Predictors of post-traumatic stress disorder following physical trauma: an examination of the stressor criterion

Associations among traumatic experiences, threat exposure, and mental health in Pakistani journalists

Pakistan is considered to be relatively unsafe for journalists; however, little is known about how working in situations that involve a high risk of trauma exposure and personal threat impacts journalists' mental health. The present study aimed to examine the associations among reporting on topics that carry a high risk of trauma exposure; work-related personal threat exposure; and symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, and stress in a sample of Pakistani journalists. Participants completed online assessments to report the extent of their exposure to trauma and threat in the last 6 months with regard to reporting on militancy, crime, bomb blasts, and natural disasters and exposure to electronic, verbal, and physical threats; stalking; kidnapping; and detention. Further, we assessed symptoms of PTSD, depression, anxiety, and stress using self-report instruments. Of the 296 participants, 34.1% showed clinically significant levels of PTSD, moderately elevated levels of depression, and severely elevated levels of anxiety. Linear regression analyses demonstrated an association between PTSD symptoms and a higher frequency of reporting on natural disasters, β = 2.40, p = .004, whereas symptoms of anxiety, depression, and stress were associated with a lower frequency of reporting on bomb and suicide blasts, βs = -.93 - 1.61, p = <.001 - .047. Ideally, these findings will raise awareness about their situation, inform prevention and intervention efforts dedicated to journalists' mental health, and promote future research to elucidate the causal factors implicated in mental health symptoms in this population.

Prevalence and prediction of PTSD and depression in mothers of children surviving a motor vehicle crash

Introduction: Few studies have examined the psychopathological consequences for parents of children who were survivors of a motor vehicle crash (MVC). This study assessed the impact of dissociation and peritraumatic distress on the severity of PTSD and post-traumatic major depressive episode (MDE) symptoms in mothers during the first years after the MVC and the role that cortisol response might play in this association. Methods: 125 mothers were included. Peritraumatic distress and dissociation were assessed. Morning salivary cortisol was tested at the baseline. Participants were assessed for a probable diagnosis of PTSD and MDE at 5 weeks, 6 months and 12 months. Results: At 5 weeks, 12 (13.6%) mothers exhibited probable PTSD. During the first year, the PCL score was higher when the (i) Peritraumatic Distress Inventory (PDI) score increased and (ii) the Peritraumatic Dissociation Experience Questionnaire (PDEQ) score increased. Cortisol levels were lower when the PDI score increased. Conclusion: This is the first study to assess the mothers of MVC survivors for one year following the trauma. We confirm that peritraumatic responses are useful for predicting the severity of PTSD symptoms. These results could encourage the implementation of follow-up programmes not only for survivors but also for their mothers. HIGHLIGHTS Mothers of children involved in motor vehicle accident are at risk for developing PTSD.Peritraumatic responses (distress and dissociation) are associated to the severity of PTSD symptoms.Low salivary cortisol levels were associated with high peritraumatic distress.

The Postinjury Psychological Sequelae of High-Level Jamaican Athletes: Exploration of a Posttraumatic Stress Disorder–Self-Efficacy Conceptualization

Context: Athletes at the highest levels appear to be most affected by sport-related injuries and suffer both physiologically and psychologically. Established models of psychological responses to injury, however, do not offer a comprehensive explanation based on posttraumatic stress disorder (PTSD), although some studies suggest that injuries may be interpreted as traumatic. Studies also suggest that perceived self-efficacy may be a mediator of PTSD development. Objective: This study examines the psychological sequelae experienced by high-level athletes as a result of sport-related injuries based on a PTSD–self-efficacy framework. Design: A cross-sectional survey design was used. Participants: Forty-six athletes (30 males and 16 females) from 4 different sports were conveniently sampled and completed a questionnaire battery assessing injury characteristics, trauma sequelae, and self-efficacy. Main Outcome Measures: Present injury status, PTSD symptomatology, and general self-efficacy. Results: Injury was found to be associated with elevated levels of PTSD symptomatology. The presence of injury was a significant predictor of general PTSD and, specifically, hyperarousal symptoms; however, general self-efficacy was not found to predict trauma-related symptoms. There were indications, however, that self-efficacy beliefs may affect injury-related factors. Conclusions: This research highlights the presence of PTSD-related psychological dysfunction associated with sport injury, and further uncovers the possible impacts of self-efficacy beliefs in managing the stress of injury. These findings highlight the need for psychological support as injured athletes undergo rehabilitation.

The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect

OBJECTIVE

To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator.

MATERIALS AND METHODS

The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).

RESULTS

The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).

CONCLUSIONS

Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients' mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients' mental, the impact of the Orthofix LRS was less severe.

Prophylactic Ketamine Attenuates Learned Fear

Ketamine has been reported to be an efficacious antidepressant for major depressive disorder and posttraumatic stress disorder. Most recently, ketamine has also been shown to be prophylactic against stress-induced depressive-like behavior in mice. It remains unknown, however, when ketamine should be administered relative to a stressor in order to maximize its antidepressant and/or prophylactic effects. Moreover, it is unknown whether ketamine can be prophylactic against subsequent stressors. We systematically administered ketamine at different time points relative to a fear experience, in order to determine when ketamine is most effective at reducing fear expression or preventing fear reactivation. Using a contextual fear conditioning (CFC) paradigm, mice were administered a single dose of saline or ketamine (30 mg/kg) at varying time points before or after CFC. Mice administered prophylactic ketamine 1 week, but not 1 month or 1 h before CFC, exhibited reduced freezing behavior when compared with mice administered saline. In contrast, ketamine administration following CFC or during extinction did not alter subsequent fear expression. However, ketamine administered before reinstatement increased the number of rearing bouts in an open field, possibly suggesting an increase in attentiveness. These data indicate that ketamine can buffer a fear response when given a week before as prophylactic, but not when given immediately before or after a stress-inducing episode. Thus, ketamine may be most useful in the clinic if administered in a prophylactic manner 1 week before a stressor, in order to protect against heightened fear responses to aversive stimuli.

Emotional Processing in Individuals with Substance Use Disorder and Posttraumatic Stress Disorder

Previous research has shown that individuals with substance use disorder (SUD) and posttraumatic stress disorder (PTSD) have emotional processing difficulties. However, no studies have specifically investigated the role of emotional processing in those with co-morbid SUD-PTSD. This study investigated whether there are more emotional processing abnormalities among patients with SUD-PTSD, than those with either a single diagnosis of PTSD or SUD. Emotional processing was assessed in three groups [1) SUD (without PTSD); 2) PTSD (without SUD); and 3) co-morbid SUD-PTSD] using the Emotional Processing Scale (EPS-25) and the International Affective Picture System (IAPS). Each of the three groups reported evidence of emotional processing dysfunction relative to the normal population. Within the SUD-PTSD group there was significant evidence that the additional impact of trauma increased emotional processing dysfunction but less evidence to suggest that substance use increased emotional processing dysfunction further. These findings call into question current United Kingdom guidelines for the treatment of co-morbid SUD-PTSD, which recommend that the drug or alcohol problem should be treated first.

Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to systematically assess the existing literature and to derive a pooled estimate of the prevalence of depression and posttraumatic stress disorder (PTSD) in adult patients after acute orthopaedic trauma.

DATA SOURCES

A comprehensive search of databases, including MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials databases was conducted through June 2015.

STUDY SELECTION

We included studies that assessed the prevalence of depression or PTSD in patients who experienced acute orthopaedic trauma to the appendicular skeleton or pelvis. Studies with a sample size of ≤10 were excluded.

DATA EXTRACTION

Two authors independently extracted data from the selected studies and the data collected were compared with verify agreement.

DATA SYNTHESIS

Twenty-seven studies and 7109 subjects were included in the analysis. Using a random-effects model, the weighted pooled prevalence of depression was 32.6% (95% CI, 25.0%-41.2%) and the weighted pooled prevalence of PTSD was 26.6% (95% CI, 19.0%-35.9%). Six studies evaluated the prevalence of both depression and PTSD in patients with acute orthopaedic injuries. The weighted pooled prevalence of both depression and PTSD for those patients was 16.8% (95% CI, 9.0%-29.4%).

CONCLUSIONS

Nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from PTSD after an acute orthopaedic injury suggesting that strategies to address both the mental and physical rehabilitation after an orthopaedic injury should be considered to optimize patient recovery.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term psychiatric effects of trauma on children

Even minor physical trauma can lead to significant psychological difficulties in children and adolescents, which are often overlooked. Their immediate reactions include behavioural, emotional and cognitive difficulties. Their thinking about the world can be disrupted, leading to further problems. Initial reactions can have a further knock-on effect, with significant consequences sometimes leading to an impact upon their adult personality. Major disaster plans should include a psychosocial aspect. Immediately following trauma, children should be re-united with their carers or a familiar adult as soon as possible. They should be offered an age-appropriate, careful, explanation of what has happened to them and what their treatment involves. Routine screening for psychological problems may help to prevent chronic psychological sequelae. Various treatments are available for psychological problems that persist.

Predicting Posttraumatic Stress Symptoms Following Mild, Moderate, and Severe Traumatic Brain Injury: The Role of Posttraumatic Amnesia

OBJECTIVE

To explore the relation between posttraumatic amnesia (PTA) and posttraumatic stress symptoms in traumatic brain injury.

DESIGN

Single-site prospective cohort study.

PARTICIPANTS

A total of 1114 individuals between the ages of 18 and 65 years with a traumatic brain injury seen on average 3 months following injury. Participants were divided into 4 groups according to their duration of PTA: less than 1 hour; 1 to 24 hours; 24 hours to 1 week; and more than 1 week.

MAIN MEASURES

Glasgow Coma Scale, PTA, computed tomographic brain scan abnormalities, Impact of Event Scale, the 28-item General Health Questionnaire, and Rivermead Postconcussion Disorder Questionnaire.

RESULTS

The duration of PTA less than 1 hour was associated with more avoidant (P < .01) and intrusive (P < .001) posttraumatic stress symptoms and more anxiety according to the General Health Questionnaire (P < .01) than other groups. Regression analysis identified PTA and 3 concussive symptoms (light sensitivity, noise intolerance, and difficulties concentrating) as independent predictors of intrusive posttraumatic stress symptoms.

CONCLUSION

Our data, representative of the full range of traumatic brain injury severity, indicate that a brief duration of PTA is a significant risk factor for the development of posttraumatic stress disorder symptoms. The persistence of certain symptoms of postconcussion disorder adds to the risk by possibly acting as a trigger for reminders of the traumatic event.

Posttraumatic Stress Disorder: A Risk Factor for Poor Work Outcomes in Survivors of Road Trauma

Risk factors associated with post-injury return to work are well documented. Less is known of the impact of PTSD on work outcomes. Information on worker and accident risk factors was obtained by survey, hospital records and personal interview with 40 road trauma survivors two years post-accident: Results suggest that while PTSD was an independent risk factor for negative work outcomes, PTSD also significantly contributed to the overall adverse impact of anxiety, depression and pain on work outcomes. The lack of improvement in work outcomes between from 12 weeks post-accident for those with PTSD indicated that early vocational interventions are critical for this population.

The course of PTSD in naturalistic long-term studies: high variability of outcomes. A systematic review

BACKGROUND

With a lifetime prevalence of 8% posttraumatic stress disorder (PTSD) is one of the most common mental disorders; nevertheless, its longitudinal course is largely unknown.

AIMS

Our aim was to conduct a systematic review summarizing available findings on the prospective, naturalistic long-term course of PTSD and its predictors.

METHODS

Databases MEDLINE and PsycINFO were searched. Main selection criteria were: 1) naturalistic cohort study with a follow-up period of at least 3 years, 2) adult participants with observer-rated or probable PTSD at baseline.

RESULTS

Twenty-four cohorts (25 studies) were retrieved (14 with observer-assessed, 10 with probable PTSD). In total, they comprised about 10,500 participants with PTSD at baseline that were included in the long-term follow-ups. Studies investigating patient populations with observer-assessed PTSD found that between 18% and 50% of patients experienced a stable recovery within 3-7 years; the remaining subjects either facing a recurrent or a more chronic course. Outcomes of community studies and studies investigating probable PTSD varied considerably (remission rates 6-92%). Social factors (e.g. support) as well as comorbid physical or mental health problems seem to be salient predictors of PTSD long-term course and special focus should be laid on these factors in clinical settings.

CONCLUSIONS

Included studies differed notably with regard to applied methodologies. The resulting large variability of findings is discussed. More standardized systematic follow-up research and more uniformed criteria for remission and chronicity are needed to gain a better insight into the long-term course of PTSD.

A historical review of trauma-related diagnoses to reconsider the heterogeneity of PTSD

Based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, there are 636,120 ways for an individual to qualify for a diagnosis of posttraumatic stress disorder (PTSD) (Galatzer-Levy & Bryant, 2013). To unravel this heterogeneity, we examine the historical trajectory of trauma-related diagnoses. Our review addresses four traumas (i.e., combat, natural disaster, life-threatening accident and sexual assault) that have contributed the most to conceptual models of PTSD. Although these trauma types are all subsumed under the same diagnostic label, our literature review indicates that the psychological consequences of different traumatic experiences are traditionally studied in isolation. Indeed, most research addresses hypotheses regarding specific trauma types using samples of individuals selected for their experience with that specific event. We consider the possibility that PTSD is not a single, unified construct and what this means for future research and clinical applications.

Incidence and predictors of acute psychological distress and dissociation after motor vehicle collision: a cross-sectional study

OBJECTIVE

We examined the incidence and predictors of peritraumatic distress and dissociation after one of the most common forms of civilian trauma exposure: motor vehicle collision (MVC).

METHOD

In this study, patients presenting to the emergency department after MVCs who were without serious injury and discharged to home after evaluation (n = 935) completed an emergency department interview evaluating sociodemographic, collision-related, and psychological characteristics.

RESULTS

The incidence and predictors of distress (Peritraumatic Distress Inventory score ≥23) and dissociation (Michigan Critical Events Perception Scale score >3) were assessed. Distress was present in 355 of 935 patients (38%), and dissociation was present in 260 of 942 patients (28%). These outcomes showed only moderate correlation (r = .45) and had both shared and distinct predictors. Female gender, anxiety symptoms prior to the MVC, and vehicle damage severity predicted both distress and dissociation. Higher socioeconomic status (higher education, higher income, full-time employment) had a protective effect against distress but not dissociative symptoms. Better physical health and worse overall mental health were associated with increased risk of dissociation but not distress. Distress but not dissociation was associated with lower patient confidence in recovery and a longer expected duration of recovery.

CONCLUSION

There are unique predictors of peritraumatic distress and dissociation. Further work is needed to better understand the neurobiology of peritraumatic distress and dissociation and the influence of these peritraumatic outcomes on persistent psychological sequelae.

Psychobiology of PTSD in the acute aftermath of trauma: Integrating research on coping, HPA function and sympathetic nervous system activity

Research on the psychobiological sequelae of trauma has typically focused on long-term alterations in individuals with chronic posttraumatic stress disorder (PTSD). Far less is known about the nature and course of psychobiological risk factors for PTSD during the acute aftermath of trauma. In this review, we summarize data from prospective studies focusing on the relationships among sympathetic nervous system activity, hypothalamic-pituitary-adrenal function, coping strategies and PTSD symptoms during the early recovery (or non-recovery) phase. Findings from pertinent studies are integrated to inform psychobiological profiles of PTSD-risk in children and adults in the context of existing models of PTSD-onset and maintenance. Data regarding bidirectional relations between coping strategies and stress hormones is reviewed. Limitations of existing literature and recommendations for future research are discussed.

Mexican journalists: an investigation of their emotional health

Mexican journalists are frequently the victims of violence, often drug related. The purpose of the study was to assess their mental well-being. Of 104 journalists recruited from 3 news organizations, those who had stopped working on drug-related stories because of intimidation from the criminal drug cartels (n = 26) had significantly greater social dysfunction (p = .024); and more depressive (p = .001) and higher intrusive (p = .027), avoidance (p = .005), and arousal (p = .033) symptoms than journalists living and working under threat in regions of drug violence (n = 61). They also had more arousal (p = .05) and depressive (p = .027) symptoms than journalists (n = 17) never threatened before and living in regions without a drug problem. These findings provide preliminary data on the deleterious effects of drug-related violence on the Mexican media, amplifying the concerns expressed by journalist watchdog organizations monitoring the state of the press in the country.

Comparison of depressive symptoms during the early recovery period in patients with a distal radius fracture treated by volar plating and cast immobilisation

INTRODUCTION

Patients with orthopaedic trauma experience substantial psychological and physical morbidities. The purpose of this study was to assess depressive symptoms in patients with a distal radius fracture, and to determine whether early use of the wrist after volar plating reduces depressive symptoms as compared with cast immobilisation during the early recovery period.

MATERIALS AND METHODS

Twenty-six patients with a distal radius fracture, who underwent volar plating and were allowed immediate use of the wrist, and 24 patients treated by cast immobilisation for 6 weeks were prospectively compared with respect to depressive symptoms at week 0, and at 2, 6, 12 and 24 weeks after injury, using the Center for Epidemiologic Studies Depression Scale (CES-D). Physical morbidity was assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and a pain Numerical Rating Scale (NRS). Multivariate analysis was performed to identify factors that independently predicted CES-D scores at each time point.

RESULTS

No differences in the CES-D scores were found between the volar plating and the cast immobilisation groups, although volar plating group had marginally better CES-D scores at 24 weeks. Multivariate analysis indicated that CES-D scores at each time were independently associated with pain NRS scores at 0 and 24 weeks, and DASH scores at 6 weeks.

CONCLUSION

Early use of the wrist after volar plating was not found to reduce depressive symptoms as compared with cast immobilisation in the early treatment period following a distal radius fracture. Pain was found to be an important predictor of depression, suggesting that caution is needed to address pain during the early rehabilitation period.

Gender differences in PTSD symptoms: an exploration of peritraumatic mechanisms

Females are at higher risk than males for developing posttraumatic stress disorder symptoms (PTSS) following exposure to trauma, which may stem from gender differences in initial physiological and psychological responses to trauma. The present study aimed to examine a number of peri- and initial posttraumatic reactions to motor vehicle accidents (MVAs) to determine the extent to which they contributed to gender differences in PTSS. 356 adult MVA survivors (211 males and 145 females) reported on peritraumatic dissociation, perception of life threat and initial PTSS. In addition, heart rate and urinary cortisol levels were collected in-hospital. 6 weeks and 6 months later, PTSS were assessed via clinical interviews. Results suggested that initial PTSS and peritraumatic dissociation were marginally significant mediators at 6-week follow-up and significant mediators at 6-month follow-up, providing partial support for the hypothesis that initial responses to trauma may account for observed gender differences in PTSS development.

Injury-specific predictors of posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is an important source of morbidity in military personnel, but its relationship with characteristics of battle injury has not been well defined. The aim of this study was to characterise the relationship between injury-related factors and PTSD among a population of battle injuries.

PATIENTS AND METHODS

A total of 831 American military personnel injured during combat between September 2004 and February 2005 composed the study population. Patients were followed through November 2006 for diagnosis of PTSD (ICD-9 309.81) or any mental health outcome (ICD-9 290-319).

RESULTS

During the follow-up period, 31.3% of patients received any type of mental health diagnosis and 17.0% received a PTSD diagnosis. Compared with minor injuries those with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.61-3.48), serious (OR, 4.07; 95% CI, 2.55-6.50), and severe (OR, 5.22; 95% CI, 2.74-9.96) injuries were at greater risk of being diagnosed with any mental health outcome. Similar results were found for serious (OR, 3.03; 95% CI, 1.81-5.08) and severe (OR, 3.21; 95% CI, 1.62-6.33) injuries with PTSD diagnosis. Those with gunshot wounds were at greater risk of any mental health diagnosis, but not PTSD, in comparison with other mechanisms of injury (OR 2.07; 95% CI, 1.35, 3.19). Diastolic blood pressure measured postinjury was associated with any mental health outcome, and the effect was modified by injury severity.

CONCLUSIONS

Injury severity was a significant predictor of any mental health diagnosis and PTSD diagnosis. Gunshot wounds and diastolic blood pressure were significant predictors of any mental health diagnosis, but not PTSD. Further studies are needed to replicate these results and elucidate potential mechanisms for these associations.

Eye Movement Desensitization of Body Image

This single case history reports the use of eye movement desensitization, a new cognitive therapy procedure originally developed for post-traumatic stress disorder and similar problems, to treat anxieties and body image problems resulting from operation scars and a degree of physical disability. The procedure was effective within one session and subsequent improvements in behaviour and cognitions reported.

Early post-traumatic stress disorder in relation to acute stress reaction: an ICD-10 study among help seekers following an earthquake

Disaster research related to earthquakes has almost exclusively dealt with their long-term psychosocial impact; besides, diagnoses were previously based only on DSM criteria. Therefore, it is pertinent to assess stress-related reactions of earthquake victims during the early post-disaster period through the application of ICD-10 criteria. For the first 3 weeks following an earthquake, 102 help-seekers were assessed based on a checklist of sociodemographic variables and a semi-structured interview for the detection of acute stress reaction (ASR) and posttraumatic stress disorder (PTSD) according to ICD-10. Forty-four subjects (43%) fulfilled the ICD-10 criteria for PTSD; all but one of them had suffered ASR. Moreover, among a series of potential predictors for PTSD, ASR was found to be the only significant one; this indicates a definite association between ASR and early development of PTSD. Logistic regression to predict group membership (PTSD/no PTSD) based on specific ASR symptoms showed that accelerated heart rate and feelings of derealization were the only significant predictors for early PTSD. Individuals who fulfill the ICD-10 diagnostic criteria for ASR following an earthquake are at high risk for subsequent occurrence of early PTSD. Increased heart rate and feelings of derealization within the first 48 h after the traumatic event appear to be the principal factors associated with the development of early PTSD. In addition to their potential value for timely prevention and treatment, these findings raise important nosological issues pertaining to the current diagnostic classification of stress-related disorders (ICD-10 versus DSM-IV).

Longitudinal studies of PTSD: overview of findings and methods

Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.

A model of care for managing traumatic psychological injury in a workers' compensation context

Work-related traumatic psychological injuries are a significant health problem that can result in distress and disability. To improve outcomes following a workplace trauma, the Workers' Compensation Board of Alberta (WCB-AB) has developed and implemented an evidence-based care model (CM) to assist its staff to manage these claims. A CM acts as a disability management "road map" that illustrates typical recovery patterns, treatment best practices, and checkpoints where decisions for further service provision can be made. The model was developed from a recent literature review, and the opinions of local and international experts in the field of traumatic psychological injury. A formal evaluation of the effectiveness of this model is being planned.

Posttraumatic syndromes in children and adolescents after road traffic accidents--a prospective cohort study

BACKGROUND

The impact of road traffic accidents (RTAs) on the physical health of children is well recognized, but their psychological consequences have only recently become a topic of research. While other traumatic experiences in childhood are well studied, this kind of trauma has been poorly investigated to date.

SAMPLING AND METHODS

A prospective cohort study was conducted of 8- to 18-year-old children and adolescents who were involved in RTAs in a large urban area during a 6-month period. The children and adolescents were interviewed within 1 week after the accident and, again, 3 months later. In total, 72 children and adolescents took part in the study. Symptoms of posttraumatic stress, depression and anxiety were assessed by a structured clinical interview and standardized questionnaires.

RESULTS

One week after the accident, 11% of the children met the diagnostic criteria for posttraumatic stress disorder (PTSD) according to ICD-10 and a further 13% met the criteria for 'subsyndromal PTSD'. Complex syndromes consisting of subsyndromal posttraumatic stress, (separation) anxiety and depression were common among those children. Isolated cases of anxiety and depression symptoms were also observed but rarely reached an impairing level. Three months after the accident, 25% of the children reported persistence of the PTSD symptoms (measured by the Impact of Event Scale - Revised). The strongest predictor of the extent of posttraumatic stress after 3 months was proven to be the initial level of PTSD symptoms. This predictor alone accounted for 38% of its variance.

CONCLUSIONS

Our results provide evidence that even after 'everyday' RTAs, psychological consequences are common. Special attention should be paid to the common occurrence of subsyndromal psychological disturbances and more complex syndromes. The results further indicate the limitations of the PTSD concept in the assessment of posttraumatic disturbances in childhood and adolescence.

A preliminary test of the role of experiential avoidance in post-event functioning

Experiential avoidance is the unwillingness to experience unwanted thoughts, emotions, or bodily sensations and an individual's attempts to alter, avoid, or escape those experiences. The aim of the current studies was to broaden previous research indicating that experiential avoidance often leads to the development and maintenance of psychological distress. Results indicated that experiential avoidance is significantly correlated with psychological distress and post-traumatic symptomatology over and above other measures of psychological functioning. Limitations and implications for treatment and prevention of psychological distress are discussed.

Symptoms of posttraumatic stress disorder after orthopaedic trauma

BACKGROUND

The purpose of this study was to determine the prevalence of posttraumatic stress disorder among patients seen following an orthopaedic traumatic injury and to identify whether injury-related or demographic variables are associated with the disorder.

METHODS

Five hundred and eighty patients who had sustained orthopaedic trauma completed a Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder questionnaire. Demographic and injury data were collected to analyze potential variables associated with posttraumatic stress disorder.

RESULTS

Two hundred and ninety-five respondents (51%) met the criteria for the diagnosis of posttraumatic stress disorder. Patients with posttraumatic stress disorder had significantly higher Injury Severity Scores (p = 0.04), a higher sum of Extremity Abbreviated Injury Scores (p = 0.05), and a longer duration since the injury than those without posttraumatic stress disorder (p < 0.01). However, none of these three variables demonstrated a good or excellent ability to discriminate between patients who had posttraumatic stress disorder and those who did not. The response to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," was significantly associated with the presence of posttraumatic stress disorder (p < 0.0001) and showed a fair ability to identify patients with the disorder.

CONCLUSIONS

Posttraumatic stress disorder is common after orthopaedic trauma. Patients who respond positively to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," may meet diagnostic criteria for this disorder and should be evaluated further.

The Impact of Major Trauma: Quality-of-Life Outcomes Are Worse in Women than in Men, Independent of Mechanism and Injury Severity

BACKGROUND

The importance of gender differences in quality of life and psychologic morbidity after major trauma is a newly recognized focus of trauma outcomes research. The Trauma Recovery Project is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL), and psychologic sequelae such as depression and early symptoms of acute stress reaction (SASR). The specific objectives of the present report are to examine gender differences in QoL outcomes and the early incidence of combined depression and SASR after injury, controlling for injury severity, specific body area injured, and mechanism.

METHODS

Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay greater than 24 hours. QoL outcome after trauma was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Depression was assessed using the Center for Epidemiologic Studies scale. SASR was assessed using the Impact of Events scale. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge.

RESULTS

Women (n = 313) were significantly more likely to have poor QoL outcomes at follow-up than men (n = 735) (women vs. men: 12-month follow-up odds ratio [OR] = 2.2, p < 0.001; 18-month follow-up OR = 2.0, p < 0.001). Quality of Well-being scores at each of the 6-, 12-, and 18-month follow-up time points were markedly and significantly lower in women compared with men, independent of injury severity, serious and moderate injury status, lower extremity injury, intentional or unintentional injury type, and blunt or penetrating injury. Women were also significantly more likely to develop early combined depression and SASR at discharge (OR = 1.7, p < 0.01) and to have continuous depression throughout the 18-month follow-up period (OR = 2.3, p < 0.001).

CONCLUSION

These analyses provide further important and more detailed evidence that women are at risk of worse QoL outcomes and early psychologic morbidity after major trauma than men, independent of mechanism and injury severity. A better understanding of the impact of major trauma in men and women will be an important component of efforts to improve trauma care and long-term outcome in mature trauma systems.

Psychological distress associated with severe lower-limb injury

BACKGROUND

Little is known about the psychological morbidity associated with limb-threatening injuries. It was hypothesized that a substantial proportion of patients who sustain a severe lower-limb injury will report serious psychological distress.

METHODS

Adult patients who were admitted to one of eight level-I trauma centers for treatment of an injury threatening the lower limb were enrolled during their initial hospitalization. Patients were recontacted at three, six, twelve, and twenty-four months after the injury and asked to complete the Brief Symptom Inventory (BSI), a fifty-three-item, self-reported measure of psychological distress. Patients who screen positive on the BSI are considered likely to have a psychological disorder and should receive a mental health evaluation. Longitudinal regression techniques were used to model positive case status (i.e., likely to have a psychological disorder) as a function of patient, injury, and treatment characteristics.

RESULTS

Of the 569 patients enrolled, 545 (96%) completed at least one BSI and 385 (68%) completed all four. Forty-eight percent of the patients screened positive for a likely psychological disorder at three months after the injury, and this percentage remained high (42%) at twenty-four months. Two years after the injury, almost one-fifth of the patients reported severe phobic anxiety and/or depression. While these two subscales reflected the highest prevalence of severe psychological distress, none of the BSI subscales reflected the prevalence expected from a normal sample (i.e., 2% to 3%). Factors associated with a likely psychological disorder included poorer physical function, younger age, non-white race, poverty, a likely drinking problem, neuroticism, a poor sense of self-efficacy, and limited social support. Relatively few patients reported receiving any mental health services following the injury (12% at three months and 22% at twenty-four months).

CONCLUSIONS

Severe lower-limb injury is associated with considerable psychological distress. More attention to the psychological as well as the physical health of patients who sustain a limb-threatening injury may be needed to ensure an optimal recovery following these devastating injuries.

Capacity of screening questionnaires to predict psychiatric morbidity 18 months after motor vehicle accidents

Motor vehicle accidents are one of the most common causes of trauma-related psychiatric morbidity. Previous studies have suggested that symptom screening instruments may be useful in predicting risk of longer-term psychiatric morbidity, but results have varied. The present study is based on 83 of an eligible 102 consecutive hospital-admitted survivors of road trauma who completed a structured clinical interview at baseline and 18-month follow-up. A subsample returned symptom questionnaires within 2 weeks of the accident, with between 60 and 66 completing the questionnaire. Receiver Operator Characteristic curve analyses were applied to obtain optimal predictive scores on each screening measure. Combining the derived cutoff scores on the Impact of Event Scale (measuring posttraumatic stress disorder symptoms) and the Beck Depression Inventory yielded an odds ratio of 82.9 in predicting any psychiatric morbidity at 18 months, with a specificity of 95%, and high positive (89%) and negative (91%) predictive indices. If these exploratory findings are confirmed by future studies, the case will be strengthened for routine screening of motor vehicle accident survivors to allow ongoing monitoring and selective early interventions for the high-risk subgroup. Compliance with completing and returning questionnaires remains a major challenge in this population, however, as indicated by the level of attrition in our study.

Horowitz's Impact of Event Scale evaluation of 20 years of use

OBJECTIVE

The main objective of this meta-analysis was to model the relations between a set of independent variables (age and gender of the trauma group, country where the study was performed, year of publication, type of event, time elapsed between event and measurement) and stress symptoms.

METHODS

Data from 66 studies that used Horowitz's IES to examine the psychological impact of a major life event were subjected to meta-analysis.

RESULTS

Results from hierarchical regression analysis indicated that type of event (episodes of illness and injury, natural and technological disaster, bereavement and loss, violence, sexual abuse, and war exposure) is a strong predictor of levels of intrusive and avoidant symptoms after a traumatic event. Intrusive and avoidant reactions reported by trauma victims tended to decrease linearly over time after the trauma. This finding was supported by the results reported by 20 different studies of stress reactions at two different time points after various events. Gender and cultural difference were relatively insignificant, whereas type of event induced different levels of stress reactions as measured with the IES.

CONCLUSION

These data provide evidence for the value of the IES as a measure of stress reactions in a number of different populations. Data summarized here will be useful as a comparison resource in future studies of stress response syndromes.

Personality disorders and posttraumatic stress disorder in motor vehicle accident survivors

This study examined the impact of a co-occurring personality disorder on the development and remission of posttraumatic stress disorder (PTSD) in 158 motor vehicle accident (MVA) survivors followed prospectively for 1 year. Participants were assessed 1 to 4 months after trauma and at 6-month and 1-year follow-up evaluations during 1991 through 1993. These archival data were analyzed in the present study. The prevalence of at least one personality disorder was 13.3%, with the majority (52.4%) presenting with obsessive-compulsive personality disorder. Persons with a personality disorder were significantly more likely to be diagnosed with PTSD at 1-year follow-up evaluation. For persons diagnosed with PTSD at the initial assessment, those with a personality disorder were significantly less likely to remit by 1 year. The presence of a preexisting personality disorder may increase the risk of chronic PTSD and impede remission.

Acute stress reactions following the assassination of Mexican presidential candidate Colosio

Considerable evidence suggests that exposure to traumatic events increases the risk of developing anxiety-spectrum disorders in response to later traumatization. We conducted a survey in Guadalajara, Mexico to assess factors associated with acute stress reactions to the assassination of a political figure. Participants included 86 adults who completed the Stanford Acute Stress Reaction Questionnaire (SASRQ) and measures of the perceived impact of the assassination, exhibited emotional behavior following the assassination, and had exposure to a specific prior disaster (a gas pipeline explosion). The results suggest that acute stress reactions can occur in response to an assassination, and that those most susceptible are those most emotionally invested, those who engage in emotional behavioral responses, and those whose lives have been affected by a previous potentially traumatic event.

The psychological burden of injury: an 18 month prospective cohort study

OBJECTIVES

To determine the prevalence of post-trauma psychological problems among a cohort of male accident and emergency department patients admitted to hospital. To identify the changes in their psychological symptoms over an 18 month follow up period.

METHODS

A prospective cohort study of male accident and emergency department patients who were admitted for treatment of an injury. Baseline interview recorded demographic details and accident details. Standardised questionnaires measured baseline psychological state and personality type. Follow up at six weeks, six months, and 18 months after injury was by face to face interview or postal questionnaire and recorded progress since injury, and documented psychological status through the use of standardised questionnaires to detect psychiatric disorder and symptoms of post-traumatic stress disorder (PTSD).

RESULTS

210 male patients were recruited into the study. Psychiatric disorder was identified in 47.6% of responders at six weeks, and 43.4% at six months after injury. This improved significantly at 18 months. PTSD symptoms were moderate in 25%-30% and severe in 5%-14% and did not change significantly over the study period. A significant relation was found between previous psychiatric history and psychological symptoms at 18 months after injury. No relation was identified between injury severity and psychological status after injury.

CONCLUSION

This study finds a high prevalence of psychological distress in male accident and emergency department patients after injury. Although some symptoms resolve over the follow up period, a proportion remain and may be related to previous psychiatric history. There was no relation identified between severity of injury and psychological morbidity.

Early psychological stress after forearm nerve injuries: a predictor for long-term functional outcome and return to productivity

Forearm and wrist injuries can result in a nonfunctional hand caused by loss of motor and sensory functions. Psychological stress is known to accompany traumatic hand injuries and may therefore affect functional outcome. The authors conducted a retrospective study of 107 patients diagnosed with a median, ulnar, or combined median-ulnar nerve injury (79% response rate) who completed a questionnaire package consisting of the Impact of Event Scale (IES); Disabilities of Arm, Shoulder, and Hand; and a questionnaire concerning return to work and time off work. In an outpatient setting, motor and sensory recovery were examined. Ninety-four percent of those studied experienced early psychological stress. Thirty-six percent of patients reported sufficient symptoms 1 month postoperatively to be classified as in need for psychological treatment (IES score > 30 points). Combined median-ulnar nerve injuries (mean, 35.0 +/- 20.3 points [standard deviation]) were accompanied by a higher psychological stress compared with single nerve injuries (median injuries: mean, 24.2 +/- 20.6 points; ulnar injuries: mean, 22.6 +/- 19.5 points; p = 0.049 and p = 0.021 respectively). Multiple linear regression adjusting for age, gender, and severity of the trauma revealed an association between the IES score and the functional symptom score (beta = 0.51; 95% confidence interval [CI], 0.35-0.65), mean time off work (beta = 0.44; 95% CI, 0.25-0.75), and motor recovery (grip: beta = 0.37; 95% CI, 0.09-0.65; tip-pinch: beta = 0.46; 95% CI, 0.13-0.80). Patients with higher scores on the IES were found to be at increased risk for incapacity for work (odds ratio, 3.32; 95% CI, 1.60-6.91). Higher education was found to be a protecting variable for posttraumatic psychopathology (beta = -0.23; 95% CI, -6.05--0.246). This study demonstrated a high level of early posttraumatic psychological stress after forearm and wrist nerve injuries. These data provide evidence that functional outcome and work resumption are influenced negatively by early psychological stress, independent from severity of the somatic trauma. This indicates that outcome after upper extremity nerve injuries may be influenced positively by psychological intervention.

Posttraumatic stress disorder following cancer. A conceptual and empirical review

Life-threatening illness has recently been recognized as a stressor that can precipitate posttraumatic stress disorder (PTSD). This development has raised questions over the extent to which the PTSD diagnosis is applicable to the psychological reaction to being diagnosed with cancer. This paper identifies the core conceptual issues pertaining to cancer-related PTSD, critically reviews the empirical literature on PTSD following cancer, and considers the possible mechanisms and course of PTSD following a diagnosis of cancer. Specific issues that need to be considered in the assessment and treatment of cancer-related PTSD are reviewed. This review highlights that there is a need for stronger empirical base to guide clinical management of PTSD in cancer patients.

Psychological impact of traumatic injuries: what the surgeon can do

In their treatment of accident and assault victims, plastic surgeons have unique opportunities to identify and refer patients with posttraumatic stress symptoms. This article describes brief assessments that surgeons or their clinic staff can use to evaluate traumatically injured adults and children for trauma-related psychological symptoms. An immediate postinjury evaluation (within 10 days of the trauma) consists of 11 questions to determine the presence of the following risk factors for posttrauma maladjustment: panic during or immediately after the trauma, reexperiencing symptoms, avoidance, sleep disturbance, injury from an assault, previous trauma and psychiatric history, and blaming someone else for the injury. The seven follow-up interview questions assess reexperiencing symptoms, avoidance, trauma-related phobias, depression, irritability, and increased substance use, all of which, if present, suggest psychological impairment. Questions recommended for the evaluation of younger children assess changes in play and recreational activity, sleep disturbance, night terror, aggression, irritability, avoidance, emergence of new fears, and loss of recently acquired developmental skills. The assessments require less than 2 minutes and are easily integrated into the hospital or clinic examinations of these patients.

Relationship between compensation claims for psychiatric injury and severity of physical injuries from motor vehicle accidents

OBJECTIVE

To examine the relationship between compensation claims for psychiatric injury after motor vehicle accidents and physical injuries sustained.

DESIGN

Audit of Compulsory Third Party (CTP) insurance claims.

SUBJECTS AND SETTING

559 consecutive CTP claims referred by NRMA Insurance Limited to its sole provider of CTP legal services during a three-month period in 1994 after the claimant had engaged legal representation.

MAIN OUTCOME MEASURES

Claim for psychiatric injury (any psychiatric disorder excluding traumatic brain injury) supported by a medicolegal report from a psychiatrist, other medical practitioner or psychologist; pre-existing psychiatric disorders; Injury Severity Score; initial treatment setting; hospital stay; percentage of accidents involving loss of consciousness or a death.

RESULTS

522 claims were eligible for the study; 19.5% (102/522) included a claim for psychiatric injury. A pre-existing depression or anxiety disorder was documented in 11 claims (2.1% of all claims and 3.9% of those claiming psychiatric injury). Only very severe injuries, particularly those involving loss of consciousness, were associated with an increased rate of claims for psychiatric injury.

CONCLUSIONS

No association was found between claims for psychiatric injury and severity of physical injuries, except among those most severely injured.