 2.7% of these patients, PTSD had been diagnosed in clinical routine (ICD-10: F43.1); 6.6% of the men and 11.3% of the women met the diagnostic criteria for lifetime prevalence of PTSD. All in all, patients with PTSD had higher levels of depression and anxiety and lower levels of sense of coherence (P < .001) than did patients without PTSD (all P < .001). In addition, PTSD patients reported significantly higher rates of medical consultations (P < .001), psychotropic medication (P < .001), and psychotherapy (P < .001). CONCLUSIONS: About one third of the outpatients suffered from DSM-IV traumas, and 10%, from PTSD. However, PTSD had been diagnosed only in very few patients within the routine diagnostic procedure. These findings suggest that PTSD is frequently overlooked not only in primary but also in tertiary care settings. Finally, our study supports previous results that PTSD patients use more service utilization and are more affected by psychopathology symptoms.     

Comorbidity of axis I disorders in patients with traumatic grief.

BACKGROUND: Traumatic grief has been found to be a distinct disorder from both depression and anxiety; however, there is no information in the literature regarding comorbidity of traumatic grief with other psychiatric disorders. METHOD: Twenty-three bereaved subjects who presented for treatment of traumatic grief symptomatology were included in this study. The Inventory of Complicated Grief (ICG) was used to confirm the presence of traumatic grief and assess its severity. In addition, the Structured Clinical Interview for DSM-IV was performed. RESULTS: Most subjects met criteria for a current or lifetime Axis I diagnosis. Fifty-two percent (N = 12) met criteria for current major depressive disorder, and 30% (N = 7), for current posttraumatic stress disorder (PTSD). ICG scores and functional impairment were higher among patients with more than one concurrent Axis I diagnosis. CONCLUSION: Comorbid major depressive disorder and PTSD may be prevalent in patients presenting for treatment of traumatic grief.     

Mental health treatment received by primary care patients with posttraumatic stress disorder

BACKGROUND: Posttraumatic stress disorder (PTSD) is receiving growing attention as a pervasive and impairing disorder but is still undertreated. Our purpose was to describe the characteristics of mental health treatment received by primary care patients diagnosed with PTSD. METHOD: 4383 patients from 15 primary care, family practice, or internal medicine clinics were screened for anxiety symptoms using a self-report questionnaire developed for the study. Those found positive for anxiety symptoms (N = 539) were interviewed with the Structured Clinical Interview for DSM-IV. Of these patients, 197 met diagnostic criteria for PTSD and were examined in the present study regarding the rates and types of mental health treatment they were currently receiving. Data were gathered from July 1997 to May 2001. RESULTS: Nearly half (48%) of the patients in general medical practice with PTSD were receiving no mental health treatment at the time of intake to the study. Of those receiving treatment, psychopharmacologic interventions were most common. Few patients were receiving empirically supported psychosocial interventions. Current comorbid major depressive disorder and current comorbid panic disorder with agoraphobia were significantly associated with receiving mental health treatment (major depressive disorder, p <.10; panic disorder with agoraphobia, p <.05). The most common reason patients gave for not receiving medication was the failure of physicians to recommend such treatment, which was also among the most common reasons for not receiving psychosocial treatment. CONCLUSIONS: Despite the morbidity, psychosocial impairment, and distress associated with PTSD, substantial proportions of primary care patients with the disorder are going untreated or are receiving inadequate treatment. Results suggest a need for better identification and treatment of PTSD in the primary care setting.