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.     

Symptom overlap in posttraumatic stress disorder and major depression

Over the past decade there has been consistent criticism of the diagnostic criteria of posttraumatic stress disorder (PTSD) because of its high comorbidity with other mental disorders. Part of the problem surrounding PTSD may be related to the heterogeneity of its symptoms. In fact, recent research has identified a subset of PTSD symptoms, including symptoms of numbing and dysphoria, that may explain much of the overlap between PTSD and major depressive disorder (MDD). The present study sought to extend prior work by investigating the various subsets of PTSD symptoms in individuals from all four diagnostic combinations of PTSD and MDD (no MDD-PTSD, MDD-only, PTSD-only, and comorbid MDD-PTSD). Consenting participants completed diagnostic interviews and were categorized into the four groups. Based on responses to a self-report measure of PTSD symptoms, participants with no MDD-PTSD reported the least severe symptoms while the participants with comorbid MDD-PTSD reported the most severe symptoms. Interesting, participants in the MDD-only and PTSD-only groups consistently reported similar scores across all PTSD symptom scales. These findings further highlight the problematic diagnostic criteria and comorbidity in PTSD and emphasize the need to incorporate transdiagnostic treatment practices that focus on the overlapping symptoms, rather than specific diagnostic categories.     

Symptom correlates of posttraumatic stress disorder in clients with borderline personality disorder

Limited research has examined the clinical and functional impact of concurrent posttraumatic stress disorder (PTSD) in people with borderline personality disorder (BPD). Such information is particularly lacking for BPD clients with the most disabling symptoms: those who meet criteria for severe and persistent mental illness. We evaluated individuals with severe mental illness to assess whether PTSD in individuals with BPD was associated with more severe symptoms and impaired functioning than BPD alone and replicated these findings in an independent sample. In both the studies, the clients with PTSD and BPD reported significantly higher levels of general distress, physical illness, anxiety, and depression than those with BPD alone. Because individuals with both of these disorders are likely to require more intensive clinical services to reduce distress and improve functioning, work is needed to develop and evaluate interventions designed to address these comorbid conditions.     

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.     

Short screening scale for DSM-IV posttraumatic stress disorder.

OBJECTIVE: The authors' goal was to construct a short screening scale for DSM-IV posttraumatic stress disorder (PTSD). METHOD: They used data from the Detroit Area Survey of Trauma, which is a representative population sample of 2,181 subjects 18-45 years of age. Random digit dialing was used to select the sample, and a computer-assisted telephone interview was used to collect data on traumatic experiences and PTSD. Presence or absence of PTSD was assessed with a telephone-administered structured interview that closely followed the National Institute of Mental Health Diagnostic Interview Schedule for DSM-IV and the World Health Organization Composite International Diagnostic Interview, version 2.1. Best-subset regression analysis and receiver operating characteristic analysis were used to select a subset of items from the structured interview that most efficiently predicted PTSD as diagnosed in the full-length interview. RESULTS: A seven-symptom screening scale for PTSD was selected; five of the symptoms were from the avoidance and numbing group, and two were from the hyperarousal group. A score of 4 or greater on this scale defined positive cases of PTSD with a sensitivity of 80%, specificity of 97%, positive predictive value of 71%, and negative predictive value of 98%. CONCLUSIONS: The short screening scale is an efficient method to screen for PTSD in epidemiologic and clinical studies, given limitations on resources and burden on respondents.     

Trauma exposure and posttraumatic stress disorder among primary care patients with bipolar spectrum disorder

Objective:  To examine relationships between exposure to trauma, bipolar spectrum disorder (BD) and posttraumatic stress disorder (PTSD) in a sample of primary care patients.
Methods:  A systematic sample (n = 977) of adult primary care patients from an urban general medicine practice were interviewed with measures including the Mood Disorders Questionnaire, the PTSD Checklist–Civilian Version, and the Medical Outcomes Study 12-Item Short Form Health Survey.
Results:  Compared with patients who screened negative for BD (n = 881), those who screened positive (n = 96) were 2.6 times [95% confidence interval (CI): 1.6–4.2] as likely to report physical or sexual assault, and 2.9 times (95% CI: 1.6–5.1) as likely to screen positive for current PTSD. Among those screening positive for BD, comorbid PTSD was associated with significantly worse social functioning. These results controlled for selected background characteristics, current major depressive episode, and current alcohol/drug use disorder.
Conclusion:  In an urban general medicine setting, trauma exposure was related to BD, and the frequency of PTSD among patients with BD appears to be common and clinically significant. These results suggest an unmet need for mental health care in this specific population and are especially important in view of available treatments for BD and PTSD.     

Trauma and comorbid posttraumatic stress disorder in individuals with schizophrenia and substance abuse

Objectives

The aim of this study was to investigate the occurrence of trauma and comorbid posttraumatic stress disorder (PTSD) in dual diagnosis patients and whether the trauma was related to the patient's behavior or illness.

Method

One hundred ten patients with schizophrenia and comorbid substance or alcohol abuse were assessed for PTSD using self-report and structured interview. Traumatic events were classified as independent or dependent upon the patient's behavior, illness, or symptoms.

Results

One hundred patients (91%) reported at least 1 trauma (mean, 4.3). Sixty-three patients (57%) reported a traumatic event that met modified-criterion A for PTSD. Thirty-one patients (28%) met criteria for full PTSD, and 18 (16%) had a trauma directly related to their illness. Patients with PTSD had significantly higher scores on positive psychotic symptoms and depression.

Conclusions

Exposures to traumatic events and comorbid PTSD are high but are inflated by reactions to illness-related events such as hospitalization and psychotic symptoms.     

Large‐scale white matter network reorganization in posttraumatic stress disorder

Recently, graph theoretical approaches applied to neuroimaging data have advanced understanding of the human brain connectome and its abnormalities in psychiatric disorders. However, little is known about the topological organization of brain white matter networks in posttraumatic stress disorder (PTSD). Seventy‐six patients with PTSD and 76 age, gender, and years of education‐matched trauma‐exposed controls were studied after the 2008 Sichuan earthquake using diffusion tensor imaging and graph theoretical approaches. Topological properties of brain networks including global and nodal measurements and modularity were analyzed. At the global level, patients showed lower clustering coefficient (p = .016) and normalized characteristic path length (p = .035) compared with controls. At the nodal level, increased nodal centralities in left middle frontal gyrus, superior and inferior temporal gyrus and right inferior occipital gyrus were observed (p < .05, corrected for false‐discovery rate). Modularity analysis revealed that PTSD patients had significantly increased inter‐modular connections in the fronto‐parietal module, fronto‐striato‐temporal module, and visual and default mode modules. These findings indicate a PTSD‐related shift of white matter network topology toward randomization. This pattern was characterized by an increased global network integration, reflected by increased inter‐modular connections with increased nodal centralities involving fronto‐temporo‐occipital regions. This study suggests that extremely stressful life experiences, when they lead to PTSD, are associated with large‐scale brain white matter network topological reconfiguration at global, nodal, and modular levels.     

Developing a Symptom Validity Test for posttraumatic stress disorder: application of the binomial distribution

The past decade has witnessed a significant increase in research on the detection of malingered Posttraumatic Stress Disorder (PTSD) in civil litigation, other disability pension contexts, and in forensic cases. This article reviews the basic principles and statistical procedures that can be used to design and develop a Symptom Validity Test (SVT) for PTSD. We demonstrate how the practical application of the binomial distribution can detect response bias in specific psychiatric disorders such as PTSD and can provide empirically grounded probabilistic evidence of malingering. We cite the Morel Emotional Numbing Test for Posttraumatic Stress Disorder (MENT) as an example.     

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.     

Rumination in posttraumatic stress disorder

Recent studies have shown that rumination is a powerful predictor of persistent posttraumatic stress disorder (PTSD). However, to date, the mechanisms by which rumination maintains PTSD symptoms are little understood. Two studies of assault survivors, a cross-sectional (N = 81) and a 6-month prospective longitudinal study (N = 73), examined several facets of ruminative thinking to establish which aspects of rumination provide the link to PTSD. The current investigation showed that rumination is not only used as a strategy to cope with intrusive memories but it also triggers such memories. Certain characteristics of rumination, such as compulsion to continue ruminating, occurrence of unproductive thoughts, and "why" and "what if" type questions, as well as negative emotions before and after rumination, were significantly associated with PTSD, concurrently and prospectively. These characteristics explained significantly more variance in PTSD severity than the mere presence of rumination, thereby indicating that not all ways of ruminative thinking are equally maladaptive.     

Early prognostic screening for posttraumatic stress disorder with the Davidson Trauma Scale and the SPAN

Background: This study examined the accuracy of the 17‐item Dutch version of the Davidson Trauma Scale (DTS) and the four‐item SPAN (Startle, Physiological Arousal, Anger and Numbness) to detect survivors at risk for posttraumatic stress disorder (PTSD) within the first 2 weeks after the trauma. Methods: 203 civilian survivors of recent trauma with relatively mild symptoms completed the DTS a mean of 8.7 days after experiencing trauma. SPAN scores were computed from the DTS. At a mean of 64.6 days posttrauma, 160 respondents were assessed for diagnosis of PTSD with the Structured Interview for PTSD. Results: Receiver operating characteristic curves showed that the DTS showed good overall screening accuracy (84%). At a cut‐off value of 64, the DTS demonstrated a sensitivity of 0.86, a specificity of 0.70, a positive predictive value (PPV) of 0.12, and a negative predictive value (NPV) of 0.98. Overall accuracy of the SPAN was good (89%). At a cut‐off of 10 the SPAN showed a sensitivity of 0.86, a specificity of 0.86, a PPV of 0.22, and a NPV of 0.98. The low PPVs were possibly due to the low of prevalence of PTSD in our sample (4.4%). Conclusions: This study shows that both the DTS and the SPAN are comparably accurate in screening early trauma survivors at risk for developing PTSD. The very brief four‐item SPAN may be preferred over the longer 17‐item DTS especially in settings in which time and resources are limited. Future studies should aim to cross‐validate these results in random samples. Depression and Anxiety, 2008. © 2008 Wiley‐Liss, Inc.