Vulnerability-stress factors in development of posttraumatic stress disorder

Long-term associations between early attachment and parenting and adolescent susceptibility to post-traumatic distress in a South African high-risk sample

BACKGROUND

It has been proposed that children and young people living in low- and middle-income countries (LMICs) are not only exposed more frequently to trauma but also have a higher likelihood of encountering traumas of greater severity than those living in high-income countries (HICs). This may lead to higher rates of post-traumatic stress symptoms (PTSS). However, developmental pathways to risk or resilience after trauma exposure in LMICs are underresearched.

METHODS

We examined early parenting and attachment as potentially important formative factors for later stress reactivity in a longitudinal cohort of South African children (N = 449). Parenting and attachment were assessed at child age 18 months, and interpersonal trauma exposure, PTSS and parenting stress were measured at 13 years (N = 333; core sample with data on all measures: N = 213). Following a vulnerability-stress approach, separate regression models were run to investigate whether parent-child attachment at 18 months, parental sensitivity and intrusiveness during play at 12 months, and current parenting stress at 13 years, interacted with adolescents' extent of interpersonal trauma exposure to predict their PTSS levels at 13 years.

RESULTS

We found no predictive effects of either early attachment or current parenting stress in relation to child PTSS. There was some evidence for predictive influences of parental early intrusiveness and sensitivity on adolescent outcomes, though associations were unexpectedly positive for the latter. No interaction effects supporting a vulnerability-stress model were found.

CONCLUSIONS

Overall, we found limited evidence that elements of the early parent-child environment predict child risk/resilience to trauma in LMIC children. Future studies should include more frequent assessments of relevant constructs to capture changes over time and consider further what comprises adaptive parenting in high-risk contexts.

Emotional responses in archival work

Building on previous work investigating the impact of exposure to (a) records with traumatic potentialities and (b) interactions with donors and community researchers whose suffering is documented in the archives, this study sought to better understand emotional aspects of archival work. Using a diary research methodology, 15 archivists engaged in diary keeping for approximately four months. What emerged was a broad set of events and experiences that triggered a wide range of emotional responses arising from archival work. This included: pre-existing emotional states and characterological traits; emotional exchanges in the workplace with colleagues and others; emotional demands of the work (including emotion work and emotional labour); team and leader interactions arising from group tasks and leader behaviour; and organizational policies, climate, resources and demands. This broader set of interactional factors forms the foundation on which traumatic and other troubling events are encountered. Future research must consider the nature of archival organizations and interactions within them that contribute to the overall working experience. In addition, archival organizations need to take responsibility for creating a culture that demonstrates respect and appreciation for workers, acknowledges the interpersonal challenges of the work, and provides supports for archivists who are shouldering the challenges.

“Humans and records are entangled”: empathic engagement and emotional response in archivists

There is growing awareness in archival communities that working with records that contain evidence of human pain and suffering can result in unsettling emotions for archivists. One important finding of this work, however, is the considerable variability in not only the nature of responses, but also the nature of records that provoke emotional responses. Using in-depth qualitative interviews with 20 archivists from across Canada and one from the United States, and employing grounded theory methodology, this study sought to better understand the nature of emotional responses and factors associated with distress. Archivists described a wide range of reactions including shock, intrusive thoughts, profound senses of anger, sadness and despair, and ultimately at times disrupted functioning in personal and occupational spheres. One factor that has been associated with increasing vulnerability to distress in other occupational groups is empathic engagement, which is understood to have two elements: a vicarious emotional process and a cognitive process. This article explores the impact of personal connections and the nature of empathic engagement between archivists, donors, community researchers, and the records themselves on emotional response.

Positive interventions for stress-related difficulties: A systematic review of randomized and non-randomized trials

The effectiveness of positive psychology interventions in the treatment of stress-related difficulties have not been well established. To estimate the effectiveness of positive psychology interventions on the reduction of stress-related symptoms, a systematic review using PubMed, Scopus, Wiley, Psychinfo, Cochrane and Sage databases with no limitation of date of publication was conducted. We identified additional studies by searching positive psychology reviews and academic books. Only studies trying positive interventions that included measures of anxiety, stress, or posttraumatic stress disorder symptoms were reviewed. We extracted data using predefined data fields and study quality was assessed with the National Institutes of Health study quality assessment tools. Twenty-nine records were included in this study: 23 controlled trials and six pre-post studies. Every study showed significant improvement in at least one dimension. Several studies reported improvements in well-being as well. This review shows promising results of positive psychology interventions as a treatment for stress-related difficulties. However, important methodological biases and strong heterogeneity among the studies highlight the need for replication and better validation of positive psychology interventions.

Impact of prior trauma exposure on the development of PTSD symptoms after suspected acute coronary syndrome

OBJECTIVE

To determine the association between PTSD symptoms due to prior trauma and prior trauma type with PTSD symptoms after suspected acute coronary syndrome (ACS).

METHOD

A consecutive sample of patients presenting to the emergency department (ED) for suspected ACS were surveyed. Logistic regression was used to estimate the odds of elevated ACS-related PTSD symptoms [PCL-S ≥ 33] at 1-month associated with PTSD symptoms due to prior trauma and prior trauma type at the time of suspected ACS, adjusting for demographics, comorbidities, depression, and etiology of ACS symptoms.

RESULTS

Of 984 patients, 81.6% reported ≥1 prior trauma type and 22.5% reported PTSD symptoms due to prior trauma at the time of suspected ACS. One month later, 18.0% had ACS-related PTSD symptoms. Patients with versus without PTSD symptoms due to prior trauma at the time of the suspected ACS had increased odds of ACS-related PTSD symptoms one month later (42.1% vs 9.9%; aOR 4.49, 95% CI:3.05-6.60; p < .001). Prior life-threatening illness was the only trauma type significantly associated with ACS-related PTSD symptoms (aOR 1.57, 95% CI:1.03-2.39; p = .04).

CONCLUSIONS

PTSD symptoms from prior trauma and history of life-threatening medical illness at the time of suspected ACS increased risk of ACS-related PTSD symptoms one month later.

Neural Markers of Vulnerability to Anxiety Outcomes after Traumatic Brain Injury

Anxiety outcomes after traumatic brain injury (TBI) are complex, and the underlying neural mechanisms are poorly understood. Here, we developed a multi-dimensional behavioral profiling approach to investigate anxiety-like outcomes in mice that takes into account individual variability. Departing from the tradition of comparing outcomes in TBI versus sham groups, we identified a subgroup within the TBI group that is vulnerable to anxiety dysfunction, and present increased exploration of the anxiogenic zone compared to sham controls or resilient injured animals, by applying dimensionality reduction, clustering, and post hoc validation to behavioral data obtained from multiple assays for anxiety at several post-injury time points. These vulnerable animals expressed distinct molecular profiles in the corticolimbic network, with downregulation in gamma-aminobutyric acid and glutamate and upregulation in neuropeptide Y markers. Indeed, among vulnerable animals, not resilient or sham controls, severity of anxiety-related outcomes correlated strongly with expression of molecular markers. Our results establish a foundational approach, with predictive power, for reliably identifying maladaptive anxiety outcomes after TBI and uncovering neural signatures of vulnerability to anxiety.

A test of the diathesis-stress model in the emergency department: who develops PTSD after an acute coronary syndrome?

Most acute coronary syndrome (ACS) patients first present to the emergency department (ED). Patients who present to overcrowded EDs develop more posttraumatic stress disorder (PTSD) symptoms due to the ACS than do patients who present to less crowded EDs, but no research has indicated whether some patients may be more vulnerable to the effects of ED crowding than others. In an observational cohort study, we tested whether depressed patients developed more ACS-induced PTSD symptoms under conditions of ED overcrowding than patients who had never been depressed. We conducted psychiatric interviews for current and past depression in 189 ACS patients admitted through the ED within a week of hospitalization, and screened for PTSD symptoms 1 month later using the Impact of Events Scale-Revised. The sum of ED admissions for the 12 h prior to and 12 h after each participant's admission was categorized into tertiles for analysis. In a 3 (ED crowding tertile) by 3 (never, past, current depression) analysis of covariance adjusted for demographic and clinical factors, we found significant effects for ED crowding, depression status, and their interaction (all p's < .05). Mean PTSD scores were significantly higher (p = .005) for participants who were currently depressed and were treated during times of high ED crowding [25.38, 95% CI = 16.18-34.58], or had a history of depression [10.74, 95% CI = 6.86-14.62], relative to all other participants, who scored 5.6 or less. These results suggest that depressed ACS patients may be most vulnerable to the stress-inducing effects of ED crowding.

Mental health problems and post-migration stress among multi-traumatized refugees attending outpatient clinics upon resettlement to Norway

Refugees have often been exposed to multiple traumas making them prone to mental health problems later. The aim of this study is to describe the prevalence and symptom load of psychiatric disorders in refugees admitted to psychiatric outpatient clinics and to investigate the relationship between multiple exposure to traumatic events, the severity of traumatic symptoms and post-migration stressors. A clinical sample of 61 refugee outpatients from psychiatric clinics in Southern Norway was cross-sectionally examined using three structured clinical interviews (SCID-PTSD, SIDES and MINI) and self-report psychometric instruments (HSCL-25, IES-R). Post-traumatic Stress Disorder (PTSD) was diagnosed in 82% of the patients, while Disorders of Extreme Stress Not Otherwise Specified (DESNOS) was present in 16% of them. Comorbidity was considerable; 64% of the patients had both PTSD and major depression disorder (MDD) and 80% of those who had PTSD had three or more additional diagnoses. Multi-traumatized refugees in outpatient clinics have high prevalence of PTSD, DESNOS, comorbid depression and anxiety disorders. A more severe symptomatology was found in patients diagnosed with both PTSD and DESNOS, than in those diagnosed with only PTSD. Higher rates of unemployment, weak social network and weak social integration were also prevalent in these outpatients, and related to increased psychiatric comorbidity and severity of symptoms. Further research may clarify the existence of a cumulative relationship between pre-resettlement traumas and post-resettlement stressors in the mental health of refugees, which in turn may help to improve therapeutic interventions.

Trauma and victims: epidemiology of post-traumatic stress disorder

Scopo- Presentare una esaustivareviewdegli studi riguardanti l'epidemiologia del DPTS condotti nella popolazione generale, tra i soggetti a rischio, e, infine, tra gruppi clinicamente selezionati.Disegno- AttraversoExcepta Medica PsychiatryCD-ROM 1980-1993 (ottobre), utilizzando come parola chiave «Post-Traumatic Stress Disorder», sono stati identificati 1.057 articoli pubblicati nel periodo considerate Sono stati anche consultati altridata basedella letteratura medica (MEDLINE CD-ROM 1988-1993); è stata quindi operata una ricerca manuale su tutti i numeri delJournal of Traumatic Stress. Risultati- In totale, 135 lavori che hanno soddisfatto i criteri di inclusione prescelti sono stati inclusi nella review. I due terzi (n = 86, 64%) di queste ricerche sono state condotte negli USA. Solo 8 (6%) sono le indagini effettivamente realizzate nei paesi del Terzo Mondo. L'ampiezza del campione varia da un minimo di 11 soggetti, numero riscontrato in due studi, sino ad un massimo di 22.436, per un campione medio di 500 e mediano di 108. Per quanto attiene ai metodi di valutazione, in un terzo degli studi (n = 45, 33%), i ricercatori hanno impiegato un questionario (auto- o etero- somministrato). In un altro terzo delle ricerche elencate (n = 44, 33%) e stata somministrata un'intervista strutturata (la DIS, la SCID, o la SADS), mentre nei rimanenti studi la valutazione diagnostica si è basata o su una procedura clinica non strutturata, o sulla somministrazione di altri strumenti specifici dai quali è possibile inferire una diagnosi di DPTS (M-PTSD, IES, SCL-90-R,o pochi altri). In 77 studi (57%) i ricercatori hanno basato la loro valutazione sui criteri diagnostici propri del DSM-III, mentre in altri 55 (41%) su quelli del DSM-III-R. La prevalenza del DPTS e analizzata quindi separatamente per le diverse popolazioni studiate.Conclusioni- Nell'arco di soli 13 anni, a partire cioe dalla definizione di criteri diagnostici operazionali ben definiti per il DPTS, sono stati condotti numerosi studi volti ad indagare la prevalenza, i fattori di rischio, la storia naturale, il decorso e l' esito di questo disturbo tra campioni diversi di popolazioni a rischio; inoltre, anche il livello qualitativo di queste ricerche, per quanto attiene alia sofisticazione metodologica, si è accresciuto sensibilmente in un tempo tutto sommato breve. Molte aree, pero', restano tuttora inesplorate, ed inoltre appare imperativo avviare ricerche estensive tra le popolazioni dei paesi in via di sviluppo, maggiormente esposte a disastri naturali o provocati dall'uomo.

Alexithymia and posttraumatic stress: subscales and symptom clusters

This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difficulty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed.

Post-traumatic stress disorder: present and future

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event - an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity. It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed. Indeed, a 'threat' as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

The long-term psychological sequelae of orofacial injury

Significant subsets of patients who experience orofacial injury are at risk for developing adverse psychological sequelae such as posttraumatic stress disorder and depression. If undetected and untreated, the psychopathology can become recalcitrant and burden the social and vocational functioning of the patients and greatly diminish their quality of life. The hospital encounter and follow-up care visits provide the oral and maxillofacial surgeon with opportunities to screen for emerging psychological problems. Several screening instruments are available to assist the surgeon in identifying individuals who are at risk for subsequent mental health problems. Facilitated referrals to mental health services can be a practical approach for improving comprehensive medical care for vulnerable individuals and for reducing the potential morbidity of these covert, but disabling, sequelae.

After facing traumatic stress: brain activation, cognition and stress coping in policemen

INTRODUCTION

Resilience can be defined as the capacity to recover following stress or trauma exposure by adopting healthy strategies for dealing with trauma and stress. Although the importance of stress resilience has been recognized, the underlying neurocognitive mediators have not yet been identified. Thus, the primary goal of this study was to investigate memory-related brain activity in traumatized policemen who attended a pre-traumatic general stress coping program.

METHOD

Ten traumatized male police officers were compared to demographically matched non-traumatized officers (n=15) on associative memory by using a block design paradigm. Participants with either another psychiatric comorbidity or neurological disorder were excluded. During functional brain imaging (1.5-Tesla), face-profession pairs had to be encoded twice. For subsequent retrieval the faces were presented as cue stimuli for associating the category of the prior learned profession. Additionally, clinical pattern, stress coping style, and cognitive parameters were assessed.

RESULTS

Less BOLD activation was found in the hippocampus, parahippocampal gyrus and fusiform gyrus in the trauma group when compared with the non-trauma group during encoding. This was accompanied by slower reaction times in the trauma group during retrieval. Further impairments were found in context memory and in the use of positive cognitive coping strategies.

DISCUSSION

Support was provided for the presence of memory-related disturbances in brain activity associated with trauma even in a resilient population. The contribution of the changes in stress coping ability needs to be further examined in longitudinal studies.

Access to mental health for asylum seekers in the European Union. An analysis of disparities between legal rights and reality

The article explores some of the issues surrounding access to mental health care for asylum seekers, using Belgium as a case in point. Asylum and immigration issues have become increasingly pressing in Europe, with member states seeking a common European Asylum System and establishing minimum standards for the reception of asylum seekers. The EU measures have fallen short of providing and implementing clear guidelines. Significant discrepancies continue to exist between member states, notably policies on health care for refugees, and in particular mental healthcare. Access to mental health care is identified as crucial, yet for many the right to access is theoretical only, and in reality care is often inaccessible. Access should refer not only to the availability, but also the quality and efficacy of care. Refugees are a particularly vulnerable population, and access in the fullest sense of the term should be an essential element in the reception of asylum seekers.

Trauma history characteristics and subsequent PTSD symptoms in motor vehicle accident victims

The present study examined the relationship between trauma history characteristics (number and type of traumas, age at first trauma, and subjective responses to prior traumas) and the development of posttraumatic stress disorder (PTSD) symptoms following a motor vehicle accident (MVA). One hundred eighty-eight adult MVA victims provided information about prior traumatization and were evaluated for PTSD symptoms 6 weeks and one year following the MVA. Results indicated that after controlling for demographics and depression, prior trauma history characteristics accounted for a small, but significant amount of the variance in PTSD symptoms. Distress from prior trauma and number of types of prior traumas were the most meaningful trauma history predictors. Results encourage further evaluation of trauma history as a multifaceted construct.

[Peritraumatic distress prospectively predicts PTDS symptoms in assault victims]

INTRODUCTION AND OBJECTIVES

Among the peritraumatic reactions after a traumatic event, one best identifies dissociation as a predictor of serious post-traumatic problems. The dimension of emotional distress is recent in the literature and we have attempted to identify how it may contribute to the prediction of the evolution of post-traumatic symptoms.

METHOD

1. Population. Victims of individual aggression and those of a hold-up were recruited consecutively in the Paris area from five consulting centers. Individuals who had lost consciousness, had psychotic or dementia problems, or had a serious somatic patho-logy were excluded. Overall, we included 101 individuals with a traumatic experience (DSM IV criteria) that took place in the past 12 months. Two evaluations with a six-month interval were made. The first involved a face-to-face consultation with a clinician and the second required the individuals to complete self-reports. 2. Instruments. The Peritraumatic Distress Inventory (PDI) was administered to measure peritraumatic emotional distress, in the first phase. The Peritraumatic Dissociative Experience Questionnaire (PDEQ) was used to measure the intensity of the trauma and the dissociation, in this first phase. The Impact of Event Scale Revised (IES-R) was administered to assess the severity of the PTSD symptoms, in the first phase and at six months. The Mini International Neuropsychiatry Interview (MINI) was used in diagnosing depression and PTSD.

RESULTS

Among the 63 subjects who were followed-up after the initial meeting and completed the second half of the study, 29 were victims of physical assault, 20 of a hold-up, 7 of a robbery, and 5 were confronted with another menacing situation; thus 40 were victims of aggression. According to the first consultation, 46 individuals presented symptoms of PTSD and 22 presented an episode of major depression. Between those who were followed-up for the whole study and those who dropped out after the initial consultation there were no significant differences with regards to gender, type of aggression, initial PDI scores (t=0.38, df=96, p=.7), PDEQ scores (t=0.7, df=96, p=0.94), or IES-R scores (t=0.23, df=97, p=0.082). Individuals who were victims of physical or sexual assault showed higher scores on the IES-R than individuals who claimed no such assault. The scores for peritraumatic dissociation were correlated with the initial IES-R scores with a correlation coefficient of 0.50. The scores from the PDEQ and the initial PDI were correlated with the IES-R scores at six months with a coefficient of 0.63. Using a multi-hierarchical linear regression controlling for type of experience, it appeared that the score of peritraumatic distress improved the variance by 14% in predicting the IES-R score at six months, compared to the prediction of the score of the initial IES-R.

DISCUSSION

This is the first study using a prospective inquiry to demonstrate the power of the peritraumatic emotional distress score. Our results suggest that the type of trauma is a strong predictor of prognosis at six months. Despite our small sample size, the absence of significant differences between the drop-out group and our subjects reduces the probability of a bias in our selection criteria to explain our results. This study points to the fact that the measurement of peritraumatic emotional distress (PDI) is a good predictor of PTSD symptoms six months down the road. This study underlines the importance of an initial psychotraumatic consultation to identify the type of trauma and to measure the intensity of the peritraumatic symptoms in order to predict the severity of the evolution.

Major depression in Chinese Americans: the roles of stress, vulnerability, and acculturation

BACKGROUND

This study examined the relationship between recent negative life events, level of acculturation and other psychosocial risk factors in predicting major depression in Chinese Americans.

METHOD

Data were collected on 1,747 Chinese immigrants and native-born residents of the United States (ages 18-65) who resided in Los Angeles County between 1993 and 1994.

RESULTS

Findings indicated that a positive psychiatric history increased risk for major depression at Time 2, while social conflicts and traumatic life events moderated the effects of negative life events in increasing risk for major depression. In addition, level of acculturation moderated the effects of recent negative events in increasing risk, but only for those who were more highly acculturated.

CONCLUSIONS

The importance of testing the cross-cultural applicability of the stress-vulnerability hypothesis among ethnic minorities and extending them to include immigrant vulnerabilities is discussed.

Two subjective factors as moderators between critical incidents and the occurrence of post traumatic stress disorders: adult attachment and perception of social support

This paper presents the result of a research which investigated the influence of the subjective factors 'adult attachment style' and 'perception of social support' in the occurrence of post traumatic stress disorders (PTSD) in a population of 544 subjects working for a security company and the Belgian Red Cross. The analysis of the results suggests that 'adult attachment style' and 'perception of social support' moderate between a critical incident and the occurrence of a PTSD. In other words, these independent variables differentiate between individuals who are more, and who are less prone, to suffer from a PTSD after having experienced a critical incident. The results of this research shed light on subjective risk factors related to PTSD. The findings can also suggest guidelines for the treatment of individuals suffering from a PTSD.

Tobacco usage interacts with postdisaster psychopathology on circadian salivary cortisol

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) have been associated with increased rates of tobacco usage as well as with dysregulations of the hypothalamus-pituitary-adrenal (HPA) axis. At the same time tobacco also affects the HPA axis. This paper examines the relationships between PTSD, posttraumatic MDD, smoking and levels of circadian cortisol 2-3 years postdisaster. Subjects were survivors of the Enschede fireworks disaster. The sample consisted of 38 healthy survivors, 40 subjects with PTSD, and 17 subjects with posttraumatic MDD. The Composite International Diagnostic Interview was used to determine mental disorders in accordance with DSM-IV criteria. Salivary cortisol samples were collected at home immediately upon awakening, 30 min after awakening, at noon, and at 10 p.m. Quantity of smoking was measured through self-report. The results of the study show that salivary cortisol concentrations were higher in smoking subjects. Survivors with MDD following the disaster had a flatter diurnal cortisol curve than subjects with PTSD or healthy survivors. In survivors with PTSD and healthy individuals the usual dynamic pattern of increase in cortisol past awakening was present, while we did not observe this in posttraumatic MDD. These survivors with MDD tended to use more tobacco per day, and the cortisol group differences could only be revealed when we adjusted for quantity of smoking. Smoking, which may be an important palliative coping style in dealing with posttraumatic arousal symptoms, seems to mediate the relationship between traumatic stress and the HPA-axis.

Traumatic Exposure Severity Scale (TESS): a measure of exposure to major disasters

The debate about the role of the intensity of the stressor has occupied a central focus in posttraumatic stress disorder literature. There is currently a paucity of instruments with established psychometric properties measuring severity of trauma exposure in disaster survivors. The Traumatic Exposure Severity Scale was developed specifically to assess dimensions of exposure to an earthquake disaster in adults. Its 24 items assess a wide range of stressors organized into five subscales, derived from factor analyses: Resource Loss, Damage to Home and Goods, Personal Harm, Concern for Significant Others, and Exposure to the Grotesque. The scale provides both Occurrence and Distress scores. It has good internal reliability and validity. The instrument correlates significantly, but moderately, with a number of traumatic stress measures and the Beck Depression Index.

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.

Acute stress disorder as a predictor of post-traumatic stress disorder in physical assault victims

The authors' objective was to examine the ability of acute stress disorder (ASD) and other trauma-related factors in a group of physical assault victims in predicting post-traumatic stress disorder (PTSD) 6 months later. Subjects included 214 victims of violence who completed a questionnaire 1 to 2 weeks after the assault, with 128 participating in the follow-up. Measures included the Harvard Trauma Questionnaire, the Trauma Symptom Checklist, and the Crisis Support Scale. Twenty-two percent met the full PTSD diagnosis and 22% a subclinical PTSD diagnosis. Previous lifetime shock due to a traumatic event happening to someone close, threats during the assault, and dissociation explained 56% of PTSD variance. Inability to express feelings, hypervigilance, impairment, and hopelessness explained another 15% of PTSD variance. The dissociative, the reexperiencing, the avoidant, and the arousal criteria of the ASD diagnosis correctly classified 79% of the subsequent PTSD cases.

A Diathesis-Stress Model of Posttraumatic Stress Disorder: Ecological, Biological, and Residual Stress Pathways

The symptoms captured within the contemporary diagnostic definition of posttraumatic stress disorder (PTSD) have been studied for more than 100 years. Yet, even with increasingly advanced discoveries regarding the etiology of PTSD, a comprehensive and up-to-date etiological model that incorporates both medical and psychological research has not been described and systematically studied. The diathesis-stress model proposed here consolidates existing medical and psychological research data on etiological factors associated with PTSD into 3 causal pathways: residual stress, ecological, and biological. In combination, these pathways illuminate how PTSD might develop and who might be at higher risk for developing the disorder. Research and treatment implications related to the diathesis-stress model are discussed.

Acute Stress Disorder in physical assault victims visiting a Danish emergency ward

The purpose of this article is to assess the prevalence of Acute Stress Disorder (ASD) following violent assault in victims who come to the emergency ward, and compare the effects with degrees of injury. Two hundred and fourteen victims of violence completed a questionnaire 1 to 2 weeks after the assault. Measures included the Harvard Trauma Questionnaire, the Trauma Symptom Checklist and the Crisis Support Scale.

RESULTS

Twenty-four percent met the full ASD diagnosis and 21% a subclinical ASD diagnosis. Childhood sexual and physical abuse and shock due to a traumatic event that happened to someone close increased the likelihood of ASD four to ten times. Feeling of security and ability to express feelings reduced the likelihood of ASD by one-quarter, while feeling let down by others and hopelessness increased the likelihood of ASD respectively 1.4 and 2.6 times.

Injury severity, prior trauma history, urinary cortisol levels, and acute PTSD in motor vehicle accident victims

This study examined the relationship between prior history of traumatic events, life threat, and injury severity experienced during a motor vehicle accident (MVA), and posttraumatic stress disorder (PTSD) assessed 1 month after the accident. In addition, initial urinary cortisol levels after the accident were examined as a possible mediator of this relationship. Fifteen-hour urinary cortisol samples were collected from MVA victims upon admission to the trauma unit. In the hospital, subjective life threat was measured and objective Injury Severity Scores (ISSs) were computed. One month after the accident, participants were assessed for prior history of traumatic experiences, presence of acute PTSD, and levels of intrusive and avoidant thoughts and behaviors. Victims, who met PTSD diagnostic criteria, reported more prior traumatic events, and significantly greater life threat despite receiving significantly lower ISSs than victims who did not develop PTSD. The relationships between ISSs and PTSD symptoms and prior trauma history and PTSD symptoms were mediated by cortisol levels. Results suggest that cortisol levels in the acute aftermath of a traumatic event may serve as a mechanism through which various factors may increase risk for PTSD.

An investigation of the psychological effects of the September 11, 2001, attacks on New York City: developing and implementing research in the acute postdisaster period

The September 11, 2001, attack on New York City was the largest human-made disaster in United States history. In the first few days after the attack, it became clear that the scope of the attacks (including loss of life, property damage, and financial strain) was unprecedented and that the attacks could result in substantial psychological sequelae in the city population. Researchers at the Center for Urban Epidemiologic Studies at the New York Academy of Medicine designed and implemented an assessment of the mental health of New Yorkers 5-8 weeks after the attacks. To implement this research in the immediate postdisaster period, researchers at the center had to develop, in a compressed time interval, new academic collaborations, links with potential funders, and unique safeguards for study respondents who may have been suffering from acute psychological distress. Results of the assessment contributed to a New York state mental health needs assessment that secured Federal Emergency Management Agency funding for mental health programs in New York City. This experience suggests that mechanisms should be in place for rapid implementation of mental health assessments after disasters.

Research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature

Tragic events such as those of September 11, 2001, underscore the increasingly prominent role that psychiatrists play in aiding survivors, emergency workers, and broader communities to cope with disaster. The present review was undertaken to identify whether there exists a scientific basis for the practice of psychiatry in the aftermath of disasters. Most of the extensive literature over the past 30 years suggests that disasters have psychopathological consequences as well as medical and social ones. Pre-existing mood and anxiety disorders, although surprisingly not psychotic illness, appear to be risk factors for further psychopathology after a disaster. Thus, both acute psychopharmacological and psychotherapeutic interventions at disaster sites may prevent long-term sequelae, although their efficacy remains uncertain. Future controlled treatment trials are needed to determine the optimal treatment strategy.

Acute stress reactions in adults

This article summarizes the literature on acute reactions to traumatic stress in adults. It describes their morphology, natural course, long-term outcome, and underlying biological factors, and outlines directions for management and research. It assumes two categories of responses: those that mediate survival and those related to learning and adaptation. The complementary roles of fear conditioning, processing novelty, and adjusting to change are discussed.

Predicting post-traumatic symptoms in cardiac patients

OBJECTIVE

The purpose of this study was to identify correlates and predictors of the symptoms of post-traumatic stress disorder (PTSD) in a cohort of patients with myocardial infarction, while the patients were in hospital and 3 months after infarction.

DESIGN

Longitudinal, consecutive referrals were used.

PATIENTS

From a possible 68 consecutive patients with a first myocardial infarction who completed questionnaires in hospital and survived to 3-month follow-up, 39 completed follow-up questionnaires.

OUTCOME MEASURES

PTSD measures were taken in hospital and 3 months after discharge. Predictor variables were measures of mood taken in hospital and measures of the immediate cognitive and emotional reactions at the time of the infarct.

RESULTS

Associations between the independent variables and PTSD symptoms were stronger at 3-month follow-up than while in hospital. At this time, the frequency of intrusive thoughts was predicted by the degree of fright at the time of the event (adjusted R(2) = 0.262; beta =.57; t = 3.30; P <.01) and positive affect scores (additional adjusted R(2) = 0.112; beta = -.37 t = -2.18; P <.05). The degree of physiologic arousal at the time of such flashbacks was predicted by levels of negative affect in hospital (adjusted R(2) = 0.174; beta =.46; t = 2.46; P <.05), which also predicted avoidance scores (adjusted R(2) = 0.203; beta =.48; t = 2.62; P <.05).

CONCLUSIONS

Because many of the symptoms of PTSD are self-remitting, and intervening too early in the course of the disorder may exacerbate the disorder, it is important not to intervene too early or over-treat this disorder. Formal treatment may be useful if provided some months after discharge from hospital. If either secondary or primary care services are to treat myocardial infarction-related PTSD effectively, it is important to identify patients who are at risk for it. These data contribute to the development of a profile of patients at risk.

Trauma and Posttraumatic Stress Disorder in Primary Care Patients

BACKGROUND: This article examines the nature of psychological trauma and posttraumatic stress disorder (PTSD) in 504 patients recruited from primary care settings. METHOD: Patients were screened for anxiety in waiting rooms at 14 general medical settings, and those with a sufficient number and severity of anxiety symptoms were administered a standardized diagnostic clinical interview. Those who met DSM-IV criteria for an anxiety disorder and who were willing to participate were included in this study. Of the 504 patients, 185 met DSM-IV criteria for PTSD. RESULTS: Results indicated that 418 (83%) of primary care patients in our sample reported at least 1 traumatic event in their lifetime. The most prevalent traumas experienced by the entire sample of participants were witnessing others being seriously injured or killed, serious accidents, and rape. Of those participants with PTSD, rape was the strongest predictor of a PTSD diagnosis. Analyses examining gender differences indicated that, for women, a history of other unwanted sexual contact or witnessing a sexual assault, being attacked with a weapon or with intent to kill, or witnessing someone being injured were found to be risk factors for a PTSD diagnosis. Examination of clinical characteristics indicated a high rate of comorbidity of psychiatric disorders among patients with PTSD, including high rates of alcohol/substance abuse, depression, and suicide attempts. CONCLUSION: These findings emphasize the continued need to assess patients presenting at general medical facilities about trauma history.

Individual predictors of posttraumatic distress: a structural equation model

OBJECTIVE

Recent research has called into question the "dose-effect" model of understanding response to trauma and has turned attention to the contribution of personality and environmental factors. This research seeks to model the interrelation of relational capacity (a component of personality), perceptions of social support, and posttraumatic distress.

METHOD

A group of firefighters (n = 164) completed questionnaires that addressed exposure to traumatic events, social support, current level of distress, and relational capacity. Structural equation modelling was used to develop a framework for understanding traumatic reactions.

RESULTS

The overall fit of the hypothesized model was excellent. Relational capacity had a significant negative effect on support, indicating that perceived social support decreased as disturbances in relational capacity increased. Perceived social support had a significant negative effect on level of distress.

CONCLUSION

While some emotional response to disturbing events may be normal, the severity of symptoms covaries with the ability of the individual to develop and sustain supportive relationships to buffer the impact of events.

Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults

Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined. Three categories of risk factor emerged: Factors such as gender, age at trauma, and race that predicted PTSD in some populations but not in others; factors such as education, previous trauma, and general childhood adversity that predicted PTSD more consistently but to a varying extent according to the populations studied and the methods used; and factors such as psychiatric history, reported childhood abuse, and family psychiatric history that had more uniform predictive effects. Individually, the effect size of all the risk factors was modest, but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.

Review and critique of the new DSM-IV diagnosis of acute stress disorder

OBJECTIVE

A new diagnosis can greatly influence scientific research, access to resources, and treatment selection in clinical practice. The authors review the historical evolution, rationale, empirical foundation, and clinical utility to date of the recently introduced diagnosis of acute stress disorder.

METHOD

The conceptual basis and relevant methods for identifying a psychiatric syndrome are reviewed with respect to acute stress disorder, including selection of criteria for core symptoms; considerations of sensitivity and specificity of a syndrome definition; longitudinal course; and distinctions between normative and pathological phenomena. Particular attention is devoted to two major issues: the implications of the core feature requirement of three of five dissociative symptoms, and the question of whether there should be two separate diagnoses (acute stress disorder and post-traumatic stress disorder [PTSD]) describing posttraumatic syndromes. The widely divergent approaches in DSM-IV and ICD-10 are also reviewed.

RESULTS

The diagnosis of acute stress disorder does not appear to achieve the important objective of providing adequate clinical coverage for individuals with acute posttraumatic symptoms. The validity and utility of requiring peritraumatic dissociative symptoms as a core feature are questionable, as is the separation of essentially continuous clinical phenomena into two disorders with different criteria sets (acute stress disorder and PTSD) based on persistence of symptoms for 30 or more days.

CONCLUSIONS

Longitudinal studies using acute stress disorder criteria, as well as broader considerations of the clinical and scientific functions that posttraumatic diagnoses should serve, suggest a need to reevaluate the current DSM-IV approach to posttraumatic syndromes.

When the earth stops shaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology

OBJECTIVE

To examine risk and protective processes for posttraumatic stress reactions and negative sequelae following the Northridge earthquake (EQ) among youths diagnosed for pre-EQ psychopathology.

METHOD

Symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety, and social impairment were evaluated using telephone interviews among 66 children participating in a family-genetic study of childhood-onset depression at the time of the EQ.

RESULTS

Significant predictors of PTSD symptoms 1 year after the EQ included perceived stress and resource loss associated with the EQ, a pre-EQ anxiety disorder, and more frequent use of cognitive and avoidance coping strategies. PTSD symptoms were associated with high rates of concurrent general anxiety symptoms, depressive symptoms, and social adjustment problems with friends. The only significant correlation between sibling scores was on measures of sibling reports of objective exposure.

CONCLUSIONS

Preexisting anxiety disorders represent a risk factor for postdisaster PTSD reactions. Postdisaster services need to attend to the needs of these youths as well as those of youths experiencing high levels of subjective stress, resource loss, and/or high exposure. That children within families show significant variation in postdisaster reactions underscores the need for attention to individual child characteristics and unshared environmental attributes.

The effects of exposure to community violence on Khmer refugee adolescents

The aim of the study was to examine the relationship between exposure to violence and mental health outcomes among Khmer refugee adolescents. Seventy-six Khmer junior and senior high school students and their parents participated in a cross-sectional survey study. Half of the adolescents survived violence directed at them, and two thirds witnessed violence. Although approximately one quarter either partially or fully met the criteria for posttraumatic stress disorder (PTSD), most were functioning adequately. Ordinary least squares regression analyses indicated that the number of violent events they were exposed to in their lifetime significantly predicted their level of functioning and PTSD. Recommendations for future research and implications for clinicians and educators working with Khmer and other refugee adolescents are discussed.

Biological factors associated with susceptibility to posttraumatic stress disorder

Because only a proportion of persons exposed to traumatic events develop posttraumatic stress disorder (PTSD), it has become important to elucidate the factors that increase the risk for the development of PTSD following trauma exposure as well as the factors that might serve to protect individuals from developing this condition. Putative risk factors for PTSD may describe the index traumatic event or characteristics of persons who experience those events. Recent data have implicated biological and familial risk factors for PTSD. For example, our recent studies have demonstrated an increased prevalence of PTSD in the adult children of Holocaust survivors, even though these children, as a group, do not report a greater exposure to life-threatening (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] Criterion A) events. These studies are reviewed. It is difficult to know to what extent the increased vulnerability to PTSD in family members of trauma survivors is related to biological or genetic phenomena, as opposed to experiential ones, because of the large degree of shared environment in families. In particular, at-risk family members, such as children, may be more vulnerable to PTSD as a result of witnessing the extreme suffering of a parent with chronic PTSD rather than because of inherited genes. But even if the diathesis for PTSD were somehow "biologically transmitted" to children of trauma survivors, the diathesis is still a consequence of the traumatic stress in the parent. Thus, even the most biological of explanations for vulnerability must at some point deal with the fact that a traumatic event has occurred.

Gender differences in clinical correlates of suicidality among young adults

Gender differences were examined in risk factors for suicidality among young adult friends of suicide victims. Data were derived from a follow-up community survey of 76 members of the social network of 23 consecutive adolescent suicide victims 6 years after the friend's death. The Beck-Kovacs Scale for Suicidal Ideation was the outcome measure. Multiple regression analyses revealed aggression to have the only significant effect on suicidality among men, whereas depression and posttraumatic stress disorder had significant independent effects on suicidality among women. Results suggest that young adult men who are aggressive and female subjects with elevated symptoms of depression and/or posttraumatic stress disorder may be at increased risk of suicidality.

Crime-related trauma: psychological distress in victims of bankrobbery

This study examines the relationship between the experience of a traumatic event, that is, a bankrobbery, and its psychological consequences. Two groups of employees of a major commercial bank in the Netherlands participated in this study. One group (n = 310) consisted of subjects who had experienced a bankrobbery and worked in high-frequency bankrobbery areas; the other matched control group (n = 214) consisted of nonrobbed employees from banks in the same area. Victimized subjects displayed more signs of psychological distress than the control subjects, but distress decreased over time. The main findings of this study are that a depressive/avoidant coping style, strong threat perception during the robbery, and additional life events were positively related to posttraumatic distress as assessed by the Impact of Event Scale and the Symptom Check List (SCL-90), and self-esteem was negatively associated with the SCL-90 only.

An open trial of paroxetine in patients with noncombat-related, chronic posttraumatic stress disorder

The symptom overlap between posttraumatic stress disorder (PTSD) and other pharmacotherapy-responsive disorders suggests that pharmacotherapy might be effective. Nevertheless, of the eight published placebo-controlled trials investigating the pharmacotherapy of PTSD, only four found statistically significant efficacy for the treatment being studied. This literature possesses a number of methodologic limitations, including the fact that most studies have been conducted with war veterans, who may constitute a more treatment-refractory population. Several open trials and one controlled trial with selective serotonin reuptake inhibitors have reported improvement in some or all core PTSD symptoms (reexperiencing, avoidance, numbing, and hyperarousal). The authors hypothesized that paroxetine might be effective in PTSD, based on findings of its particular efficacy for anxiety and agitation in studies of depressed patients. The study presented here summarizes a 12-week, open-label trial of paroxetine among patients with noncombat-related, chronic PTSD. Outcome was assessed by an independent evaluator, the treating physician, and the patient, with the use of established rating scales for depression, anxiety, general symptoms, and PTSD core symptoms. A repeated-measures analysis of variance revealed highly significant improvement in all three symptom clusters, as well as in associated anxiety, depressive, and dissociative symptoms, with 11 of 17 (65%) patients rated as much or very much improved. The mean reduction in PTSD symptom scores was 48%. Exploratory analyses revealed that cumulative childhood trauma was negatively correlated with pharmacotherapy response (r = -0.52, p = 0.03). There was also significant variation in the time course of response across symptom clusters, which is suggestive of multiple mechanisms of response. Because paroxetine seems a highly promising treatment for all three symptom clusters of PTSD, a placebo-controlled clinical trial is warranted.