Factor-analytic support for DSM-III's post-traumatic stress disorder for Vietnam veterans

Symptoms of War Trauma Induced Psychiatric Disorders: Southeast Asian Refugees and Vietnam Veterans

This article compares the symptomatology of Southeast Asian refugees suffering from mental health disorders with that of Vietnam veterans suffering from psychiatric disorders related to war trauma. Both of these groups share common unresolved feelings and have similar clinical manifestations resulting from the intensity of wartime atrocities. Similarities in the symptoms presented by these two groups suggest the Southeast Asian refugees may also suffer from the same type of war trauma induced psychiatric disorder as the Vietnam veterans.

Latent Structure of the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorder: Exploratory and Higher-Order Confirmatory Factor Analyses

A series of factor analyses evaluated the dimensionality of the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorder. Over 2,200 Vietnam theater and era veterans were divided into three random subsamples, each of which was used in a separate stage of analysis. Initial exploratory factor analyses suggested an underlying single-factor solution. In the second subsample, a second-order solution comprised of a general factor subsuming several first-order factors was supported using chi-square difference testing. This model was successfully replicated with the third subsample. Cumulative evidence suggests that the latent structure of the Mississippi Scale is best represented as an umbrella Post-Traumatic Stress Disorder (PTSD) factor leading to four subsidiary facets or dimensions.

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.

Yoga reduces symptoms of distress in tsunami survivors in the andaman islands

A month after the December 2004 tsunami the effect of a 1 week yoga program was evaluated on self rated fear, anxiety, sadness and disturbed sleep in 47 survivors in the Andaman Islands. Polygraph recordings of the heart rate, breath rate and skin resistance were also made. Among the 47 people, 31 were settlers from the mainland (i.e. India, ML group) and 16 were endogenous people (EP group). There was a significant decrease in self rated fear, anxiety, sadness and disturbed sleep in both groups, and in the heart and breath rate in the ML group, and in the breath rate alone in the EP group, following yoga (P < 0.05, t-test). This suggests that yoga practice may be useful in the management of stress following a natural disaster in people with widely differing social, cultural and spiritual beliefs.

Improving risk assessment of violence among military veterans: an evidence-based approach for clinical decision-making

Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.

Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study

BACKGROUND

An earlier study showed that a week of yoga practice was useful in stress management after a natural calamity. Due to heavy rain and a rift on the banks of the Kosi river, in the state of Bihar in north India, there were floods with loss of life and property. A week of yoga practice was given to the survivors a month after the event and the effect was assessed.

METHODS

Twenty-two volunteers (group average age +/- S.D, 31.5 +/- 7.5 years; all of them were males) were randomly assigned to two groups, yoga and a non-yoga wait-list control group. The yoga group practiced yoga for an hour daily while the control group continued with their routine activities. Both groups' heart rate variability, breath rate, and four symptoms of emotional distress using visual analog scales, were assessed on the first and eighth day of the program.

RESULTS

There was a significant decrease in sadness in the yoga group (p < 0.05, paired t-test, post data compared to pre) and an increase in anxiety in the control group (p < 0.05, paired t-test, post data compared to pre).

CONCLUSIONS

A week of yoga can reduce feelings of sadness and possibly prevent an increase in anxiety in flood survivors a month after the calamity.

TRIAL REGISTRATION

Clinical Trials Registry of India: CTRI/2009/091/000285.

Posttraumatic stress disorder and marital adjustment: the mediating role of forgiveness

The study assessed the effects of war captivity on posttraumatic stress symptoms and marital adjustment among Prisoners of War (POWs) from the Yom Kippur War. It was hypothesized that men's perception of level of forgiveness mediates the relation between posttraumatic symptoms and marital adjustment. The sample consisted of 157 Israeli veterans divided into 3 groups: 21 POWs with Posttraumatic Stress Disorder (PTSD), 58 former POWs without PTSD, and 70 control veterans. The findings indicated that former POWs with PTSD reported lower levels of marital satisfaction and forgiveness than veterans in the other 2 groups. In addition, men's perception of level of forgiveness mediated the relationship between their posttraumatic symptoms and their marital adjustment. The theoretical and clinical implications of these results are discussed.

A memory-based model of posttraumatic stress disorder: evaluating basic assumptions underlying the PTSD diagnosis

In the mnemonic model of posttraumatic stress disorder (PTSD), the current memory of a negative event, not the event itself, determines symptoms. The model is an alternative to the current event-based etiology of PTSD represented in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The model accounts for important and reliable findings that are often inconsistent with the current diagnostic view and that have been neglected by theoretical accounts of the disorder, including the following observations. The diagnosis needs objective information about the trauma and peritraumatic emotions but uses retrospective memory reports that can have substantial biases. Negative events and emotions that do not satisfy the current diagnostic criteria for a trauma can be followed by symptoms that would otherwise qualify for PTSD. Predisposing factors that affect the current memory have large effects on symptoms. The inability-to-recall-an-important-aspect-of-the-trauma symptom does not correlate with other symptoms. Loss or enhancement of the trauma memory affects PTSD symptoms in predictable ways. Special mechanisms that apply only to traumatic memories are not needed, increasing parsimony and the knowledge that can be applied to understanding PTSD.

The contribution of loneliness and posttraumatic stress disorder to marital adjustment following war captivity: a longitudinal study

This prospective study examined the relative contribution of loneliness and posttraumatic stress disorder (PTSD) to marital adjustment among Israeli veterans of the 1973 Yom Kippur war. Specifically, we examined the mediating role of loneliness as measured in 1991 in the association between PTSD as measured in 1991 and marital adjustment as measured in 2003. Our sample consisted of 225 participants divided into 2 groups: ex-prisoners of war (ex-POWs) (N = 122) and a comparison group comprised of veterans who fought in the same war but who had not experienced captivity (N = 103). The findings demonstrate that ex-POWs display lower levels of marital adjustment and higher levels of PTSD than controls. Loneliness was found to mediate the relationship between PTSD as measured in 1991 and marital adjustment as measured in 2003 for both ex-POWs and controls. Further, for ex-POWs, loneliness contributes to marital adjustment above and beyond the contribution of PTSD as measured in 2003. The theoretical implications of loneliness for the marital relationships of traumatized ex-POWs are discussed.

Prediction of numbing and effortful avoidance in female rape survivors with chronic PTSD

The purpose of the present study was to investigate the relationships among numbing, arousal, intrusion, and avoidance in a sample of 272 female rape survivors. Multiple regression analyses were conducted to test a theoretical model, which posits that hyperarousal and numbing are functionally related mechanisms and intrusions and avoidance are functionally related. Results supported the hypothesis that arousal explained the majority of the variance in numbing beyond that explained by avoidance and intrusion. In addition, intrusive symptoms explained the majority of the variance in effortful avoidance beyond that explained by numbing and arousal. The findings suggest that numbing and effortful avoidance may be separate mechanisms associated with symptoms of arousal and intrusion, respectively.

Are avoidance and numbing distinct PTSD symptom clusters?

We present the conceptual basis and empirical evidence for considering avoidance and numbing as distinct posttraumatic stress disorder (PTSD) symptom clusters. The majority of data from factor analytic studies supports the position that avoidance and numbing are distinct symptom clusters. As well, the available data suggest that (a) different treatment modalities have differential effects on reducing avoidance but not numbing, (b) patients with more severe pretreatment numbing have poorer treatment outcomes, (c) avoidance and numbing have different patterns of correlation with depression, and (d) they have different correlations with physiological indices of attention. We conclude that avoidance and numbing are distinct PTSD symptom clusters. This distinction has implications for revising current diagnostic criteria. The recognition of this distinction may lead to advances in understanding and treating PTSD.

Post-traumatic stress and disability

BACKGROUND

Post-traumatic stress is thought to account for significant disability. It is also known to be highly comorbid with other psychiatric conditions such as depression and alcohol dependence.

AIMS

To determine the relationship between post-traumatic stress, depression, alcohol dependence and disability.

METHOD

Seventy armed services personnel were assessed for DSM-IV diagnoses of post-traumatic stress disorder, major depressive disorder and alcohol dependence, and with continuous measures of symptoms of post-traumatic stress, depression and alcohol dependence following a traumatic event. These variables, as predictors of disability (using the Sheehan Disability Scale), were analysed using multivariate analysis of variance, analysis of covariance and multiple regression backward elimination models.

RESULTS

No significant interaction was found for the diagnostic variables even after controlling for the continuous symptom measures. In the regression models, symptoms of depression were a significant predictor of total disability (R(2)=0.39). Symptoms of alcohol dependence and post-traumatic stress did not significantly predict disability.

CONCLUSIONS

Since post-traumatic stress was not found to be associated with disability, its clinical importance may be questionable.

Relationship of numbing to alexithymia, apathy, and depression

The present study assessed the relationship between numbing and three associated conditions of alexithymia, apathy, and depression, utilizing data collected on 353 Vietnam combat veterans diagnosed with Posttraumatic Stress Disorder from in- and out-patient settings and an outreach center at various Department of Veterans Affairs Medical centers. All subjects completed four self-report measures: the Glover Numbing Scale, the Beck Depression Inventory, the Apathy Evaluation Scale, and the Toronto Alexithymia Scale-20. The correlation matrix indicated that scores on the four measures were moderately to highly correlated. Principal components analysis with a varimax rotation indicated a five-factor solution that provided evidence for the factorial validity of each of the constructs assessed. Results of the factor analysis of items from the four measures were consistent with numbing being a separate and distinct construct from alexithymia, apathy, and depression. In general, results indicated that all constructs measured were separate and distinct from one another.

Apparent symptom overreporting in combat veterans evaluated for PTSD

Psychometric studies have consistently shown that combat veterans evaluated for posttraumatic stress disorder (PTSD) appear to overreport psychopathology as exhibited by (a) extreme and diffuse levels of psychopathology across instruments measuring different domains of mental illness, and (b) extreme elevations on the validity scale of the MMPI-MMPI-2, in a "fake-bad" direction. The phenomenon of this ubiquitous presentational style is not well understood at present. In this review we describe and delineate the assessment problem posed by this apparent symptom overreporting, and we review the literature regarding several potential explanatory factors. Finally, we address conceptual and practical issues relevant to reaching a better understanding of the phenomenon, and ultimately the clinical syndrome of combat-related PTSD, in both research and clinical settings.

Symptom structure of PTSD following breast cancer

Identification of posttraumatic stress disorder (PTSD) symptoms and diagnoses in survivors of cancer is a growing area of research, but no published data exist regarding the symptom structure of PTSD in survivors of malignant disease. Findings from investigations of the PTSD symptom structure in other trauma populations have been inconsistent and have not been concordant with the re-experiencing, avoidance/numbing, and arousal symptom clusters specified in DSM-IV. The present study employed confirmatory factor analysis to evaluate the extent to which the implied second-order factor structure of PTSD was replicated in a sample of 142 breast cancer survivors. PTSD symptoms were measured using the PTSD Checklist--Civilian Version (PCL-C). Fit indices reflected a moderate fit of the symptom structure implied by the DSM-IV. These findings provide some tentative support for the DSM-IV clustering of PTSD symptoms and for the validity of cancer-related PTSD.

Intrusive traumatic recollections and comorbid posttraumatic stress disorder in depressed patients

OBJECTIVE

Recent studies have found evidence of the presence and role of intrusive traumatic memories in depressed patients. In this study, we attempted to replicate these findings, examining the full range of early and later traumatic events, as well as comorbid posttraumatic stress disorder, in male and female depressed patients.

METHODS

Sixty-nine outpatients meeting criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, for major depressive episode were recruited from the outpatient department of an academic hospital.

RESULTS

Seventy-five percent of the depressed patients were found to have had one or more early and/or more recent traumatic experiences. The symptom category of reexperiencing was diagnosed in 48% of these trauma-exposed respondents. Comorbid posttraumatic stress disorder was diagnosed in 13% of the total sample.

CONCLUSIONS

The findings show that depressed patients are highly likely to have experienced traumatic events and intrusive traumatic recollections. Future research should focus on the direction of any causal relationship between trauma, reexperiencing, posttraumatic stress disorder, and depression.

Posttraumatic stress disorder and interpersonal functioning in Vietnam War veterans: a mediational model

This study examines the association between posttraumatic stress disorder (PTSD) and interpersonal functioning in a New Zealand community sample of 756 Vietnam War veterans. The results support previous research findings showing that PTSD adversely affects veterans' interpersonal relationships, family functioning, and marital/dyadic adjustment and show that the effects of PTSD on family functioning and dyadic adjustment are mediated by severity of interpersonal problems. It is suggested that higher levels of PTSD affect the ability of veterans to initiate and maintain interpersonal relationships and that these interpersonal problems are evident in poorer levels of family functioning and poorer dyadic adjustment.

Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatient with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Epidemiologic and phenomenological aspects of post-traumatic stress disorder: DSM-III-R diagnosis and diagnostic criteria not validated

The aim of this cohort study was: (i) to validate the diagnostic criteria for post-traumatic stress disorder (PTSD) of the DSM-III-R; and (ii) to examine the incidence rate of PTSD in a study population exposed to two different traumatic events, i.e. a fire in a hotel ball-room and a multiple collision car-crash on a Belgian highway. One hundred and eighty-five victims (130 fire and 55 car accident victims) were assessed between 7 and 9 months after the traumatic event using the Composite International Diagnostic Interview (CIDI), PTSD Module, a fully structured diagnostic interview for the assessment of PTSD according to DSM-III-R criteria. Twenty-three percent of the study population met DSM-III-R criteria for PTSD. By means of unsupervised and supervised multivariate statistical analyses we were unable to validate the three-factorial structure, i.e. criteria B, C and D, of the DSM-III-R PTSD diagnosis. The latter relies heavily on the C diagnostic criteria, which appear to be too restrictive. Women were more likely to develop symptoms of reexperience (B) and arousal (D) than men. There was a significantly higher incidence of criteria B, C and D, but not of PTSD, in fire than in car-accident victims. Between 42 and 57% of the victims developed the first PTSD symptoms on the day of the trauma; within the next week these incidence rates increased to 77.1, 57.8 and 73.5% for criteria B, C and D, respectively. In conclusion, this study was unable to demonstrate the validity of the diagnostic criteria for PTSD according to DSM-III-R. The present cohort study has defined a number of factors that may predict new occurrences of PTSD symptoms after a traumatic event, i.e. gender, type of trauma and time delay between the trauma and the assessment of the diagnostic criteria.

The two-factorial symptom structure of post-traumatic stress disorder: depression-avoidance and arousal-anxiety

The first part of this study showed that the DSM-III-R symptom structure of post-traumatic stress disorder (PTSD), i.e. criteria B (reexperience), C (avoidance-numbing), and D (arousal), and, consequently the diagnosis of PTSD, could not be validated in fire and car-accident victims. The aims of this study were to: (i) determine the factors as well as their structure in the symptoms of PTSD; and (ii) develop a new classification or typology of PTSD. Exploratory and confirmatory factor analyses and cluster analyses were employed to: (i) examine the factors in PTSD symptomatology; and (ii) find and validate adequate diagnostic criteria for PTSD. The Composite International Diagnostic Interview (CIDI), PTSD Module, was used between 7 and 9 months after the traumatic event in a study group of 185 victims of two different traumatic events, i.e. 130 fire and 55 car-accident victims. Our findings support the existence of two factors, i.e. a first labeled 'depression-avoidance (DAV) dimension', as it contains items reminiscent of depression and avoidance, and a second labeled 'the anxiety-arousal (AA) dimension', as it contains symptoms reminiscent of anxiety and increased arousal. Cluster analysis yielded two clusters, i.e. a cluster of subjects with PTSD cases and another with non-cases. Our PTSD algorithm was significantly less restrictive than the DSM-III-R diagnosis of PTSD. There are only quantitative, but no qualitative, differences between the cluster analytically derived classes.

IN CONCLUSION

PTSD is not a well-delineated clinical entity, as there is a clinical continuum from PTSD non-cases to cases with less and more severe DAV and AA symptoms. It is more appropriate to express PTSD in terms of general severity of PTSD and severity of the DAV and AA dimensions.

A confirmatory factor analysis of posttraumatic stress symptoms

Investigators have recently identified a two-factor structure underlying posttraumatic stress symptoms through the use of exploratory factor analysis. [Taylor et al. (1988). The structure of posttraumatic stress symptoms. Journal of Abnormal Psychology, 107, 154-160]. These two factors, which were labeled as Intrusion and Avoidance, and Hyperarousal and Numbing, are consistent with current theoretical models of posttraumatic stress disorder--PTSD [e.g. Foa et al. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112, 218-238]. However, the authors of the Taylor et al. study issued caution in interpreting their findings because there has yet to be a systematic replication of their results. This paper presents a confirmatory factor analysis of the two-factor structure of posttraumatic stress symptoms in 217 survivors of serious motor vehicle accidents with varying degrees of PTSD symptoms. A hierarchical, confirmatory-factor analysis conducted with a structural equation modeling statistics package confirmed that the model proposed by Taylor et al. can adequately account for the presentation of PTSD symptoms in this sample of motor vehicle accident survivors. The implications for the assessment and diagnosis of PTSD are discussed.

Differentiating post-traumatic stress disorder (PTSD) from major depression (MDD) and generalized anxiety disorder (GAD)

Questions about the differential diagnosis of Post-Traumatic Stress Disorder (PTSD) have been raised since this category was reformulated in DSM-III (APA, 1980). Clinicians have reported difficulties distinguishing PTSD from other categories, particularly from Major Depressive and Generalized Anxiety Disorders (MDD and GAD). Diagnostic validity can be established in several ways (e.g., through clinical descriptive studies, laboratory experiments, family history studies, etc.). In this paper, we describe one approach to validation thus far not applied to PTSD: This approach centers directly on whether clinicians can distinguish PTSD from other diagnostic categories. Experienced clinicians were asked to rate the extent to which a common set of 90 symptom items characterized PTSD, MDD, and GAD. Ratings were analyzed with multivariate and univariate analyses of variance and covariance, multiple discriminant function analysis, and factor analysis; moreover, characteristics of rates were examined for possible influences. Results indicated that clinicians readily distinguish PTSD from MDD and GAD as well as MDD from GAD. Findings are presented in terms of univariate analyses, 34 best discriminating items, and factors specifying dimensions differentiating the syndromes of PTSD, MDD, and GAD. Rater characteristics did not influence diagnostic accuracy, although significant differences in magnitude of symptom intensity were found.

Modification of CAPS-1 for diagnosis of PTSD in Afghan refugees

A DSM-III-R based instrument for the assessment of posttraumatic stress disorder (PTSD), the Clinician-Administered PTSD Scale (CAPS-1), was modified to accommodate cultural differences and translated into the Afghan languages Pushto and Farsi (Dari) and administered to 30 Afghan refugees living in the United States. The modified CAPS-1 was found to be practical and reliable. Inter-item correlations were calculated on the frequency and intensity scores for the 17 cardinal symptoms and the eight associated features items of the modified CAPS-1. The four reexperiencing items demonstrated significant independence from the avoidance and arousal symptom clusters. However, the avoidance and arousal symptom clusters were not found to be independent cardinal components of PTSD in our participants. The CAPS-1 criteria for diagnosis of PTSD were met by 50% of the subjects evaluated.

The pitfalls of making a categorical diagnosis of post traumatic stress disorder in personal injury litigation

Since it first became possible to diagnose Post Traumatic Stress Disorder (PTSD) categorically with the advent of DSM-III (American Psychiatric Association, 1980), its use in the American Courts to substantiate civil claims has burgeoned. This situation may be set to repeat itself in the UK. Mental health professionals need to be aware that there is a substantial body of evidence supporting the validity of the concept of a DSM diagnosis of PTSD. However, the reliability of such a diagnosis can be called into question. There are legal and ethical issues involved in assessing and interpreting the DSM criteria, some of which may lead the expert witness to make authoritative pronouncements that are outside his legitimate field of expertise. There is a danger that the legal profession will adopt the DSM as a 'gold standard' against which to judge expert testimony. The multiaxial classification of the DSM can be a useful framework for presenting a diagnosis of PTSD, but over-rigid adherence to the criteria at the expense of clinical judgement and experience should be avoided.

A self-rating scale for the assessment of posttraumatic stress disorder in Dutch Resistance veterans of World War II

The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was .91. The scale showed an internal consistency with a coefficient alpha of .88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.

A factor analysis of the DSM-III post-traumatic stress disorder criteria

The authors factor analyzed DSM-III-based post-traumatic stress disorder symptom ratings made on 131 Vietnam-veteran PTSD patients. Five factors--termed Intrusive Thoughts and Their Effects, Increased Arousal, Impoverished Relationships, Guilt, and Cognitive Interference--emerged. The factor structure gave more support to Laufer, Brett and Gallops' conceptualization of PTSD than to the Horowitz, DSM-III, or DSM-III-R systems. It also generated suggestions for future editions of the diagnostic manual.

Conducting applied research on Vietnam combat-related post-traumatic stress disorder

A paradigmatic shift in post-traumatic stress disorder (PTSD) research is underway. Formistic and mechanistic research designs, characterized by single-category, single-cause, single-effect models, gradually are being replaced by contextual and organistic research designs that feature multi-category, multi-cause, and multi-effect interactional models. Such changes in diagnostic and treatment outcome research require solving many methodological issues in such areas as: measuring types of traumas and stressors; measuring PTSD symptoms and subtypes; measuring subject dispositional characteristics (such as ethnic differences); assessing concurrent and/or pre-existing psychiatric (Axis I) disorders; classifying personality styles and concurrent and/or pre-existing personality (Axis II) disorders; evaluating phase in the development of PTSD as a disorder; measuring current environmental stresses and interpersonal interactions; and assessing secondary gains and readiness for treatment. These and other methodological problems must be addressed as research on PTSD shifts to longitudinal measurement of subjects randomly assigned to treatment conditions.

Post-traumatic stress disorder: evidence for diagnostic validity and methods of psychological assessment

Post-traumatic stress disorder (PTSD) is a diagnosis that has been the subject of considerable criticism in the clinical literature. Of primary concern has been the question of whether PTSD is a disorder that can be discriminated reliably from already existing diagnoses, such as depression, dysthymia, or generalized anxiety disorder. This paper reviews the evidence that surrounds this controversy and employs the guidelines for validating a diagnosis established by Robins and Guze (1970) as the framework for the review. A second purpose of this paper is to present a multiaxial approach for the assessment of PTSD. This approach includes the use of structured interviews, psychometrics, and a psychophysiological assessment procedure. Studies that support the reliability and validity of the components of the multiaxial method are reviewed.

Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder

Urinary norepinephrine and epinephrine levels (microgram/day) were measured at two-week intervals during the course of hospitalization in the following patient groups: post-traumatic stress disorder (PTSD); major depressive disorder (MDD); bipolar I, manic (BP); paranoid schizophrenia (PS); and undifferentiated schizophrenia (US). The mean norepinephrine level during hospitalization was significantly higher in PTSD (76 +/- 10.4 micrograms/day) than in BP (60.6 +/- 8.4 micrograms/day), MDD (41.2 +/- 4.7 micrograms/day), PS (33.4 +/- 4.9 micrograms/day) and US (34.3 +/- 5.9 micrograms/day) groups, according to Duncan's multiple range test, (F(4,39) = 6.94, p less than 0.0003). The norepinephrine elevations in the PTSD group were sustained throughout hospitalization. The only other group to show mean levels in this range was the BP group in the first sample after hospital admission. This finding supports prior psychophysiological studies indicating increased sympathetic nervous system activity in PTSD patients. The mean epinephrine level during hospitalization was also significantly higher in PTSD (22.7 +/- 2.4 micrograms/day) than in MDD (13.6 +/- 1.7 micrograms/day), PS (14.7 +/- 2.4 micrograms/day), and US (18.9 +/- 1.8 micrograms/day), but not higher than in BP (21.5 +/- 2.7 micrograms/day). The relationship of epinephrine levels among diagnostic groups was sustained throughout hospitalization. It appears likely that the main underlying mechanisms for elevations of both hormones are psychological, but further work will be required to establish the exact nature of these mechanisms.