The long-term costs of traumatic stress: intertwined physical and psychological consequences

Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up

BACKGROUND

Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment.

AIMS

To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling.

METHOD

Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and funxctioning were assessed.

RESULTS

Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit.

CONCLUSIONS

These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

Community mental health service utilization after the L'Aquila earthquake

This study investigated the use of the facilities for the mental health by the population affected by the L'Aquila (Italy) 2009 earthquake. The data about the activities of the Mental Health Centre of L'Aquila during the years from 2008 to 2010 were obtained by the service Information System. In the months following the event the percentage of referrals was reduced. Failure to use specialized facilities after disasters should not be seen as reassuring. It is conceivable that a relevant rate of frank or sub-threshold psychopathology is present that the traditional mental health facilities may not be able to intercept.

Posttraumatic stress disorder and the risk of respiratory problems in World Trade Center responders: longitudinal test of a pathway

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with high medical morbidity, but the nature of this association remains unclear. Among responders to the World Trade Center (WTC) disaster, PTSD is highly comorbid with lower respiratory symptoms (LRS), which cannot be explained by exposure alone. We sought to examine this association longitudinally to establish the direction of the effects and evaluate potential pathways to comorbidity.

METHODS

18,896 responders (8466 police and 10,430 nontraditional responders) participating in the WTC-Health Program were first evaluated between 2002 and 2010 and assessed again 2.5 years later. LRS were ascertained by medical staff, abnormal pulmonary function by spirometry, and probable WTC-related PTSD with a symptom inventory.

RESULTS

In both groups of responders, initial PTSD (standardized regression coefficient: β = 0.20 and 0.23) and abnormal pulmonary function (β = 0.12 and 0.12) predicted LRS 2.5 years later after controlling for initial LRS and covariates. At follow-up, LRS onset was 2.0 times more likely and remission 1.8 times less likely in responders with initial PTSD than in responders without. Moreover, PTSD mediated, in part, the association between WTC exposures and development of LRS (p < .0001). Initial LRS and abnormal pulmonary function did not consistently predict PTSD onset.

CONCLUSIONS

These analyses provide further evidence that PTSD is a risk factor for respiratory symptoms and are consistent with evidence implicating physiological dysregulation associated with PTSD in the development of medical conditions. If these effects are verified experimentally, treatment of PTSD may prove helpful in managing physical and mental health of disaster responders.

Posttraumatic stress and other health consequences of catastrophic avalanches: A 16-year follow-up of survivors

To date, no study has investigated the effects of avalanches on survivor's health beyond the first years. The aim of this study was to examine long-term health status 16 years after exposure to avalanches using a matched cohort design. Mental health, sleep quality and somatic symptoms among avalanche survivors (n=286) and non-exposed controls (n=357) were examined. Results showed that 16% of survivors currently experience avalanche-specific PTSD symptoms (PDS score>14). In addition, survivors presented with increased risk of PTSD hyperarousal symptoms (>85th percentile) (aRR=1.83; 98.3% CI [1.23-2.74]); sleep-related problems (PSQI score>5) (aRR=1.34; 95% CI [1.05-1.70]); PTSD-related sleep disturbances (PSQI-A score≥4) (aRR=1.86; 95% CI [1.30-2.67]); musculoskeletal and nervous system problems (aRR 1.43; 99% CI 1.06-1.93) and gastrointestinal problems (aRR 2.16; 99% CI 1.21-3.86) compared to the unexposed group. Results highlight the need for treatment for long-term PTSD symptoms and sleep disruption in disaster communities.

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: results from a longitudinal cohort of South African women who attend alcohol-serving venues

BACKGROUND

In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use.

METHODS

Data were collected in 4 waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined (1) the relationship between traumatic stress and counts of unprotected sex and (2) whether alcohol use mediated the association between traumatic stress and unprotected sex.

RESULTS

Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b = 0.28, SE = 0.06, t = 4.82, P < 0.001). In addition, traumatic stress was associated with alcohol use (b = 0.27, SE = 0.02, t = 14.25, P < 0.001) and was also associated with unprotected sex (b = 0.20, SE = 0.06, t = 3.27, P < 0.01) while controlling for alcohol use (b = 0.28, SE = 0.07, t = 4.25, P < 0.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex.

CONCLUSIONS

These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

Acute and chronic plasma metabolomic and liver transcriptomic stress effects in a mouse model with features of post-traumatic stress disorder

Acute responses to intense stressors can give rise to post-traumatic stress disorder (PTSD). PTSD diagnostic criteria include trauma exposure history and self-reported symptoms. Individuals who meet PTSD diagnostic criteria often meet criteria for additional psychiatric diagnoses. Biomarkers promise to contribute to reliable phenotypes of PTSD and comorbidities by linking biological system alterations to behavioral symptoms. Here we have analyzed unbiased plasma metabolomics and other stress effects in a mouse model with behavioral features of PTSD. In this model, C57BL/6 mice are repeatedly exposed to a trained aggressor mouse (albino SJL) using a modified, resident-intruder, social defeat paradigm. Our recent studies using this model found that aggressor-exposed mice exhibited acute stress effects including changed behaviors, body weight gain, increased body temperature, as well as inflammatory and fibrotic histopathologies and transcriptomic changes of heart tissue. Some of these acute stress effects persisted, reminiscent of PTSD. Here we report elevated proteins in plasma that function in inflammation and responses to oxidative stress and damaged tissue at 24 hrs post-stressor. Additionally at this acute time point, transcriptomic analysis indicated liver inflammation. The unbiased metabolomics analysis showed altered metabolites in plasma at 24 hrs that only partially normalized toward control levels after stress-withdrawal for 1.5 or 4 wks. In particular, gut-derived metabolites were altered at 24 hrs post-stressor and remained altered up to 4 wks after stress-withdrawal. Also at the 4 wk time point, hyperlipidemia and suppressed metabolites of amino acids and carbohydrates in plasma coincided with transcriptomic indicators of altered liver metabolism (activated xenobiotic and lipid metabolism). Collectively, these system-wide sequelae to repeated intense stress suggest that the simultaneous perturbed functioning of multiple organ systems (e.g., brain, heart, intestine and liver) can interact to produce injuries that lead to chronic metabolic changes and disorders that have been associated with PTSD.

Early EMDR Intervention Following a Community Critical Incident: A Randomized Clinical Trial

The aim of this study was to investigate the efficacy of early eye movement desensitization and reprocessing (EMDR) intervention using the EMDR recent traumatic episode protocol (R-TEP) after a traumatic community event whereby a missile hit a building in a crowded area of a town. In a waitlist/delayed treatment parallel-group randomized controlled trial, 17 survivors with posttraumatic distress were treated with EMDR therapy using the R-TEP protocol. Volunteer EMDR practitioners conducted treatment on 2 consecutive days. Participants were randomly allocated to either immediate or waitlist/delayed treatment conditions. Assessments with Impact of Event Scale-Revised (IES-R) and the Patient Health Questionnaire (PHQ-9) brief depression inventory took place at pre- and posttreatment and at 3 months follow-up. At 1 week posttreatment, the scores of the immediate treatment group were significantly improved on the IES-R compared to the waitlist/delayed treatment group, who showed no improvement prior to their treatment. At 3 months follow-up, results on the IES-R were maintained and there was a significant improvement on PHQ-9 scores. This pilot study provides preliminary evidence, supporting the efficacy of EMDR R-TEP for reducing posttrauma stress among civilian victims of hostility, and shows that this model of intervention briefly augmenting local mental health services following large-scale traumatic incidents, using an EMDR intervention on 2 consecutive days may be effective.

Cytokine production as a putative biological mechanism underlying stress sensitization in high combat exposed soldiers

OBJECTIVE

Combat stress exposed soldiers may respond to post-deployment stressful life events (SLE) with increases in symptoms of posttraumatic stress disorder (PTSD), consistent with a model of stress sensitization. Several lines of research point to sensitization as a model to describe the relations between exposure to traumatic events, subsequent SLE, and symptoms of PTSD. Based on previous findings we hypothesized that immune activation, measured as a high in vitro capacity of leukocytes to produce cytokines upon stimulation, underlies stress sensitization.

METHODS

We assessed mitogen-induced cytokine production at 1 month, SLE at 1 year, and PTSD symptoms from 1 month up to 2 years post-deployment in soldiers returned from deployment to Afghanistan (N=693). Exploratory structural equation modeling as well as latent growth models were applied.

RESULTS

The data demonstrated significant three-way interaction effects of combat stress exposure, cytokine production, and post-deployment SLE on linear change in PTSD symptoms over the first 2 years following return from deployment. In soldiers reporting high combat stress exposure, both high mitogen-stimulated T-cell cytokine production and high innate cytokine production were associated with increases in PTSD symptoms in response to post-deployment SLE. In low combat stress exposed soldiers as well as those with low cytokine production, post-deployment SLE were not associated with increases in PTSD symptoms.

CONCLUSION

High stimulated T-cell and innate cytokine production may contribute to stress sensitization in recently deployed, high combat stress exposed soldiers. These findings suggest that detecting and eventually normalizing immune activation may potentially complement future strategies to prevent progression of PTSD symptoms following return from deployment.

Green tea extracts reduce adipogenesis by decreasing expression of transcription factors C/EBPα and PPARγ

OBJECTIVES

This study is to determine if green tea (Camellia sinensis) extracts (GTE) affects adipogenesis and further investigate the related molecular mechanisms.

METHODS

Patients with metabolic syndrome were recruited in this study. Of them, 70 patients received GTE and 64 received water to serve as the control group. The human serum adiponectin, visfatin, and leptin concentrations were determined by enzyme-linked immunosorbent assay. Adipogenesis of 3T3-L1 preadipocytes was induced with reagents and then the cells were treated with GTE. The lipids were stained with Oil Red O for analysis of adipogenesis of 3T3-L1 preadipocytes. The 3T3-L1 preadipocytes were treated with increasing concentrations (0.2-0.5%, w/v) of GTE for 2 days and the cell viability was determined by MTT assay. Reverse transcription real-time PCR and immunoblotting assays were performed to determine RNA and protein levels of relative molecules.

RESULTS

GTE increases the serum concentrations of adiponectin but decreases visfatin levels in patients received GTE. The leptin concentrations in serum were not significantly affected. The GTE reduces the adipogenesis-induced lipid accumulation in 3T3-L1 preadipocytes. GTE decreases the mRNA and protein expression of adipogenic transcription factors C/EBPα and PPARγ in 3T3-L1 cells. Expression levels of the adipocyte-specific genes encoding adipocyte protein 2, lipoprotein lipase, and glucose transporter 4 were also decreased by GTE. Furthermore, it was found that GTE reduces phosphorylation of Akt during adipocyte differentiation.

CONCLUSIONS

GTE reduces adipogenesis by decreasing expression of transcription factors C/EBPα and PPARγ by reduction of phosphorylation of Akt during adipocyte differentiation.

Orthostatic hypotension in young adults with and without posttraumatic stress disorder

The purpose of this research is (a) to evaluate differences in orthostatic hypotension (OH) among young adults with and without posttraumatic stress disorder (PTSD) and (b) to examine whether group differences may be attributable to behavioral risk factors frequently associated with PTSD. Volunteers and U.S. veterans 18 to 39 years old (N = 222) completed a semistructured interview assessment of PTSD status. Direct measurements were obtained for supine and standing systolic and diastolic blood pressure at study visits, as well as height and weight, from which body mass index (BMI) was calculated. After controlling for use of psychotropic medications, a logistic regression model revealed that PTSD status was positively associated with OH, such that participants with PTSD were at 4.51 greater odds of having OH than control participants. Moreover, this effect was partially mediated by lifetime alcohol dependence (bootstrapped 95% confidence interval [-0.83, -0.20]). Overall, PTSD may pose a significant risk for OH among younger adults. In the present sample, this relationship was primarily driven by the disproportionately high history of alcohol dependence among individuals with PTSD. These results suggest that traditional therapy for PTSD should be coupled with treatment for alcohol dependency, when applicable, to reap both psychological and physiological benefits.

Memory as a new therapeutic target

This review aims to demonstrate how an understanding of the brain mechanisms involved in memory provides a basis for; (i) reconceptualizing some mental disorders; (ii) refining existing therapeutic tools; and (iii) designing new ones for targeting processes that maintain these disorders. First, some of the stages which a memory undergoes are defined, and the clinical relevance of an understanding of memory processing by the brain is discussed. This is followed by a brief review of some of the clinical studies that have targeted memory processes. Finally, some new insights provided by the field of neuroscience with implications for conceptualizing mental disorders are presented.

Behavioral health mediators of the link between posttraumatic stress disorder and dyslipidemia

OBJECTIVES

Posttraumatic stress disorder (PTSD) has been linked to dyslipidemia, which is a major risk factor for coronary artery disease. Although this link is thought to reflect response to heightened stress, behavioral health risks, including smoking, alcohol dependence, and poor sleep quality, may mediate the relationship between PTSD and dyslipidemia.

METHODS

To test this hypothesis, serum lipid levels were collected from 220 young adults (18-39 years old), 103 of whom were diagnosed with PTSD.

RESULTS

PTSD and associated depressive symptoms were negatively related to high-density lipoprotein cholesterol (HDL-C), p=.04, and positively related to triglyceride (TG) levels, p=.04. Both associations were mediated by cigarette consumption and poor sleep quality, the latter of which accounted for 83% and 93% of the effect of PTSD and depression on HDL-C and TG, respectively.

CONCLUSIONS

These results complement recent findings highlighting the prominence of health behaviors in linking PTSD with cardiovascular risk.

Repeated fear-induced diurnal rhythm disruptions predict PTSD-like sensitized physiological acute stress responses in F344 rats

AIM

To identify objective factors that can predict future sensitized stress responses, thus allowing for effective intervention prior to developing sensitization and subsequent stress-related disorders, including post-traumatic stress disorder (PTSD).

METHODS

Adult male F344 rats implanted with biotelemetry devices were exposed to repeated conditioned fear or control conditions for 22 days followed by exposure to either no, mild or severe acute stress on day 23. Diurnal rhythms of locomotor activity (LA), heart rate (HR) and core body temperature (CBT) were biotelemetrically monitored throughout the study. In a subset of rat not implanted, corticosterone and indices of chronic stress were measured immediately following stress.

RESULTS

Rats exposed to repeated fear had fear-evoked increases in behavioural freezing and HR/CBT during exposure to the fear environment and displayed indices of chronic stress. Repeated fear produced flattening of diurnal rhythms in LA, HR and CBT. Repeated fear did not sensitize the corticosterone response to acute stress, but produced sensitized HR/CBT responses following acute stress, relative to the effect of acute stress in the absence of a history of repeated fear. Greater diurnal rhythm disruptions during repeated fear predicted sensitized acute stress-induced physiological responses. Rats exposed to repeated fear also displayed flattened diurnal LA and basal increases in HR.

CONCLUSIONS

Exposure to repeated fear produces outcomes consistent with those observed in PTSD. The results suggest that diurnal rhythm disruptions during chronic stressors may help predict sensitized physiological stress responses following traumatic events. Monitoring diurnal disruptions during repeated stress may thus help predict susceptibility to PTSD.

Inflamed by the flames? The impact of terrorism and war on immunity

The physiological impact on citizens of prolonged exposure to violence and conflict is a crucial, yet underexplored, issue within the political science and biology literature. We examined the effect of high levels of exposure to rocket and terrorist attacks on biological markers of immunity and inflammation in a sample of 92 Israelis. A stratified random sample of individuals was drawn from a pool of subjects in Israel who had previously been interviewed regarding their stress exposure and psychological distress during a period of active rocket and terrorist attacks. These individuals were reinterviewed and blood samples were collected to assess antibodies to cytomegalovirus (CMV antibodies) and C-reactive protein (CRP). Posttraumatic stress disorder (PTSD) was significantly related to CRP, β = .33, p = .034, with body mass index, depression, and exposure to terrorism included in the model. Depression scores were not significantly associated with CRP or CMV antibody levels. In contrast to the established convention that psychological distress is the sole outcome of terrorism exposure, these findings reveal that individuals exposed to terrorism experience higher levels of both PTSD/depression, and inflammation. This study has important ramifications for how policy makers and medical health professionals should formulate public health policies and medically treat individuals living in conflict zones.

Evidence for acute central sensitization to prolonged experimental pain in posttraumatic stress disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) and pain have a well-documented high comorbidity; however, the underlying mechanisms of this comorbidity are currently poorly understood. The aim of this psychophysical study was to investigate the behavioral response to a prolonged suprathreshold pain stimulus in subjects with combat-related PTSD and combat controls (CC) for clinical evidence of central sensitization.

METHODS

Ten male subjects with current PTSD related to combat and 11 CC male subjects underwent baseline quantitative sensory testing (QST), temporal pain summation, and psychological profiling followed by an intramuscular injection of capsaicin into the quadriceps muscle.

RESULTS

There was no significant between-group difference for the initial maximal pain response or an initial pain reduction for the first 15 minutes postinjection on QST or pain ratings. However, we observed significantly higher scores in the PTSD group for the second 15 minutes postinjection on both pain intensity and pain unpleasantness ratings. Assessment of temporal summation to repetitive pressure stimuli showed significantly higher subjective pain in the PTSD group.

CONCLUSION

These findings are consistent with a significantly higher degree of acute central sensitization in individuals with PTSD. Increased acute central sensitization may underlie increased vulnerability for developing pain-related conditions following combat trauma.

World War II-related post-traumatic stress disorder and breast cancer risk among Israeli women: a case-control study

BACKGROUND

Several studies have suggested that post-traumatic stress disorder (PTSD) is related to adverse health outcomes. There are limited data on PTSD and cancer, which has a long latency period. We investigated the association between World War II (WWII)-related PTSD and subsequent breast cancer (BC) risk among Jewish WWII survivors and examined whether this association was modified by exposure to hunger during WWII.

METHODS

We compared 65 BC patients diagnosed in 2005 through 2010 to 200 population-based controls who were members of various organizations for Jewish WWII survivors in Israel. All participants were born in Europe, lived at least six months under Nazi rule during WWII, and immigrated to Israel after the war. We estimated PTSD using the PTSD Inventory and applied logistic regression models to estimate the association between WWII-related PTSD and BC, adjusting for potential confounders.

RESULTS

We observed a linear association between WWII-related PTSD and BC risk. This association remained significant following adjustment for potential confounders, including obesity, alcohol consumption, smoking, age during WWII, hunger exposure during WWII, and total number of traumatic life events (OR = 2.89, 95% CI = 1.14-7.31). However, the level of hunger exposure during WWII modified this effect significantly.

CONCLUSIONS

These findings suggest an independent association between WWII-related PTSD and subsequent BC risk in Jewish WWII survivors that is modified by hunger, a novel finding. Future research is needed to further explore these findings.

Effects of yoga practice on stress-related symptoms in the aftermath of an earthquake: A community-based controlled trial

OBJECTIVES

To evaluate the effect of an integrated hatha yoga practice on perceived stress and stress-related symptoms in the aftermath of an earthquake.

DESIGN AND SETTING

Inhabitants, aged 20-67 years, from highly exposed earthquake areas of two villages in South Iceland were offered to participate in a yoga program subsequent to an earthquake. Sixty-six individuals were self-selected into the study and divided by residential convenience into an experimental group (n=31) and a waiting list control group (n=35).

INTERVENTION

The yoga program was conducted twice a week for six weeks, in normal situations among the inhabitants in the community.

MAIN OUTCOME MEASURES

Several validated questionnaires assessing stress and stress-related symptoms, posttraumatic symptoms, depression, anxiety and health related quality of life were administered at pre- and post-intervention.

RESULTS

Multivariate analysis of variance (MANOVA) revealed differences between the experimental group and waiting list control group on sleep quality (p=.03) and social relations (p=.04). These differences did not prevail at Bonferroni correction for multiple testing (at alpha level of .005). Participants in both groups showed significant improvements in stress and some stress-related symptoms such as sleep, concentration, well-being, quality of life, depression and anxiety from pre- to post-intervention.

CONCLUSIONS

The data from this small study show no statistically significant improvement of an integrated hatha yoga program above and beyond waiting list control, following exposure to an earthquake. However, the observed trend toward improved sleep quality and social relations deserve further exploration in larger effectiveness studies on the impact of Hatha yoga on recovery after natural disaster.

The weight of traumatic stress: a prospective study of posttraumatic stress disorder symptoms and weight status in women

IMPORTANCE

Posttraumatic stress disorder (PTSD) indicates a chronic stress reaction in response to trauma. This prevalent condition has been identified as a possible risk factor for obesity. Whether PTSD symptoms alter the trajectory of weight gain or constitute a comorbid condition has not been established.

OBJECTIVE

To determine whether women who develop PTSD symptoms are subsequently more likely to gain weight and become obese relative to trauma-exposed women who do not develop PTSD symptoms or women with no trauma exposure or PTSD symptoms and whether the effects are independent of depression.

DESIGN, SETTING, AND PARTICIPANTS

The Nurses' Health Study II, a prospective observational study initiated in 1989 with follow-up to 2005, using a PTSD screener to measure PTSD symptoms and time of onset. We included the subsample of the Nurses' Health Study II (54 224 participants; ages 24-44 years in 1989) in whom trauma and PTSD symptoms were measured.

EXPOSURES

Trauma and PTSD symptoms.

MAIN OUTCOMES AND MEASURES

Development of overweight and obesity using body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) cut points 25.0 and 30.0, respectively; change in BMI during follow-up among women reporting PTSD symptom onset before 1989; and BMI trajectory before and after PTSD symptom onset among women who developed PTSD symptoms in 1989 or during follow-up.

RESULTS

Among women with at least 4 PTSD symptoms before 1989 (cohort initiation), BMI increased more steeply (b = 0.09 [SE = 0.01]; P < .001) during the follow-up. Among women who developed PTSD symptoms in 1989 or later, BMI trajectory did not differ by PTSD status before PTSD onset. After PTSD symptom onset, women with at least 4 symptoms had a faster rise in BMI (b = 0.08 [SE = 0.02]; P < .001). The onset of at least 4 PTSD symptoms in 1989 or later was also associated with an increased risk of becoming overweight or obese (odds ratio, 1.36 [95% CI, 1.19-1.56]) among women with a normal BMI in 1989. Effects were maintained after adjusting for depression.

CONCLUSIONS AND RELEVANCE

Experience of PTSD symptoms is associated with an increased risk of becoming overweight or obese, and PTSD symptom onset alters BMI trajectories over time. The presence of PTSD symptoms should raise clinician concerns about physical health problems that may develop and prompt closer attention to weight status.

Prior adversities predict posttraumatic stress reactions in adolescents following the Oslo Terror events 2011

BACKGROUND

Former studies suggest that prior exposure to adverse experiences such as violence or sexual abuse increases vulnerability to posttraumatic stress reactions in victims of subsequent trauma. However, little is known about how such a history affects responses to terror in the general adolescent population.

OBJECTIVE

To explore the role of prior exposure to adverse experiences as risk factors for posttraumatic stress reactions to the Oslo Terror events.

METHOD

We used data from 10,220 high school students in a large cross-sectional survey of adolescents in Norway that took place seven months after the Oslo Terror events. Prior exposure assessed was: direct exposure to violence, witnessing of violence, and unwanted sexual acts. We explored how these prior adversities interact with well-established risk factors such as proximity to the events, perceived life threat during the terror events, and gender.

RESULTS

All types of prior exposure as well as the other risk factors were associated with terror-related posttraumatic stress reactions. The effects of prior adversities were, although small, independent of adolescents' proximity to the terror events. Among prior adversities, only the effect of direct exposure to violence was moderated by perceived life threat. Exposure to prior adversities increased the risk of posttraumatic stress reactions equally for both genders, but proximity to the terror events and perceived life threat increased the risk more in females.

CONCLUSIONS

Terror events can have a more destabilizing impact on victims of prior adversities, independent of their level of exposure. The findings may be relevant to mental health workers and others providing post-trauma health care.

Eye Movement Desensitization and Reprocessing as an Adjunctive Treatment of Unipolar Depression: A Controlled Study

Depression is a severe mental disorder that challenges mental health systems worldwide. About 30% of treated patients do not experience a full remission after treatment, and more than 75% of patients suffer from recurrent depressive episodes. Although psychotherapy and medication can improve remission rates, the success rates of current treatments are limited. In this nonrandomized controlled exploratory study, 21 patients with unipolar primary depression were treated with a mean of 44.5 sessions of Cognitive Behavioural Therapy (CBT) including an average 6.9 adjunctive sessions of Eye Movement Desensitization and Reprocessing (EMDR). A control group (n = 21) was treated with an average of 47.1 sessions of CBT sessions alone. The main outcome measure was the Beck Depression Inventory II (BDI-II). The treatment groups did not differ in their BDI-II scores before treatment, and both treatments resulted in significant improvement. There was an additional benefit for patients treated with adjunctive EMDR (p = .029). Also the number of remissions at posttreatment, as measured by a symptom level below a BDI-II score of 12, was significantly better in the adjunctive EMDR group, the group showing more remissions (n = 18) than the control group (n = 8; p < .001). This potential effect of EMDR in patients with primary depression should be examined further in larger randomized controlled studies.

Pain-related musculoskeletal disorders, psychological comorbidity, and the relationship with physical and mental well-being in Gulf War veterans

Occupational activities such as lifting loads, working in constrained spaces, and training increase the risk of pain-related musculoskeletal disorders (MSDs) in military veterans. Few studies have investigated MSD and psychological disorder in veterans, and previous studies had limitations. This cross-sectional study compared pain-related MSD and psychological comorbidity and well-being between 1381 male Australian 1990-1991 Gulf War veterans (veterans) and a military comparison group (n=1377, of whom 39.6% were serving and 32.7% had previously deployed). At a medical assessment, 2000-2002, reported doctor-diagnosed arthritis or rheumatism, back or neck problems, joint problems, and soft tissue disorders were rated by medical practitioners as nonmedical, unlikely, possible, or probable diagnoses. Only probable MSDs were analysed. Psychological disorders in the past 12 months were measured using the Composite International Diagnostic Interview. The Short-Form Health Survey (SF-12) assessed 4-week physical and mental well-being. Almost one-quarter of veterans (24.5%) and the comparison group (22.4%) reported an MSD. Having any or specific MSD was associated with depression and posttraumatic stress disorder (PTSD), but not alcohol disorders. Physical and mental well-being was poorer in those with an MSD compared to those without, in both study groups (eg, veterans with any MSD, difference in SF-12 physical component summary scale medians = -10.49: 95% confidence interval -12.40, -8.57), and in those with MSD and psychological comorbidity compared with MSD alone. Comorbidity of any MSD and psychological disorder was more common in veterans, but MSDs were associated with depression, PTSD, and poorer well-being in both groups. Psychological comorbidity needs consideration in MSD management. Longitudinal studies are needed to assess directionality and causality.

The effect of stress on health and its implications for nursing

Stress is an important issue within nursing and it is difficult to find agreement among those who are expert in the area regarding a concise definition of stress. Nevertheless stress is seen as a negative feeling affecting people's health either physically and/or psychologically. However, stress is a normal part of life and considered necessary to increase functional capacity, whereas stress over a prolonged period or when extreme can cause distress which may have debilitating effects that reduce work output, increase absenteeism and reduce one's ability to cope with situations. The most important resource in any organisation is the employee; therefore maintaining and supporting their health is vital to ensure their ability to work, maintain standards and continuously improve standards of care. Leadership styles within organisations must facilitate staff to be involved in decision making; thereby staff feel more valued and work in an autonomous way. This article identifies and discusses the effect of stress on health and its relationship to nursing.

Metabolic syndrome: relative risk associated with post-traumatic stress disorder (PTSD) severity and antipsychotic medication use

BACKGROUND

In recent years, numerous lines of converging evidence have revealed an association between post-traumatic stress disorder (PTSD) and impaired physical health outcomes, including cardiovascular disease and metabolic syndrome. Although these findings have been interpreted as indicating a direct association of PTSD with metabolic syndrome and obesity, previous studies have not addressed the important confound of antipsychotic drug usage in this population. Second generation antipsychotic medications themselves are associated with metabolic syndrome and obesity, and it is unclear whether the common utilization of these drugs in PTSD may account for some if not all of the observed metabolic problems.

OBJECTIVE

The present study examined the relative contributions of PTSD severity and use of antipsychotic medications to risk of metabolic syndrome among veterans.

METHOD

Cross-sectional clinical data, including five factors representing metabolic syndrome, psychiatric diagnoses, and medications were gathered from 253 veterans enrolling in mental health services. We used a logistic regression model to measure the relative association of antipsychotic medication use and PTSD severity on risk of metabolic syndrome.

RESULTS

We found that antipsychotic medication usage was not uniquely associated with elevated risk of metabolic syndrome (Wald = 0.30, ns) when PTSD severity and other sociodemographic, psychiatric, and behavioral variables were accounted for. Furthermore, PTSD severity continued to be a significant and unique predictor of risk for metabolic syndrome (Wald = 4.04, p < 0.05).

CONCLUSIONS

These findings suggest that chronic and moderately severe PTSD, independent of antipsychotic medications, is associated with increased risk of metabolic syndrome.

Associations between lifetime traumatic events and subsequent chronic physical conditions: a cross-national, cross-sectional study

Background

Associations between lifetime traumatic event (LTE) exposures and subsequent physical ill-health are well established but it has remained unclear whether these are explained by PTSD or other mental disorders. This study examined this question and investigated whether associations varied by type and number of LTEs, across physical condition outcomes, or across countries.

Methods

Cross-sectional, face-to-face household surveys of adults (18+) were conducted in 14 countries (n = 38, 051). The Composite International Diagnostic Interview assessed lifetime LTEs and DSM-IV mental disorders. Chronic physical conditions were ascertained by self-report of physician's diagnosis and year of diagnosis or onset. Survival analyses estimated associations between the number and type of LTEs with the subsequent onset of 11 physical conditions, with and without adjustment for mental disorders.

Findings

A dose-response association was found between increasing number of LTEs and odds of any physical condition onset (OR 1.5 [95% CI: 1.4–1.5] for 1 LTE; 2.1 [2.0–2.3] for 5+ LTEs), independent of all mental disorders. Associations did not vary greatly by type of LTE (except for combat and other war experience), nor across countries. A history of 1 LTE was associated with 7/11 of the physical conditions (ORs 1.3 [1.2–1.5] to 1.7 [1.4–2.0]) and a history of 5+ LTEs was associated with 9/11 physical conditions (ORs 1.8 [1.3–2.4] to 3.6 [2.0–6.5]), the exceptions being cancer and stroke.

Conclusions

Traumatic events are associated with adverse downstream effects on physical health, independent of PTSD and other mental disorders. Although the associations are modest they have public health implications due to the high prevalence of traumatic events and the range of common physical conditions affected. The effects of traumatic stress are a concern for all medical professionals and researchers, not just mental health specialists.

Social capital and chronic post-traumatic stress disorder among survivors of the 2007 earthquake in Pisco, Peru

This study aimed to evaluate the association between chronic Post-Traumatic Stress Disorder (PTSD) and both structural and cognitive social capital in adult survivors of the 2007 earthquake in Pisco, Peru. Cognitive social capital measures trust, sense of belonging and interpersonal relationships in the community and structural social capital measures group membership, support from community groups and individuals, and involvement in citizenship activities. We conducted a population-based cross-sectional study in five counties in Pisco, selecting 1012 adults through complex, multi-stage random sampling. All participants completed socio-demographic questions and validated Spanish-language versions of the Adapted Social Capital Assessment Tool (SASCAT) and the civilian PTSD checklist (PCL-C). After performing descriptive and bivariate analyses, we carried out prevalence ratio (PR) regression. The overall prevalence of chronic PTSD was 15.9% (95% CI: 12.3, 19.8), much higher than anticipated based on existing evidence. Cognitive social capital was found to be negatively associated with chronic PTSD, while no significant association was found for structural social capital. Specifically, those with high cognitive social capital had an almost two times lower prevalence of chronic PTSD (PR = 1.83, 95% CI: 1.50, 2.22) compared with those with low cognitive social capital. No independent association between structural social capital and chronic PTSD was found (PR = 1.44, 95% CI: 0.70, 2.97). In conclusion, cognitive social capital, but not structural social capital, has a protective influence on the occurrence of chronic PTSD in survivors of natural disasters. These results may have public health implications. For example, pre- and post-disaster community-based interventions that catalyze and foster dimensions of cognitive social capital may aid in ameliorating the effect of earthquakes and other natural disasters on populations with high vulnerability to such events and poor access to mental health and other support services.

The role of stress sensitization in progression of posttraumatic distress following deployment

PURPOSE

Military personnel exposed to combat are at risk for experiencing post-traumatic distress that can progress over time following deployment. We hypothesized that progression of post-traumatic distress may be related to enhanced susceptibility to post-deployment stressors. This study aimed at examining the concept of stress sensitization prospectively in a sample of Dutch military personnel deployed in support of the conflicts in Afghanistan.

METHOD

In a cohort of soldiers (N = 814), symptoms of post-traumatic stress disorder (PTSD) were assessed before deployment as well as 2, 7, 14, and 26 months (N = 433; 53 %) after their return. Data were analyzed using latent growth modeling. Using multiple group analysis, we examined whether high combat stress exposure during deployment moderated the relation between post-deployment stressors and linear change in post-traumatic distress after deployment.

RESULTS

A higher baseline level of post-traumatic distress was associated with more early life stressors (standardized regression coefficient = 0.30, p < 0.001). In addition, a stronger increase in posttraumatic distress during deployment was associated with more deployment stressors (standardized coefficient = 0.21, p < 0.001). A steeper linear increase in posttraumatic distress post-deployment (from 2 to 26 months) was predicted by more post-deployment stressors (standardized coefficient = 0.29, p < 0.001) in high combat stress exposed soldiers, but not in a less combat stress exposed group. The group difference in the predictive effect of post-deployment stressors on progression of post-traumatic distress was significant (χ²(1) = 7.85, p = 0.005).

CONCLUSIONS

Progression of post-traumatic distress following combat exposure may be related to sensitization to the effects of post-deployment stressors during the first year following return from deployment.

Spirituality and the health professional

The inclusion of spirituality in addictions recovery began with the 12-steps program of Alcoholics Anonymous. Cofounded by Bill Wilson, the 12-steps' spiritual orientation is based on Wilson's own recovery from alcoholism that was associated with a spiritual experience. His correspondence with Carl Jung, who verified the importance of Wilson's experience, empowered Wilson to make spirituality central to the 12 steps. Spirituality remains a source of misunderstanding between the scientific, empirically informed mental health community, and the 12-step recovery movement. This article offers an outline of spiritual development, based on neuroscience, which the professional can utilize in the spiritual aspect of a patient's recovery.

Atypical visual processing in posttraumatic stress disorder

BACKGROUND

Many patients with Posttraumatic Stress Disorder (PTSD) feel overwhelmed in situations with high levels of sensory input, as in crowded situations with complex sensory characteristics. These difficulties might be related to subtle sensory processing deficits similar to those that have been found for sounds in electrophysiological studies.

METHOD

Visual processing was investigated with functional magnetic resonance imaging in trauma-exposed participants with (N = 18) and without PTSD (N = 21) employing a picture-viewing task.

RESULTS

Activity observed in response to visual scenes was lower in PTSD participants 1) in the ventral stream of the visual system, including striate and extrastriate, inferior temporal, and entorhinal cortices, and 2) in dorsal and ventral attention systems (P < 0.05, FWE-corrected). These effects could not be explained by the emotional salience of the pictures.

CONCLUSIONS

Visual processing was substantially altered in PTSD in the ventral visual stream, a component of the visual system thought to be responsible for object property processing. Together with previous reports of subtle auditory deficits in PTSD, these findings provide strong support for potentially important sensory processing deficits, whose origins may be related to dysfunctional attention processes.

The clinical picture of late-onset PTSD: a 20-year longitudinal study of Israeli war veterans

Delayed-onset posttraumatic stress disorder (PTSD) has been under medico-legal debate for years. Previous studies examining the prevalence and clinical characteristics of delayed-onset PTSD have yielded inconclusive findings. This study prospectively examines the prevalence and clinical picture of late-onset PTSD among Israeli war veterans. It also evaluates whether or not late-onset PTSD erupts after a completely non-symptomatic period. 675 Israeli veterans from the 1982 Lebanon War, with and without antecedent combat stress reaction (CSR), have been assessed 1, 2 and 20 years post-war. They were divided into 4 groups, according to the duration of delay in PTSD onset. Participants completed self-report questionnaires tapping psychopathology, combat exposure and socio-demographics. 16.5% of the veterans suffered from late-onset PTSD. A longer delay in PTSD onset was associated with less severe psychopathology. Also, CSR was associated with a shorter delay in PTSD onset. Finally, the vast majority of veterans already suffered from PTSD symptoms prior to late PTSD onset. Our results offer further validation for the existence of delayed-onset PTSD. Delayed-onset PTSD appears to be a unique sub-type of PTSD, with an attenuated clinical picture. In addition, delayed-onset PTSD may be the result of an incubation process, wherein symptoms already exist prior to PTSD onset.

PTSD Symptoms Mediate the Effect of Attachment on Pain and Somatisation after Whiplash Injury

INTRODUCTION

The development of persistent pain post-whiplash injury is still an unresolved mystery despite the fact that approximately 50% of individuals reporting whiplash develop persistent pain. There is agreement that high initial pain and PTSD symptoms are indicators of a poor prognosis after whiplash injury. Recently attachment insecurity has been proposed as a vulnerability factor for both pain and PTSD. In order to guide treatment it is important to examine possible mechanisms which may cause persistent pain and medically unexplained symptoms after a whiplash injury.

AIM

The present study examines attachment insecurity and PTSD symptoms as possible vulnerability factors in relation to high levels of pain and somatisation after sub-acute whiplash injury.

METHODS

Data were collected from 327 patients (women = 204) referred consecutively to the emergency unit after acute whiplash injury. Within 1-month post injury, patients answered a questionnaire regarding attachment insecurity, pain, somatisation, and PTSD symptoms. Multiple mediation analyses were performed to assess whether the PTSD symptom clusters mediated the association between attachment insecurity, pain, and somatisation.

RESULTS

A total of 15% fulfilled the DSM-IV symptom cluster criteria for a possible PTSD diagnosis and 11.6% fulfilled the criteria for somatisation. PTSD increased the likelihood of belonging to the moderate-severe pain group three-fold. In relation to somatisation the likelihood of belonging to the group was almost increased four-fold. The PTSD symptom clusters of avoidance and hyperarousal mediated the association between the attachment dimensions, pain, and somatisation.

CONCLUSION

Acknowledging that PTSD is part of the aetiology involved in explaining persistent symptoms after whiplash, may help sufferers to gain early and more suited treatment, which in turn may prevent the condition from becoming chronic.

Mental health issues of women deployed to Iraq and Afghanistan

The number of women serving in the military and deployed to active-duty is unprecedented in the history of the United States. When women became a permanent sector of the U.S. Armed Services in 1948, their involvement was restricted to comprise only 2% of the military population; today women constitute approximately 14.5% of the 1.4 million active component and 18% of the 850,000 reserve component. Yet, little attention has been paid to the mental health needs of women military members. This review article highlights the history of women in the military and then focuses on the impact of combat exposure and injuries, military sexual trauma, alcohol use, and family separations which are associated with PTSD, depression, suicide, difficulty with reintegration, and homelessness.

Review of somatic symptoms in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.

Preexisting mental illness and risk for developing a new disorder after hurricane Katrina

To investigate predisaster mental illness as a risk factor of poor postdisaster mental health outcomes, veterans with (n = 249) and without (n = 250) preexisting mental illness residing in the Gulf Coast during Hurricane Katrina were surveyed after Katrina and screened for posttraumatic stress disorder (PTSD), depression, generalized anxiety disorder, and panic. Logistic regression examined the association between preexisting mental disorders and positive screens after the hurricane, adjusting for demographics and exposure to hurricane-related stressors. The odds of screening positive for any new mental disorder were 6.8 times greater for those with preexisting mental illness compared with those without preexisting mental illness. Among those with preexisting PTSD, the odds of screening positive for any new mental illness were 11.9 times greater; among those with schizophrenia, 9.1 times greater; and among those with affective disorders, 4.4 times greater. Persons with preexisting mental illnesses, particularly PTSD, should be considered a high-risk group for poor outcomes after a disaster.

Predicting PTSD using the New York Risk Score with genotype data: potential clinical and research opportunities

BACKGROUND

We previously developed a post-traumatic stress disorder (PTSD) screening instrument, ie, the New York PTSD Risk Score (NYPRS), that was effective in predicting PTSD. In the present study, we assessed a version of this risk score that also included genetic information.

METHODS

Utilizing diagnostic testing methods, we hierarchically examined different prediction variables identified in previous NYPRS research, including genetic risk-allele information, to assess lifetime and current PTSD status among a population of trauma-exposed adults.

RESULTS

We found that, in predicting lifetime PTSD, the area under the receiver operating characteristic curve (AUC) for the Primary Care PTSD Screen alone was 0.865. When we added psychosocial predictors from the original NYPRS to the model, including depression, sleep disturbance, and a measure of health care access, the AUC increased to 0.902, which was a significant improvement (P = 0.0021). When genetic information was added in the form of a count of PTSD risk alleles located within FKBP5, COMT, CHRNA5, and CRHR1 genetic loci (coded 0-6), the AUC increased to 0.920, which was also a significant improvement (P = 0.0178). The results for current PTSD were similar. In the final model for current PTSD with the psychosocial risk factors included, genotype resulted in a prediction weight of 17 for each risk allele present, indicating that a person with six risk alleles or more would receive a PTSD risk score of 17 × 6 = 102, the highest risk score for any of the predictors studied.

CONCLUSION

Genetic information added to the NYPRS helped improve the accuracy of prediction results for a screening instrument that already had high AUC test results. This improvement was achieved by increasing PTSD prediction specificity. Further research validation is advised.

The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review

The present meta-analysis systematically examined associations between physical health and posttraumatic stress disorder (PTSD)/PTSD symptoms (PTSS), as well as moderators of this relationship. Literature searches yielded 62 studies examining the impact of PTSD/PTSS on physical health-related quality of life (HR-QOL), general health symptoms, general medical conditions, musculoskeletal pain, cardio-respiratory (CR) symptoms, and gastrointestinal (GI) health. Sample-specific and methodological moderators were also examined. Results revealed significantly greater general health symptoms, general medical conditions, and poorer HR-QOL for PTSD and high PTSS individuals. PTSD/PTSS was also associated with greater frequency and severity of pain, CR, and GI complaints. Results of moderation analyses were mixed. However, consistent relationships emerged regarding PTSD assessment method, such that effect sizes were largest for self-reported PTSD/PTSS and all but one health outcome. Results highlight the need for prospective longitudinal examination of physical health shortly following trauma, and suggest variables to consider in the design of such studies.

A randomized, controlled pilot study of MDMA (± 3,4-Methylenedioxymethamphetamine)-assisted psychotherapy for treatment of resistant, chronic Post-Traumatic Stress Disorder (PTSD)

Psychiatrists and psychotherapists in the US (1970s to 1985) and Switzerland (1988-1993) used MDMA legally as a prescription drug, to enhance the effectiveness of psychotherapy. Early reports suggest that it is useful in treating trauma-related disorders. Recently, the first completed pilot study of MDMA-assisted psychotherapy for PTSD yielded encouraging results. Designed to test the safety and efficacy of MDMA-assisted psychotherapy in patients with treatment-resistant PTSD; our randomized, double-blind, active-placebo controlled trial enrolled 12 patients for treatment with either low-dose (25 mg, plus 12.5 mg supplemental dose) or full-dose MDMA (125 mg, plus 62.5 mg supplemental dose). MDMA was administered during three experimental sessions, interspersed with weekly non-drug-based psychotherapy sessions. Outcome measures used were the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (PDS). Patients were assessed at baseline, three weeks after the second and third MDMA session (end of treatment), and at the 2-month and 1-year follow-ups. We found that MDMA-assisted psychotherapy can be safely administered in a clinical setting. No drug-related serious adverse events occurred. We did not see statistically significant reductions in CAPS scores (p = 0.066), although there was clinically and statistically significant self-reported (PDS) improvement (p = 0.014). CAPS scores improved further at the 1-year follow-up. In addition, three MDMA sessions were more effective than two (p = 0.016).

The New York PTSD risk score for assessment of psychological trauma: male and female versions

We previously developed a new posttraumatic stress disorder (PTSD) screening instrument-the New York PTSD Risk Score (NYPRS). Since research suggests different PTSD risk factors and outcomes for men and women, in the current study we assessed the suitability of male and female versions of this screening instrument among 3298 adults exposed to traumatic events. Using diagnostic test methods, including receiver operating characteristic (ROC) curve and bootstrap techniques, we examined different prediction domains, including core PTSD symptoms, trauma exposures, sleep disturbances, depression symptoms, and other measures to assess PTSD prediction models for men and women. While the original NYPRS worked well in predicting PTSD, significant interaction was detected by gender, suggesting that separate models are warranted for men and women. Model comparisons suggested that while the overall results appeared robust, prediction results differed by gender. For example, for women, core PTSD symptoms contributed more to the prediction score than for men. For men, depression symptoms, sleep disturbance, and trauma exposure contributed more to the prediction score. Men also had higher cut-off scores for PTSD compared to women. There were other gender-specific differences as well. The NYPRS is a screener that appears to be effective in predicting PTSD status among at-risk populations. However, consistent with other medical research, this instrument appears to require male and female versions to be the most effective.

Electrophysiological correlates of fearful and sad distraction on target processing in adolescents with attention deficit-hyperactivity symptoms and affective disorders

In this study we used event-related brain potentials (ERP) as neural markers of cognitive operations to examine emotion and attentional processing in a population of high-risk adolescents with mental health problems that included attention deficit and hyperactivity disorder (ADHD), anxiety, and depression. We included a healthy control group for comparison purposes, and employed a modified version of the emotional oddball paradigm, consisting of frequent distracters (scrambled pictures), infrequent distracters (sad, fearful, and neutral pictures), and infrequent targets (circles). Participants were instructed to make a right hand button press to targets and a left hand button press to all other stimuli. EEG/ERP recordings were taken using a high-density 256-channel recording system. Behavioral data showed that for both clinical and non-clinical adolescents, reaction time (RT) was slowest in response to the fearful images. Electrophysiological data differentiated emotion and target processing between clinical and non-clinical adolescents. In the clinical group we observed a larger P100 and late positive potential (LPP) in response to fearful compared to sad or neutral pictures. There were no differences in these ERPs in the healthy sample. Emotional modulation of target processing was also identified in the clinical sample, where we observed an increase in P300 amplitude, and a larger sustained LPP in response to targets that followed emotional pictures (fear and sad) compared to targets that followed neutral pictures or other targets. There were no differences in these target ERPs for the healthy participants. Taken together, we suggest that these data provide important and novel evidence of affective and attention dysfunction in this clinical population of adolescents, and offer an example of the disruptive effects of emotional reactivity on basic cognition.

Health surveillance of deployed military personnel occasionally leads to unexpected findings

Post-traumatic stress disorder (PTSD) can be caused by life threatening illness, such as cancer and coronary events. The study by Forbes et al. made the unexpected finding that military personnel evacuation with medical illness have similar rates of PTSD to those evacuated with combat injuries. It may be that the illness acts as a nonspecific stressor that interacts with combat exposures to increase the risk of PTSD. Conversely, the inflammatory consequence of systemic illness may augment the effects to traumatic stress and facilitate the immunological abnormalities that are now being associated with PTSD and depression. The impact of the stress on cytokine systems and their role in the onset of PTSD demands further investigation. Military personnel evacuated due to physical illness require similar screening and monitoring for the risk of PTSD to those injured who are already known to be at high risk.

Co-occurring lower respiratory symptoms and posttraumatic stress disorder 5 to 6 years after the World Trade Center terrorist attack

OBJECTIVES

We have described the epidemiology of co-occurring lower respiratory symptoms (LRS) and probable posttraumatic stress disorder (PTSD) 5 to 6 years after exposure to the 9/11 disaster.

METHODS

We analyzed residents, office workers, and passersby (n = 16,363) in the World Trade Center Health Registry. Using multivariable logistic regression, we examined patterns of reported respiratory symptoms, treatment sought for symptoms, diagnosed respiratory conditions, mental health comorbidities, quality of life, and unmet health care needs in relation to comorbidity.

RESULTS

Among individuals with either LRS or PTSD, 24.6% had both conditions. The odds of comorbidity was significantly higher among those with more severe 9/11 exposures. Independent of 9/11 exposures, participants with LRS had 4 times the odds of those without it of meeting criteria for PTSD, and those with PTSD had 4 times the odds of those without it of meeting criteria for LRS. Participants with comorbidity had worse quality of life and more unmet mental health care needs than did all other outcome groups.

CONCLUSIONS

Respiratory and mental illness are closely linked in individuals exposed to 9/11 and should be considered jointly in public health outreach and treatment programs.

The renin-angiotensin pathway in posttraumatic stress disorder: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are associated with fewer traumatic stress symptoms

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a debilitating stress-related illness associated with trauma exposure. The peripheral and central mechanisms mediating stress response in PTSD are incompletely understood. Recent data suggest that the renin-angiotensin pathway, essential to cardiovascular regulation, is also involved in mediating stress and anxiety. In this study, the authors examined the relationship between active treatment with blood pressure medication, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), and PTSD symptom severity within a highly traumatized civilian medical population.

METHOD

Cross-sectional, observational data were analyzed from a larger study; patients were recruited from Grady Memorial Hospital's outpatient population from 2006 to November 2010. Multivariable linear regression models were fit to statistically evaluate the independent association of being prescribed an ACE inhibitor or ARB with PTSD symptoms, using a subset of patients for whom medical information was available (n = 505). Categorical PTSD diagnosis was assessed using the modified PTSD Symptom Scale (PSS) based on DSM-IV criteria, and PTSD symptom severity (the primary outcome of interest) was measured using the PSS and Clinician Administered PTSD Scale.

RESULTS

A significant association was determined between presence of an ACE inhibitor/ARB medication and decreased PTSD symptoms (mean PSS score 11.4 vs 14.9 for individuals prescribed vs not prescribed ACE inhibitors/ARBs, respectively [P = .014]). After adjustment for covariates, ACE inhibitor/ARB treatment remained significantly associated with decreased PTSD symptoms (P = .044). Notably, other blood pressure medications, including β-blockers, calcium channel blockers, and diuretics, were not significantly associated with reduced PTSD symptoms.

CONCLUSIONS

These data provide the first clinical evidence supporting a role for the renin-angiotensin system in the regulation of stress response in patients diagnosed with PTSD. Further studies should examine whether available medications targeting this pathway should be considered for future treatment and potential protection against PTSD symptoms.