Signs and symptoms of posttraumatic stress disorder

The Postpartum Specific Anxiety Scale: Confirmatory factor analyses and relationships with birth experience

The Postpartum Specific Anxiety Scale [PSAS] was developed and validated as a research tool with a four-factor structure; with predictive validity corroborated in studies examining infant-feeding and maternal bonding outcomes. The PSAS has not been examined in relation to birth experiences. We aimed to confirm the PSAS four-factor structure and examine these domains of anxiety in relation to subjective and objective birth experiences. Postpartum mothers (≤ 12-months; N = 500) completed the PSAS alongside measures of subjective birth satisfaction and objective obstetric interventions/complications. Confirmatory factor analyses [CFA] tested eight models, theoretically derived from the preceding exploratory work. Structural equation modelling [SEM] tested associations between each PSAS factor and birth experience variables in the best-fitting model. An identical 51-item four-factor model fits the data well. SEM analyses revealed associations between lower perceptions of quality of intrapartum care and increased maternal competence and attachment anxieties, practical infant care anxieties, and infant safety and welfare anxieties. High subjective stress and negative emotional response to labour were associated with increased psychosocial adjustment to motherhood anxieties. Specific associations were found between neonatal care unit admission and practical infant care anxieties; and infant asphyxia and infant safety and welfare anxieties. Findings confirm construct and convergent validity of the four-factor PSAS and its use in measuring postpartum anxiety. Unique associations were also identified, indicating specific subjective and objective experiences occurring during birth may elicit a differential anxiety response, in that they are related to specific forms of postpartum anxiety which occur during the first postpartum year.

Ask the question: 'Have You Ever Served?' Caring for military members and veterans in civilian healthcare

ABSTRACT

This article discusses health issues affecting US military members and veterans, and provides occupation-specific questions to guide civilian healthcare professionals in providing high-quality care to veterans and their families.

Feasibility of a Brief Online Mindfulness and Compassion-Based Intervention to Promote Mental Health Among University Students During the COVID-19 Pandemic

Objectives

The COVID-19 pandemic constitutes a global mental health challenge that has disrupted the lives of millions of people, with a considerable effect on university students. The aim of this study was to assess the feasibility of a brief online Mindfulness and Compassion-based Intervention to promote mental health among first year university students during COVID-19 home confinement.

Methods

Participants (n=66) were first-year psychology students from a university in Spain with no prior meditation experience. Intervention lasted for 16 days and was designed ad-hoc. Using a pre–post within-subjects design, feasibility was assessed in five domains (acceptability, satisfaction, implementation, practicality, and limited efficacy testing). Participants completed both baseline and post-intervention assessments of perceived stress, anxiety, and self-compassion.

Results

The intervention showed to be feasible in all domains evaluated. It was implemented as planned with constrained resources, and limited efficacy testing showed promising results. After the intervention, stress and anxiety levels decreased significantly (p<0.001, Hedges’s g=0.5146; p<0.001, Hedges’s g=0.6068, respectively) whereas self-compassion levels were augmented significantly (p<0.001, Hedges’s g=0.6968).

Conclusions

Our findings suggest that a brief online mindfulness and compassion intervention may be a feasible way of promoting mental health among university students during COVID-19 lockdown. Further studies are required to address the limitations of the present study. We conclude that online interventions may constitute a promising pathway to buffer the mental health burden derived from the COVID-19 pandemic.

A national COVID-19 quarantine survey and its impact on the Italian sports community: Implications and recommendations

The outbreak of the 2019 coronavirus disease (COVID-19) created an international public health emergency, challenging the psychological resilience of the general population. Regarding this matter, a web-based survey was performed. Data were collected from the following 1,668 self-selected volunteers: 800 athletes (28.30 ± 10.93 years old); 558 coaches (36.91 ± 11.93 years old); and 310 sports managers (42.07 ± 13.38 years old). To assess the level of psychological stress, an Impact of the Event Scale-Revised (IES-R) questionnaire was used. The results indicated that 34.4% of the participants who were interviewed were affected by subjective distress while 26.4% rated their psychological impact from the sports activity interruption as severe. Separated one-way analysis of variance (ANOVA) tests showed significant differences in the IES-R total score (TS), indicating that the level of stress in terms of gender revealed that women were more stressed than men (p = 0.000), for "sports roles" in which the manager and coaches were more stressed than the athletes (p < 0.05), and "type of sport" in which fitness and individual athletes were more stressed than team athletes (p < 0.01). The middle-level athletes showed significantly more hyperarousal levels than high-level athletes (p = 0.012). The results of this survey may raise awareness of this problem and help athletic associations to have appropriate guidelines in order to better sustain their memberships and organize an optimal resumption of their sports activities. Along these lines, social interactions, which are typical of team sports, are crucial to warrant resilience and psychological health. The athletes by managing independently the new rules and measures, thanks to a clear communication, could improve their adaptive stress reaction.

Psychological Impact of the Quarantine-Induced Stress during the Coronavirus (COVID-19) Outbreak among Italian Athletes

The 2019 Coronavirus (COVID-19) outbreak caused home confinement, as well as training and sport competitions withdrawals. The prolonged inactivity impact, and lack of in-person interactions among teammates-coaches, could negatively affect athletes. Total of 1508 self-selected Italian athletes, 338 children (aged 10.52 ± 1.31), 499 adolescents (aged 14.17 ± 1.13), and 671 adults (aged 27.59 ± 10.73), completed the Impact of Event Scale (IES-8, IES-15, and IES-R, respectively). Differences by gender, type of sport (individual vs. team), and competitive level (elite vs. amateur) were examined. One-way ANOVAs showed, in adults, significant differences between genders for perceived stress impact total score (TS; p = 0.017) and avoidance behavior, with higher scores in women (p = 0.045). Between individual and team sport, significant differences were found in TS (p = 0.038) and hyperarousal (p = 0.030), with higher results in individual. Adult elite athletes showed significantly higher scores in hyperarousal (p = 0.020) than amateurs. Significant differences were found between gender in adolescents for avoidance (p = 0.011), and between competitive levels in children, for intrusion (p = 0.020). These evidences may raise awareness on distress effects of COVID-19 lockdown among athletes and suggested applying specific well-being protocols during the activity resumption, considering gender, type of sport, and competitive level.

The validity of the Melancholia Scale (MES) in predicting outcome of antidepressants in chronic idiopathic pain disorders

In patients with chronic idiopathic pain disorders we have analysed the construct validity of the Melancholia Scale as compared to the results with the scale in primary depression. The patients (n= 253) were treated in a placebo controlled trial with either clomipramine or mianserin independently of the Melancholia score. The construct validity of the Melancholia Scale was further analysed by the testing of the intensity model of depression versus anxiety using the Beck Depression Inventory, the Hamilton Anxiety Scale, the Spielberger State-Trait Anxiety Scale, and the Melancholia Scale. The construct validity in terms of scale homogeneity was analysed by Loevinger coefficients which can be considered as a latent structure evaluation. The Melancholia Scale showed acceptable homogeneity, while the Hamilton Anxiety Scale lacked sufficient homogeneity. In total, 33% of the patients had a score of 10 or more on the Melancholia Scale (corresponding to 13 or more on the Hamilton Depression Scale). The predictive validity of the Melancholia Scale was evaluated using active treatment versus placebo response after 6 weeks of therapy. It was shown that in patients with a Melancholia Scale score of 10 or more (corresponding to “less than major depression”) 72% had full recovery when treated with clomipramine, while 36% of the placebo treated patients obtained a full recovery (P≤0.05). The patients treated with mianserin obtained a full recovery in 52%. The group of patients with a Melancholia Scale score of 10 or more scored higher also on the anxiety scales indicating that the relation between depression and anxiety is a matter of severity. The depressed patients had significantly lower imipramine binding sites than the non-depressed patients.

Exposure to combat and deployment; reviewing the military context in The Netherlands

This paper reviews the military context of exposure to combat and deployment in Dutch soldiers. It does so by reviewing war victims and military psychiatry after WWII in the Netherlands, and describes Dutch deployments from the late 1970s to the present. 'Who is the Dutch soldier' is asked to articulate the mental load on the individual soldier before, during, and after deployment. The narrative review of this paper allows one to review how the armed forces personnel is challenged in relation to their specific assignment and in what respect the psychological dimensions are addressed and met in the face of risk and adversity. Finally, some critical considerations for future veterans care programmes are raised.

Earthquakes, attributions, and psychopathology: a study in a rural community

Background: Attributions of both cause and blame form part of the diagnostic criteria for PTSD in DSM-5. Most work on attributions and psychopathology has focused on survivors of interpersonal violence and the two types of attribution have not been investigated together in natural disaster contexts. Previous work has identified that attributions to God's role may be associated with survivors' mental health following disasters. We studied the relation between attributions to God and other actors/entities in a rural community with high levels of religiosity that had suffered extensive damage and loss of life due to a series of earthquakes. Methods: A sample of survivors (N = 127) was assessed for degree of earthquake exposure, resource loss, attributions of cause and blame for the earthquake damage, and psychopathology three months after a series of major earthquakes in Italy. Results: Nature and chance were associated with higher cause than blame attributions whereas the State, the municipality, building firms, and the mafia were associated with higher blame than cause attributions. Additionally, both cause and blame attributions towards God and chance were positively correlated with PTSD and psychological distress symptoms. These associations remained significant while controlling for degree of earthquake exposure, resource loss, gender, age, and education. Conclusion: The current study supports the role played by cognitions about the cause of traumatic events, as introduced into the PTSD diagnosis in DSM-5, and extends this to blame of other entities such as God and chance following disasters.

Impact of mild traumatic brain injury on cingulate functions

Mild traumatic brain injury (mTBI) is a condition of normal neuroimaging, because conventional MRI is not sensitive to brain lesions. Neurocognitive deficits persist for years after injury in 15% of patients. Persistent TAI can continue after the trauma and contribute to progressive disability. Neuropathologic studies underestimate the total axonal damage, by failure to identify fine-caliber unmyelinated fiber. Swollen axons represent the "tip of the iceberg" of damage. Progression of molecular changes, including mitochondrial dysfunction, leads to secondary injuries. Primary low-intensity "invisible injury" is solely detectable at ultrastructural levels. Over the long term, mTBI is not a static event but a progressive injury, increasing risk of neurodegenerative diseases. Lack of evidence of brain injury has led to the development of more sensitive methods: morphometric MRI (VBM, DTI) and functional techniques (fMRI, PET, SPECT). By deformation of the surface of gray matter cingulate gyrus and disruption of long-coursing WM of CB structures, striking the falx, mTBI causes alteration of cingulate functions. Postconcussion, blast, and whiplash-associated disorders are the main mechanisms providing behavior and cognitive symptoms after mTBI.

Refugee Trauma

Epidemiological studies and theoretical models of refugee trauma based on ethnographic, biomedical and sociopolitical perspectives have focused on a variety of cultural and ethnic groups since World War II. Subjective distress and problems in psychosocial functioning are influenced by individual, fam ily, cultural and social variables. Refugees are at risk for developing psychiatric illness resulting from pre-migration, migration and post-migration experiences. This paper reviews biological, psychological and sociocultural models for recog nizing, conceptualizing and treating the psychiatric problems of traumatized refugees. The treatment approach of the Oregon Indochinese Psychiatric Program is summarized.

The Free State Floods: A Case Study

This is an exploratory study of the stress experiences of 20 flood victims in the Bloemfontein area. Measures consisted of demographic variables, Rotter's Locus of Control scale, Horowitz's Impact of Event scale and unstructured interviews. Whereas female subjects reported higher levels of stress than male subjects, no differences in the subjects' experiences of stress were found with regard to age, occupation or the measure of internal-external locus of control. In accordance with Lazarus's stress model, the interviews revealed that the subjects' initial reactions to the disaster (primary appraisals) included feelings of numbness, despondency, helplessness and reduced control over their circumstances. With regard to secondary appraisals the subjects reported having employed a number of successful as well as inadequate coping strategies. Sex differences occurred especially with regard to the subjects' accounts of primary appraisals and their use of external (outwardly directed) coping strategies.

Who Helps the Helpers? The Effects of a Disaster on the Rescue Workers

There is virtually no literature detailing the effects of a disaster on the rescue workers. This paper reports the results of a questionnaire survey conducted one month after the Granville rail disaster on ninety-five of the personnel involved in the rescue work and a follow-up on thirteen of them one year later. Seventy-seven of the ninety-five found the experience stressful; in particular, the feelings of helplessness engendered by the disaster, the magnitude of the destruction, the sight and smell of mutilated bodies, the anguish of relatives, and the need to work under pressure were items highlighted by the respondents. While only about 20 percent experienced specific psychological sequelae as a result of the disaster (depression, anxiety, insomnia), approximately 70 percent of the helpers showed evidence of being temporarily strained (half of them being over this by the end of one week). Thirty-five percent felt more positive about their own lives as a result of their involvement. The utility of debriefing sessions to assist workers to come to terms with and assimilate their experiences is discussed.

Trauma and Victimization

The topics of victimization and traumatic stress have become focal issues within the last two decades. This article synthesizes theoretical and empirical findings about psychological responses to traumatization across survivors of rape, childhood sexual or physical abuse, domestic violence, crime, disasters, and the Vietnam war. Five major categories of response, emotional, cognitive, biological, behavioral, and interpersonal, are described. Based on these findings, the authors present a new theoretical model for understanding individual variations in victim responses. In this model, they propose a complex relation among traumatic experiences, cognitive schemas within the areas of safety, trust, power, esteem, and intimacy, and psychological adaptation. Implications for assessment, treatment intervention, and further research within the area of traumatic stress are discussed.

Post-traumatic stress disorder and occupational characteristics of police officers in Republic of Korea: a cross-sectional study

OBJECTIVE

South Korean police officers have a greater workload compared to their counterparts in advanced countries. However, few studies have evaluated the occupational challenges that South Korean police officers face. Therefore, this study aimed to evaluate the police officer's job characteristics and risk of post-traumatic stress disorder (PTSD) among South Korean police officers.

DESIGN

Cross-sectional study.

SETTING

Police officers in South Korea.

PARTICIPANTS

3817 police officers with a traumatic event over a 1-year period.

MAIN OUTCOME MEASURES

Officers with a response to the Impact of Event Scale (revised Korean version) score of ≥ 26 were classified as high risk, and we evaluated their age, sex, department and rank, as well as the frequency and type of traumatic events that they experienced.

RESULTS

Among the respondents, 41.11% were classified as having a high risk of PTSD. From the perspective of the rank, Inspector group (46.0%) and Assistant Inspector group (42.7%) show the highest frequencies of PTSD. From the perspective of their working division, Intelligence and National Security Division (43.6%) show the highest frequency, followed by the Police Precinct (43.5%) and the Traffic Affairs Management Department (43.3%). It is shown that working in different departments was associated with the prevalence of PTSD (p=0.004).

CONCLUSIONS

The high-risk classification was observed in 41.11% of all officers who had experienced traumatic events, and this frequency is greater than that for other specialised occupations (eg, firefighters). Therefore, we conclude that groups with an elevated proportion of high-risk respondents should be a priority for PTSD treatment, which may help increase its therapeutic effect and improve the awareness of PTSD among South Korean police officers.

Symptoms of posttraumatic stress disorder after ritual female genital surgery among bedouin in Israel: myth or reality?

OBJECTIVE

Ritual female genital surgery (RFGS), or female circumcision, is common among certain ethnic groups in Asia and Africa and describes a range of practices involving complete or partial removal of the female external genitalia for nonmedical reasons. Several studies in African populations, in which more severe forms of RFGS are performed, reported an increased prevalence of posttraumatic stress disorder and other psychiatric syndromes among circumcised women than among uncircumcised controls. Among the Bedouin population in southern Israel, RFGS has become a symbolic operation without major mutilation. However, in a study performed in 1999, Bedouin women after RFGS reported difficulties in mother-daughter relationships and trust. This pilot study assessed the mental health of Bedouin women from southern Israel after RFGS compared to age-matched controls without RFGS.

METHOD

The psychological impact of RFGS was assessed in 19 circumcised Bedouin women compared to 18 age-matched controls. The Post Traumatic Stress Disorder Scale, Symptom Checklist, Impact of Event Scale, and a demographics and background questionnaire were used to assess traumatization and psychiatric illnesses. The study was conducted from March to July 2007.

RESULTS

No statistically significant differences were found between the 2 groups.

CONCLUSIONS

The prevailing procedure of RFGS among the Bedouin population of southern Israel had no apparent effect on mental health.

Factors associated with psychological distress among women of African descent at high risk for BRCA mutations

Little is known about psychological distress among women of African descent who are at high risk for a BRCA mutation. This is a group for whom breast cancer risk reduction is critical due to the group's high rates of breast cancer mortality. Distress is important to consider as it may reduce the potential benefit of genetic counseling and negatively affect decision making related to risk reduction. The goals of the current study were to examine breast cancer-specific distress and depressive symptoms in women of African descent at who are at high risk for a BRCA mutation and to identify background factors associated with these outcomes. Participants were 148 high-risk African American and Caribbean women who were part of a larger study that offered participants BRCA counseling at no cost. Participants completed the Impact of Events Scale, which assessed breast cancer-specific distress, and the Center of Epidemiological Studies-Depression Scale, which assessed depressive symptoms. Results of analyses revealed that almost half of the sample achieved scores indicating high and clinically significant breast cancer-specific distress, while almost one-third had clinically significant depression scores. Results further showed that low income was significantly associated with cancer-specific distress, while having a cancer diagnosis was significantly associated with depressive symptoms. These results underscore the need for targeted psychological support throughout the genetic risk assessment process for this particular high-risk group.

The effect of early trauma exposure on serotonin type 1B receptor expression revealed by reduced selective radioligand binding

CONTEXT

Serotonergic dysfunction is implicated in the pathogenesis of posttraumatic stress disorder (PTSD), and recent animal models suggest that disturbances in serotonin type 1B receptor function, in particular, may contribute to chronic anxiety. However, the specific role of the serotonin type 1B receptor has not been studied in patients with PTSD.

OBJECTIVE

To investigate in vivo serotonin type 1B receptor expression in individuals with PTSD, trauma-exposed control participants without PTSD (TC), and healthy (non-trauma-exposed) control participants (HC) using positron emission tomography and the recently developed serotonin type 1B receptor selective radiotracer [(11)C]P943.

DESIGN

Cross-sectional positron emission tomography study under resting conditions.

SETTING

Academic and Veterans Affairs medical centers.

PARTICIPANTS

Ninety-six individuals in 3 study groups: PTSD (n = 49), TC (n = 20), and HC (n = 27). Main Outcome Measure  Regional [(11)C]P943 binding potential (BP(ND)) values in an a priori-defined limbic corticostriatal circuit investigated using multivariate analysis of variance and multiple regression analysis.

RESULTS

A history of severe trauma exposure in the PTSD and TC groups was associated with marked reductions in [(11)C]P943 BP(ND) in the caudate, the amygdala, and the anterior cingulate cortex. Participant age at first trauma exposure was strongly associated with low [(11)C]P943 BP(ND). Developmentally earlier trauma exposure also was associated with greater PTSD symptom severity and major depression comorbidity.

CONCLUSIONS

These data suggest an enduring effect of trauma history on brain function and the phenotype of PTSD. The association of early age at first trauma and more pronounced neurobiological and behavioral alterations in PTSD suggests a developmental component in the cause of PTSD.

Personality disorders associated with full and partial posttraumatic stress disorder in the U.S. population: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

While it is well known that personality disorders are associated with trauma exposure and PTSD, limited nationally representative data are available on DSM-IV personality disorders that co-occur with posttraumatic stress disorder (PTSD) and partial PTSD.

METHODS

Face-to-face interviews were conducted with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses controlling for sociodemographics and additional psychiatric comorbidity evaluated associations of PTSD and partial PTSD with personality disorders.

RESULTS

Prevalence rates of lifetime PTSD and partial PTSD were 6.4% and 6.6%, respectively. After adjustment for sociodemographic characteristics and additional psychiatric comorbidity, respondents with full PTSD were more likely than trauma controls to meet criteria for schizotypal, narcissistic, and borderline personality disorders (ORs = 2.1-2.5); and respondents with partial PTSD were more likely than trauma controls to meet diagnostic criteria for borderline (OR = 2.0), schizotypal (OR = 1.8), and narcissistic (OR = 1.6) PDs. Women with PTSD were more likely than controls to have obsessive-compulsive PD. Women with partial PTSD were more likely than controls to have antisocial PD; and men with partial PTSD were less likely than women with partial PTSD to have avoidant PD.

CONCLUSIONS

PTSD and partial PTSD are associated with borderline, schizotypal, and narcissistic personality disorders. Modestly higher rates of obsessive-compulsive PD were observed among women with full PTSD, and of antisocial PD among women with partial PTSD.

From hysteria and shell shock to posttraumatic stress disorder: comments on psychoanalytic and neuropsychological approaches

In this paper, we look back at some of the earliest psychoanalytic approaches to trauma. The theoretical feasibility of reconciling psychoanalytic and neurobiological accounts of the effects of severe stress is examined. First, several epistemic considerations about the concepts of falsifiability and complexity in science are discussed with regard to neuroscience and psychoanalysis. We report the decisive discussions and descriptions of shell shock and hysteria that laid the foundation for the modern notions of dissociation and posttraumatic stress disorder (PTSD). We particularly underline the differences between "traumatic memory", which merely and unconsciously repeats the past, and "narrative memory", which narrates the past as past. Then, the construction of the modern concept of PTSD is described and the classification of conversion and dissociative disorders is questioned. In the next section, several recent neurobiological findings in patients with PTSD are reviewed. We place particular emphasis on cognitive impairment and cognitive bias relative to threatening stimuli, and on a general pattern of facilitated and heightened activation of the amygdala for threat-related stimuli, which are both recognized symptoms of PTSD. A possible meeting point between Cannon's and Freud's theoretical concepts is discussed in the frame of a deregulation of the stress system which helps not only to regulate homeostasis but also to adjust behaviour to external threats. We conclude that, although psychoanalysis and neuroscience may reciprocally complement and enlighten each other, their objects and methods, and thence their concepts, are fundamentally different.

The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121

The range of symptoms experienced by refugees of war has not been empirically assessed. The New Mexico Refugee Symptom Checklist-121 (NMRSCL-121) was developed utilizing established guidelines and evaluated for its psychometric properties. Community-dwelling Kurdish and Vietnamese refugees reported 48 (SD = 31) persistent and bothersome somatic and psychological symptoms on the NMRSCL-121. Internal consistency and test-retest reliability for the total scale and for most subscales were acceptable, and construct and concurrent validity for the NMRSCL-121 data was shown. There were modest ethnic group differences on symptom severity and psychometric properties of NMRSCL-121 subscales. The NMRSCL-121 produces reliable and valid assessments of a wide range of symptoms in 2 broad community samples of displaced adult refugees.

Symptoms of Acute Posttraumatic Stress Disorder After Intensive Care

Background Admission to intensive care is often a sudden and unexpected event precipitated by a life-threatening condition, 2 determinants thought to influence the development of posttraumatic stress disorder.

Objectives To identify the frequency of acute symptoms of posttraumatic stress disorder and to describe factors predictive of these symptoms in patients 1 month after discharge from intensive care.

Methods In this prospective cohort study, all patients meeting the inclusion criteria during the study period were invited to participate. Participants completed the Impact of Event Scale-Revised, and demographic and clinical data were accessed from an intensive care unit database.

Results During a 9-month period, 114 of 137 patients who met the inclusion criteria consented to participate in the study, and 100 (88%) completed it. The mean total score on the Impact of Event Scale-Revised was 17.8 (SD, 13.4; possible range, 0–88). A total of 13 participants (13%) scored higher than the cutoff score for clinical posttraumatic stress disorder. Neither sex nor length of stay was predictive of acute symptoms of post-traumatic stress disorder. In multivariate analysis, the only independent predictor of symptoms was age. Patients younger than 65 years were 5.6 times (95% confidence interval, 1.17–26.89) more likely than those 65 years and older to report symptoms.

Conclusion The rate of symptoms of posttraumatic stress disorder 1 month after discharge from intensive care was relatively low. Consistent with findings of previous research, being younger than 65 years was the only independent predictor of symptoms.

Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis

Introduction

The aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward.

Method

A retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands.

Results

The response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms.

Conclusion

Nearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.

Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma

Children and adults exposed to chronic interpersonal trauma consistently demonstrate psychological disturbances that are not captured in the posttraumatic stress disorder (PTSD) diagnosis. The DSM-IV (American Psychiatric Association, 1994) Field Trial studied 400 treatment-seeking traumatized individuals and 128 community residents and found that victims of prolonged interpersonal trauma, particularly trauma early in the life cycle, had a high incidence of problems with (a) regulation of affect and impulses, (b) memory and attention, (c) self-perception, (d) interpersonal relations, (e) somatization, and (f) systems of meaning. This raises important issues about the categorical versus the dimensional nature of posttraumatic stress, as well as the issue of comorbidity in PTSD. These data invite further exploration of what constitutes effective treatment of the full spectrum of posttraumatic psychopathology.

Forgivingness, Vengeful Rumination, and Affective Traits

Trait forgivingness is the disposition to forgive interpersonal transgressions over time and across situations. We define forgiveness as the replacement of negative unforgiving emotions with positive, other-oriented emotions. Rumination has been suggested as a mediator between forgivingness and emotional outcomes; however, we suggest that different content of rumination leads to different outcomes after transgressions. In four studies of 179, 233, 80, and 66 undergraduate students, trait forgivingness was negatively correlated with trait anger, hostility, neuroticism, fear, and vengeful rumination and was positively correlated with agreeableness, extraversion, and trait empathy. The disposition to ruminate vengefully mediated the relationship between trait forgivingness and (1) anger-related traits and (2) both revenge motivations and state anger following a specific recent transgression, but it did not mediate between forgivingness and (1) fearfulness and (2) avoidance motivations following a specific transgression. Self-hate statements, a proxy for depressive rumination, mediated the relationship between forgivingness and both depression and fearfulness but not the relationship between forgivingness and trait anger. Future research should distinguish the contents of mental rumination following interpersonal transgressions.

Cognitive approaches to posttraumatic stress disorder: the evolution of multirepresentational theorizing

The evolution of multirepresentational cognitive theorizing in psychopathology is illustrated by detailed discussion and analysis of a number of prototypical models of posttraumatic stress disorder (PTSD). Network and schema theories, which focus on a single, explicit aspect/format of mental representation, are compared with theories that focus on 2 or more explicit representational elements. The author argues that the latter theories provide a more complete account of PTSD data, though are not without their problems. Specifically, it is proposed that at least 3 separate representational elements-associative networks, verbal/propositional representations, and schemas-are required to generate a comprehensive cognitive theory of PTSD. The argument that the development of multirepresentational cognitive theory in PTSD is a paradigm case for the development of similar theories in other forms of psychopathology is elaborated, and a brief agenda is proposed promoting 2 levels of theorizing-deep, formal theory alongside more localized, applied theory.

The psychosocial effects of landmines in Jaffna

The victims of landmines in Jaffna were studied from a psychosocial perspective in order to identity major problem areas and give priorities for rehabilitation. Sixty-seven victims of landmines from April 1996 to March 1998 in the Valikamam area of Jaffna were studied. There were three times as many males as females. About 48 per cent were aged 20-39 years. About one-fifth of the victims were children. Of the females, 60 per cent were unmarried. The majority belonged to the lower socioeconomic strata. Half lost their earning capacity after the injury. Post-traumatic stress disorder (72 per cent), acute stress reaction (73 per cent), anxiety disorder (80 per cent) and depression (73 per cent) were found to be very significantly higher in this group than in the general population. There were also remarkable changes in the areas of functional ability, religious practice, use of alcohol and social relationships. The 'phantom limb' phenomenon was a striking feature among amputees. The psychosocial impact of landmine injuries has to be considered seriously in rehabilitation work.

Time does not heal all wounds: quality of life and psychological distress of people who survived the holocaust as children 55 years later

The present study assessed posttraumatic stress disorder (PTSD) symptoms, psychological distress, and subjective quality of life (QoL) in a group of 43 child Holocaust survivors and a community sample of 44 persons who had not personally experienced the Holocaust. The participants were administered the PTSD-Scale, the SCL-90, and the WHOQOL-Bref. Results showed that the child survivors had higher PTSD symptom scores, higher depression, anxiety, somatization, and anger-hostility scores; and lower physical, psychological, and social QoL than did the comparison group. The findings suggest that the psychological consequences of being a child during the Holocaust can be long lasting.

The relation between memory of the traumatic event and PTSD: evidence from studies of traumatic brain injury

OBJECTIVE

This paper focuses on the relation between memory and posttraumatic stress disorder (PTSD). More specifically, it addresses the debate regarding the role of memory of the traumatic event in the development of PTSD. Traumatic brain injury (TBI) is used as a naturally occurring model for traumatic exposure that is often associated with memory impairment.

METHOD

We present a critical review of the literature on studies assessing the relation between TBI and PTSD, with a focus on memory of the traumatic event as a critical factor. We also discuss results from recent studies conducted by our group.

RESULTS

The literature review offers an inconclusive picture wherein a significant proportion of the studies indicate that PTSD and TBI are mutually exclusive, especially in individuals who exhibit lack of memory for the traumatic event. This finding supports the possibility that lack of memory may protect against the development of PTSD. However, some studies show that PTSD does occur in patients with head injury, suggesting that PTSD may develop in TBI survivors--even in those who cannot remember the traumatic event. Generally speaking, though, the overall balance of the findings (including our own findings) seems to support the possibility that, in subjects with TBI, impaired memory of the traumatic event is associated with reduced prevalence of PTSD.

CONCLUSIONS

The suggestion that amnesia regarding the traumatic event may protect against the development of PTSD has both theoretical and practical importance. This review focused on the case of traumatic brain injury as a model for impaired memory for the traumatic event. However, it still remains to be proven that the conclusions based on these findings are generalizable beyond the case of TBI. While some patients with posttraumatic amnesia do develop PTSD despite lack of memory for the traumatic event, the majority of those who lack memory for the event seem to be protected from developing the disorder. Nevertheless, based on this assumption, we suggest that pharmacologic disruption of newly acquired--or even old--traumatic memories, which has been shown to be possible in animals, might therapeutically benefit trauma survivors.

Peritraumatic dissociation and posttraumatic stress after pregnancy loss: a prospective study

This study examined (1). predictors for peritraumatic dissociation, (2). its relations with acute and chronic symptoms of posttraumatic stress disorder (PTSD), and (3). pathways regarding these relations in response to pregnancy loss. In early pregnancy, about 1370 women volunteers completed questionnaires for neuroticism, control over emotions, dissociative tendencies, absorption, and prior life events. Of these, 126 subsequently experienced pregnancy loss and most of them completed measures 1 month (N = 118) and 4 months (N = 104) later. At 1 month, peritraumatic dissociation, memory of pregnancy loss (degree of fragmentation, sensory impressions, and emotional intensity), thought suppression, and PTSD symptoms were assessed, and at 4 months, PTSD symptoms were re-assessed. Peritraumatic dissociation was predicted by prior low control over emotions, dissociative tendencies, and lower education. It was not predicted by neuroticism, absorption, and prior life events. Peritraumatic dissociation was related to acute PTSD symptoms and LISREL analyses indicated that self-reported memory fragmentation and thought suppression of pregnancy loss mediated this relation. It also predicted chronic PTSD symptoms, and this relation was mediated by acute PTSD symptoms.

Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War

Confirmatory factor analysis was used to compare 6 models of posttraumatic stress disorder (PTSD) symptoms, ranging from 1 to 4 factors, in a sample of 3,695 deployed Gulf War veterans (N = 1,896) and nondeployed controls (N = 1,799). The 4 correlated factors-intrusions, avoidance, hyperarousal, and dysphoria-provided the best fit. The dysphoria factor combined traditional markers of numbing and hyperarousal. Model superiority was cross-validated in multiple subsamples, including a subset of deployed participants who were exposed to traumatic combat stressors. Moreover, convergent and discriminant validity correlations suggested that intrusions may be relatively specific to PTSD, whereas dysphoria may represent a nonspecific component of many disorders. Results are discussed in the context of hierarchical models of anxiety and depression.

Does everyone have a name? Psychological distress and quality of life among child holocaust survivors with lost identity

Knowing one's identity, name, and biological parents is considered essential to personality development and psychological well-being. This study assessed post-traumatic stress disorder (PTSD) symptoms, subjective quality of life (QoL), psychological distress, and potency in a group of adults who were children during the Holocaust (child Holocaust survivors) and who did not know their true identity. Twenty-three such survivors were compared to 23 child Holocaust survivors who knew their identity. Results showed that survivors with lost identity had lower physical, psychological, and social QoL and higher somatization, depression, and anxiety scores than did survivors with known identity. The findings suggest that the psychological consequences of not knowing one's identity are long-lasting.