Post-traumatic stress disorder

Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms

BACKGROUND

The Gaza Strip has been embroiled in a violent military assault since October 2023, with an immense toll on the civilian population. Armed conflicts threaten the mental health of affected communities and survivors, and psychiatric morbidity increases with forced displacement and with severe and recurrent trauma. This study investigates the prevalence and predisposing factors of depression, anxiety, stress, and PTSD symptoms in a group of young adult students from the Gaza Strip during the war.

METHODS

A cross-sectional, internet-based survey recruited medical students from the Gaza Strip and used the DASS21, SWLS, and PCL-5 instruments. PTSD diagnosis required having a PCL-5 score ≥ 23 and fulfilling the DSM-5 criteria. Rates of depression, anxiety, stress, and life satisfaction were compared with a previous dataset collected in 2022. Finally, logistic regression models were fitted using R software to identify factors significantly associated with depression, anxiety, stress, and PTSD.

RESULTS

Three hundred thirty-nine medical students participated. Most had been displaced several times, and the great majority had lost a relative, colleague, or friend. Also, a majority had lost their homes and income. 97.05% of participants suffered mild depressive symptoms or higher, while 84.37% and 90.56% reported mild anxiety and mild stress symptoms or higher, respectively. High levels of life dissatisfaction were also found, and 63.40% suffered from PTSD. Symptoms were significantly more prevalent than baseline rates. All participants with PTSD had at least one psychiatric comorbidity. Living in a shelter and having moderate stress symptoms or higher were significantly associated with depression. Being a female, losing a friend, having moderate stress symptoms or higher, and having PTSD predicted having moderate anxiety or higher. Having moderate or higher depression symptoms, moderate or higher anxiety symptoms, and PTSD predicted having moderate stress symptoms or higher. Finally, moderate or higher anxiety and stress symptoms predicted having PTSD.

CONCLUSION

The study detected very high rates of psychiatric disorders among its population of young adult medical students and outlined a myriad of risk factors associated with higher comorbidity. Interventions are needed to prevent a brewing mental health crisis in the Gaza Strip.

I'm About to Explode, I'm About to Strangle: Emotional Experiences of Turkish Veterans and Their Spouses Diagnosed with Post Traumatic Stress Disorder

INTRODUCTION

The aim of this study is to examine in depth the experiences of Turkish veterans diagnosed with Posttraumatic Stress Disorder (PTSD) and their spouses in the dimension of affective development in the light of their trauma experiences with a qualitative design and phenomenological approach.

METHODS

The study group of the research consisted of 21 veterans diagnosed with PTSD and accepted as veterans, and the spouses of the 21 veterans. The data of the study were collected through in-depth interviews with the participants used a semi-structured interview form (Appendıx). Data analyses were performed used the MAXQDA 2020 software.

RESULTS

Study, the main themes determined as pretraumatic positive emotions and posttraumatic negative emotions. There were 4 themes under negative emotions after trauma and 24 sub-themes under 4 themes.

DISCUSSION AND CONCLUSION

As a result of the study, it was understood that trauma experience and PTSD affect the affective development dimension of veterans and their spouses at different levels, and these effects have negative elements. According to these findings, it was determined that veterans and their spouses need psychosocial services that address the affective development dimension.

Post-pandemic stress of COVID-19 among high-risk groups: A systematic review and meta-analysis

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) is considered as a prevalent outcome of the COVID-19 pandemic. This study aimed to present a global picture of the prevalence of PTSD in high-risk groups for COVID-19 (HRGs-COVID19) and determine its risk factors.

METHODS

Cross-sectional studies published between March 11, 2020, and October 11, 2021, in English, were searched in seven databases on the prevalence of PTSD in HRGs-COVID19. After screening the retrieved records, their quality was assessed, and the required data were extracted. R-4.1.3 software and random effect model with 95 % confidence interval (CI) were used to synthesize and analyze the data.

RESULTS

The pooled prevalence of PTSD in HRGs-COVID19 was 30 % (95 % CI: 21-39 %). The pooled prevalence of PTSD was significantly different in terms of the variables of data collection during the lockdown, gender, and data collection season (P < 0.05). Subgroup analyses could not identify sources of heterogeneity.

LIMITATIONS

The included studies did not cover all HRGs-COVID19 such as smokers and the elderly.

CONCLUSION

Considering the higher pooled prevalence of PTSD in HRGs-COVID19 than the general population, COVID-19 patients, and health care workers, prioritizing this subgroup for prevention and treatment of psychological outcomes is highly recommended. Predicting and implementing psychological interventions early in the pandemic is more critical when applying restrictive measures and among HRGs-COVID19 women.

Social Anxiety Disorder: Associated Conditions and Therapeutic Approaches

Social anxiety disorder (SAD) is a highly distressing chronic psychiatric disorder characterized by persistent fear of social situations in anticipation of being judged negatively by others. As shyness mimics some of the symptoms of SAD, people suffering from this debilitating disease are often underdiagnosed. It can have a devastating impact on all areas of life including academic performance, social growth, relationship status, and work performance. In recent years, research on anxiety and related disorders has proliferated due to the increased use of cognitive-behavioral models. The understanding of SAD has evolved greatly from distinguishing it from shyness to implementing modalities to comprehend the sophisticated underlying mechanism of disease prevalence and progression as well as methods to treat it. This review summarizes the concept of SAD, its epidemiology, symptoms, and diagnostic tools. Frequent comorbidities including other psychiatric disorders are also discussed. Additionally, we examine the latest evidence related to treatment options including psychotherapy and pharmacotherapy as well as recommendations for managing SAD.

Efficacy and Risk Factor Analysis of DBT Therapy for PTSD-Related Symptoms in Mainland Chinese College Students Based on Data Mining

Posttraumatic stress disorder (PTSD) is a mental disorder characterized by a delayed onset and long-lasting psychiatric disorder in an individual due to unusual threatening or catastrophic stressful events, characterized by repeated experiences of the situation, avoidant behaviors, emotional numbness, hypervigilance, and other mental symptoms. It seriously affects the occupational, psychological, and social functions of the human body, leads to a decrease in the quality of life, and brings a greater economic burden to the patients themselves, their families, and the society. It has attracted widespread attention worldwide. Due to social transformation and fierce competition, college students are increasingly exposed to various stressful or traumatic events, and PTSD is becoming more and more obvious. Therefore, this study took a university student as the research object, analyzed the risk factors of PTSD, and used the method of data mining to analyze the effectiveness of DBT therapy and completed the following work: (1) this paper introduces the research status of PTSD pathogenesis at home and abroad and expounds the treatment methods and research results of DBT. (2) The basic principle of BPNN is introduced, the weight and threshold of BPNN are screened by genetic algorithm, and the best weight and threshold after screening are given to BPNN. A GA-BP model is constructed to improve the learning quality of BPNN. (3) The optimal parameters of the model are selected through experiments, and the model is verified by the collected data. The results show that the model has superiority in evaluating the effectiveness of DBT therapy. Then, it was proved by experiments that DBT therapy has a good effect in the treatment of PTSD. Finally, the influencing factors of PTSD were analyzed one by one through the experimental results.

Prevalence of Posttraumatic Stress Disorder Symptoms Following Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis

BACKGROUND

Limited evidence is currently available on the prevalence of posttraumatic stress disorder (PTSD) following traumatic spinal cord injury (SCI). This systematic review and meta-analysis aims to assess the prevalence and geographic distribution of PTSD symptoms after SCI.

METHODS

After a search in the MEDLINE, Embase, Scopus, and Web of Science databases, two reviewers independently summarized relevant studies published through 20 October 2021. Observational studies were included. The studies were eligible if they assessed PTSD symptoms using standard self-report or clinician-based instruments. Data and results were reported using the overall prevalence and the odds ratio (OR), with 95% confidence intervals (CIs).

RESULTS

24 articles (5646 patients) met the inclusion criteria. The prevalence of PTSD symptoms ranged from 6.33% (95% CI, 2.73-13.97) to 61.76% (95% CI, 52.07-70.61). Pooled analysis demonstrated that the overall prevalence of PTSD symptoms in SCI patients was significantly higher in developing countries (41.64%; 95% CI, 31.11-52.55) than in developed countries (19.35%; 95% CI, 14.66-24.51) (OR = 1.24; 95% CI, 1.08-1.42; p = .003). The highest prevalence of PTSD symptoms was reported in South Africa (56.25%; 95% CI, 47.01-65.08), followed by Sri Lanka (45.71%; 95% CI, 30.47-61.81), and Greece (43.55%; 95% CI, 31.94-55.91). By contrast, Norway (6.33%; 95% CI, 2.73-13.97), Switzerland/Germany (8.65%; 95% CI, 4.8-13.42), and Denmark (10.71%; 95% CI, 6.89-16.30) were found to have the lowest prevalence of PTSD symptoms after SCI.

CONCLUSION

Many traumatic SCI patients suffer from PTSD symptoms, and their prevalence seems to be higher in developing countries than in developed countries. These findings underscore the need to consider the psychological aspects of traumatic SCI.

Post-Traumatic Stress Disorder Trajectories the Year after COVID-19 Hospitalization

Background: Coronavirus disease (COVID-19) hospitalization has been related to Post-Traumatic Stress Disorder (PTSD). Available information is limited by insufficient follow-up and lack of longitudinal studies. Baseline factors (e.g., sex; obesity) have been related to PTSD, but post-hospitalization factors have not been studied. Objective: This study aimed to analyse prevalence, baseline, post-discharge factors and possible clinical courses of PTSD after hospitalization for COVID-19. Method: 109 patients (94.7% of the original sample) completed a programme of three follow-up telephone assessments during the year following hospitalization. Data included clinical and sociodemographic factors as well as psychometric tools assessing PTSD, social support, and perception of threat to life (PTL). Mixture model analysis was performed to study the longitudinal course of PTSD symptoms. Chronic (>6 months) PTSD predictors were also analysed. Results: 1-year PTSD period prevalence was 23.9%, peaking at six months; 11% of the patients suffered chronic PTSD. Pre- and post-hospitalization factors influenced the onset and course of PTSD over time. These included working status, PTL, and lack of social support. Interestingly, obesity, pulmonary diseases and family cluster infection seem specifically related to PTSD following COVID-19. Inversely, clinical interventions, older age and male gender were protective. Conclusions: PTSD following COVID-19 hospitalization is common. The analysed demographic, social, clinical, and psychological factors predict PTSD symptomatology over time and can modify odds of a chronic course. Clinicians could better identify cases at risk of a chronic PTSD course. Finally, treatment as usual appeared related to a better outcome and should be proposed to patients with PTSD.

S-Ketamine Pretreatment Alleviates Anxiety-Like Behaviors and Mechanical Allodynia and Blocks the Pro-inflammatory Response in Striatum and Periaqueductal Gray From a Post-traumatic Stress Disorder Model

This study aims to explore the regulatory effect of S-ketamine on the mechanical allodynia, anxiety-like behaviors and microglia activation in adult male rats exposed to an animal model of post-traumatic stress disorder (PTSD). The rat PTSD model was established by the exposure to single-prolonged stress (SPS), and 1 day later, rats were intraperitoneally injected with 5 mg/kg S-ketamine or normal saline, respectively. Paw withdrawal mechanical threshold was measured 2 days before, and 1, 3, 5, 7, 10, 14, 21 and 28 days after injection to assess mechanical allodynia in the SPS-exposed rats. For anxiety-like behaviors, the open field test and elevated plus maze test were performed at 7 and 14 days after S-ketamine treatment in the SPS-exposed rats, respectively. SPS-induced rats presented pronounced mechanical allodynia and anxiety-like behaviors, which were alleviated by S-ketamine treatment. After behavioral tests, rats were sacrificed for collecting the anterior cingulate cortex (ACC), prefrontal cortex (PFC), dorsal striatum, and periaqueductal gray (PAG). Protein levels of TNF-α, IL-1β, p-NF-κB, and NF-κB in brain regions were examined by Western blot. In addition, microglia activation in each brain region was determined by immunofluorescence staining of the microglia-specific biomarker Iba-1. Interestingly, pro-inflammatory cytokines were significantly upregulated in the dorsal striatum and PAG, rather than ACC and PFC. Activated microglia was observed in the dorsal striatum and PAG as well, and upregulated p-NF-κB was detected in the dorsal striatum. Inflammatory response, phosphorylation of NF-κB and microglia activation in certain brain regions were significantly alleviated by S-ketamine treatment. Collectively, S-ketamine is a promising drug in alleviating mechanical allodynia, anxiety-like behaviors, and pro-inflammatory responses in discrete brain regions in a model of PTSD.

Early pharmacological interventions for universal prevention of post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition. Several pharmacological interventions have been proposed with the aim to prevent or mitigate it. These interventions should balance efficacy and tolerability, given that not all individuals exposed to a traumatic event will develop PTSD. There are different possible approaches to preventing PTSD; universal prevention is aimed at individuals at risk of developing PTSD on the basis of having been exposed to a traumatic event, irrespective of whether they are showing signs of psychological difficulties.

OBJECTIVES

To assess the efficacy and acceptability of pharmacological interventions for universal prevention of PTSD in adults exposed to a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase, two other databases and two trials registers (November 2020). We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 13 November 2020.

SELECTION CRITERIA

We included randomised clinical trials on adults exposed to any kind of traumatic event. We considered comparisons of any medication with placebo or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. In a random-effects model, we analysed dichotomous data as risk ratios (RR) and number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD).

MAIN RESULTS

We included 13 studies which considered eight interventions (hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare enteral formula, Oxepa enteral formula and 5-hydroxytryptophan) and involved 2023 participants, with a single trial contributing 1244 participants. Eight studies enrolled participants from emergency departments or trauma centres or similar settings. Participants were exposed to a range of both intentional and unintentional traumatic events. Five studies considered participants in the context of intensive care units with traumatic events consisting of severe physical illness. Our concerns about risk of bias in the included studies were mostly due to high attrition and possible selective reporting. We could meta-analyse data for two comparisons: hydrocortisone versus placebo, but limited to secondary outcomes; and propranolol versus placebo. No study compared hydrocortisone to placebo at the primary endpoint of three months after the traumatic event. The evidence on whether propranolol was more effective in reducing the severity of PTSD symptoms compared to placebo at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, serious inconsistency amongst the studies' results, and very serious imprecision of the estimate of effect (SMD -0.51, 95% confidence interval (CI) -1.61 to 0.59; I2 = 83%; 3 studies, 86 participants; very low-certainty evidence). No study provided data on dropout rates due to side effects at three months post-traumatic event. The evidence on whether propranolol was more effective than placebo in reducing the probability of experiencing PTSD at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, and very serious imprecision of the estimate of effect (RR 0.77, 95% CI 0.31 to 1.92; 3 studies, 88 participants; very low-certainty evidence). No study assessed functional disability or quality of life.  Only one study compared gabapentin to placebo at the primary endpoint of three months after the traumatic event, with inconclusive evidence in terms of both PTSD severity and probability of experiencing PTSD, because of imprecision of the effect estimate, serious risk of bias and serious imprecision (very low-certainty evidence). We found no data on dropout rates due to side effects, functional disability or quality of life. For the remaining comparisons, the available data are inconclusive or missing in terms of PTSD severity reduction and dropout rates due to adverse events. No study assessed functional disability.

AUTHORS' CONCLUSIONS

This review provides uncertain evidence only regarding the use of hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare formula, Oxepa formula, or 5-hydroxytryptophan as universal PTSD prevention strategies. Future research might benefit from larger samples, better reporting of side effects and inclusion of quality of life and functioning measures.

Impact of COVID-19 on psychological wellbeing

This cross-sectional study aims to record post-traumatic stress (PTS) and post-traumatic growth (PTG) of the general population of China during the first wave of COVID-19 spread. Method: An online survey was distributed in China during February and March 2020 to record the general population's PTS (using the Post-traumatic Stress Disorder Checklist-Civilian Version, PCL-C) and PTG (using the Post-traumatic Growth Inventory, PTGI) due to COVID-19. Confirmatory Factor Analyses (CFAs) and a Two-Part Model (TPM) of regression analysis were conducted. Results: In total, 29,118 Chinese participants completed the survey (54.20% were in their 20s, 68% were males, and 60.30% had a university education). CFA results illustrated that bifactor models described the Chinese psychometric traits of PTS and PTG over the default models. Results of TPM suggested that female, low-educated, and middle-aged individuals were more vulnerable to PTS. Remarkably, mutual and positive correlations between the PTS and the PTG, though small in statistics, were observed through regression analyses. Conclusions: The current results presented new best-fit structural models, potential predictors, and valuable baseline information on the PTS and the PTG of the Chinese population in the context of COVID-19.

Classification and Prediction of Post-Trauma Outcomes Related to PTSD Using Circadian Rhythm Changes Measured via Wrist-Worn Research Watch in a Large Longitudinal Cohort

Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition resulting from threatening or horrifying events. We hypothesized that circadian rhythm changes, measured by a wrist-worn research watch are predictive of post-trauma outcomes.

APPROACH

1618 post-trauma patients were enrolled after admission to emergency departments (ED). Three standardized questionnaires were administered at week eight to measure post-trauma outcomes related to PTSD, sleep disturbance, and pain interference with daily life. Pulse activity and movement data were captured from a research watch for eight weeks. Standard and novel movement and cardiovascular metrics that reflect circadian rhythms were derived using this data. These features were used to train different classifiers to predict the three outcomes derived from week-eight surveys. Clinical surveys administered at ED were also used as features in the baseline models.

RESULTS

The highest cross-validated performance of research watch-based features was achieved for classifying participants with pain interference by a logistic regression model, with an area under the receiver operating characteristic curve (AUC) of 0.70. The ED survey-based model achieved an AUC of 0.77, and the fusion of research watch and ED survey metrics improved the AUC to 0.79.

SIGNIFICANCE

This work represents the first attempt to predict and classify post-trauma symptoms from passive wearable data using machine learning approaches that leverage the circadian desynchrony in a potential PTSD population.

BHLHE40 modulates post-traumatic stress disorder behaviors with the involvement of the PI3K/AKT signaling pathway

Post-traumatic stress disorder (PTSD) is closely related to the exposure to traumatic events and results in the structural and functional changes of hippocampus. Human basic helix-loop-helix family member e40 (BHLHE40) was reported to be implicated with neuron maturity and neuronal differentiation. The present study aimed to reveal the role of BHLHE40 on single-prolonged stress (SPS) model of PTSD in mice. The morris water maze test, open field test and contextual fear test were conducted to assess memory deficits, anxiety-like behaviors, and freezing of mice. Western blot was performed to identify proteins and reveal their levels in hippocampal tissues. We found that mice receiving SPS exhibited increased anxiety-like behaviors, memory deficits, and prolonged freezing time. The protein levels of BHLHE40 were downregulated in the hippocampal tissues of SPS mice. SPS reduced the protein levels of glutamate receptors, while overexpression of BHLHE40 promoted glutamate receptor protein levels in SPS mice. Moreover, BHLHE40 overexpression activated the PI3K/AKT pathway. BHLHE40 overexpression ameliorated the SPS-induced PTSD-like behavioral deficits. Overall, BHLHE40 promotes glutamate receptor protein levels to ameliorate PTSD-like behaviors with the involvement of the PI3K/AKT pathway. This novel discovery may provide a potential target for the improvement of PTSD.

Engaging parent-child dyad and healthcare provider stakeholders in a patient-centered comparative effectiveness study

Aim: Describe engagement activities in a comparative effectiveness study evaluating two interventions for promoting psychosocial health among youth ages 10-17 who have recently experienced a nonintentional injury. Methods: Institutional, community and patient stakeholders from four children's hospitals were engaged through consultation meetings, individual interviews and a collaborative meeting. Results: 67 engagement activities were conducted across four hospitals. Feedback to improve recruitment, retention and continuous engagement in the study was obtained. Finally, disseminating study interventions to school and healthcare settings, and adding alternative delivery formats were identified as priority next steps. Conclusion: Results highlight diverse methods of engaging patient and professional stakeholders, critical recommendations for improving study engagement and retention, and future directions for this patient-engaged comparative effectiveness research.

Fatal chlorine gas exposure at a metal recycling facility: Case report

At least four workers at a metal recycling facility were hospitalized and one died after exposure to chlorine gas when it was accidentally released from an intact, closed-valved cylinder being processed for scrap metal. This unintentional chlorine gas release marks at least the third such incident at a metal recycling facility in the United States since 2010. We describe the fatal case of the worker whose clinical course was consistent with acute respiratory distress syndrome (ARDS) following exposure to high concentrations of chlorine gas. This case report emphasizes the potential risk of chlorine gas exposure to metal recycling workers by accepting and processing intact, closed-valved containers. The metal recycling industry should take steps to increase awareness of this established risk to prevent future chlorine gas releases. Additionally, public health practitioners and clinicians should be aware that metal recycling workers are at risk for chlorine gas exposure.

The neurobiology of brain recovery from traumatic stress: A longitudinal DTI study

BACKGROUND

Previous studies demonstrated decreased brain microstructure integrity in people that were exposed to extreme life stress but did not meet posttraumatic stress disorder (PTSD) diagnostic criteria. It is unclear how the brain recovers from traumatic stress in these trauma-exposed non-PTSD people (TENP).

METHODS

Twenty-two TENP individuals were recruited from the most affected area of Wenchuan quake, and scanned twenty-five days after the quake and at a two-year follow-up. Tract-based spatial statistics was used to examine brain microstructure changes over the two years. Correlation analyses were conducted to investigate relationships between brain microstructure changes and both stress recovery and demographic factors. To assess DTI stability, fifteen healthy subjects were scanned twice in a year and analysed similarly.

RESULTS

Significantly increased fractional anisotropy (FA) was found in the left posterior limb of internal capsule, left superior and posterior corona radiata (SCR and PCR), and left external capsule. The FA increase of these regions was primarily a result of radial diffusivity reduction. Recovery in symptoms was positively correlated with FA increase of SCR. Changes were related to participant age and sex. No DTI measures were changed for the healthy subjects.

LIMITATIONS

Generalizability of the findings was constrained by the relatively small sample size.

CONCLUSIONS

The TENP individuals showed a recovery from the trauma over the follow-up, and that was accompanied with increased brain microstructure integrity in fiber tracts primarily involving corticostriatal networks. These changes may contribute to the psychological resilience to a severe life stress that led to PTSD in quake victims. In particular，this study adds to Psychoradiology, which is a promising subspecialty for clinical radiology focusing on psychiatric disorders.

Link for Injured Kids: A Patient-Centered Program of Psychological First Aid After Trauma

OBJECTIVE

Injury, the most common type of pediatric trauma, can lead to a number of adverse psychosocial outcomes, including posttraumatic stress disorder. Currently, few evidence-based parent programs exist to support children hospitalized after a traumatic injury. Using methods in evaluation and intervention research, we completed a formative research study to develop a new program of psychological first aid, Link for Injured Kids, aimed to educate parents in supporting their children after a severe traumatic injury.

METHODS

Using qualitative methods, we held focus groups with parents and pediatric trauma providers of children hospitalized at a Level I Children's Hospital because of an injury in 2012. We asked focus group participants to describe reactions to trauma and review drafts of our intervention materials.

RESULTS

Health professionals and caregivers reported a broad spectrum of emotional responses by their children or patients; however, difficulties were experienced during recovery at home and upon returning to school. All parents and health professionals recommended that interventions be offered to parents either in the emergency department or close to discharge among admissions.

CONCLUSIONS

Results from this study strongly indicate a need for posttrauma interventions, particularly in rural settings, to support families of children to address the psychosocial outcomes in the aftermath of an injury. Findings presented here describe the process of intervention development that responds to the needs of an affected population.

Psychological Interventions for Post-traumatic Stress Symptoms in Psychosis: A Systematic Review of Outcomes

Individuals with severe mental health problems, such as psychosis, are consistently shown to have experienced high levels of past traumatic events. They are also at an increased risk of further traumatisation through victimization events such as crime and assault. The experience of psychosis itself and psychiatric hospitalization have also been recognized to be sufficiently traumatic to lead to the development of post-traumatic stress (PTS) symptoms. Rates of post-traumatic stress disorder (PTSD) are elevated in people with psychosis compared to the general population. The current guidance for the treatment of PTSD is informed by an evidence base predominately limited to populations without co-morbid psychiatric disorders. The systematic review therefore sought to present the current available literature on the use of psychological treatments targeting PTS symptoms in a population with a primary diagnosis of a psychotic disorder. The review aimed to investigate the effect of these interventions on PTS symptoms and also the effect on secondary domains such as psychotic symptoms, affect and functioning. Fifteen studies were identified reporting on cognitive behavior therapy, prolonged exposure, eye movement desensitisation and reprocessing and written emotional disclosure. The review provides preliminary support for the safe use of trauma-focused psychological interventions in groups of people with severe mental health problems. Overall, the interventions were found to be effective in reducing PTS symptoms. Results were mixed with regard to secondary effects on additional domains. Further research including studies employing sufficiently powered methodologically rigorous designs is indicated.

Crosstalk between Activated Microglia and Neurons in the Spinal Dorsal Horn Contributes to Stress-induced Hyperalgesia

Stress has been shown to enhance pain sensitivity resulting in stress-induced hyperalgesia. However, the underlying mechanisms have yet to be elucidated. Using single-prolonged stress combined with Complete Freund's Adjuvant injection model, we explored the reciprocal regulatory relationship between neurons and microglia, which is critical for the maintenance of posttraumatic stress disorder (PTSD)-induced hyperalgesia. In our assay, significant mechanical allodynia was observed. Additionally, activated neurons in spinal dorsal horn were observed by analysis of Fos expression. And, microglia were also significantly activated with the presence of increased Iba-1 expression. Intrathecal administration of c-fos antisense oligodeoxynucleotides (ASO) or minocycline (a specific microglia inhibitor) attenuated mechanical allodynia. Moreover, intrathecal administration of c-fos ASO significantly suppressed the activation of neurons and microglia. Interestingly, inhibition of microglia activation by minocycline significantly suppressed the activation of both neurons and microglia in spinal dorsal horn. P38 inhibitor SB203580 suppressed IL-6 production, and inhibition of IL-6 receptor (IL-6R) activation by tocilizumab suppressed Fos expression. Together, our data suggest that the presence of a "crosstalk" between activated microglia and neurons in the spinal dorsal horn, which might contribute to the stress-induced hyperactivated state, leading to an increased pain sensitivity.

The Resilience Program: preliminary evaluation of a mentalization-based education program

In order to manage with the burden of mental health problems in the world we need to develop cost-effective and safe preventive interventions. Education about resilience to support the ability to cope with life challenges in general, may be a useful strategy. We consider the concepts of Theory of Mind and Mentalization to be relevant in this context. In this paper we describe a simple modular intervention program based on these concepts which can be tailored to specific needs and situations in individual therapy as well as group levels. The program has shown promising results in pilot studies and is now tested in controlled trials in settings such as schools and educational institutions, adults diagnosed with ADHD, and children in care.

Repetitive transcranial magnetic stimulation over the dorsolateral prefrontal cortex for treating posttraumatic stress disorder: an exploratory meta-analysis of randomized, double-blind and sham-controlled trials

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) applied to the dorsolateral prefrontal cortex (DLPFC) has yielded promising results as a treatment for posttraumatic stress disorder (PTSD). However, to date, no quantitative review of its clinical utility has been published.

METHOD

We searched for randomized and sham-controlled trials from 1995 to March 2013 using MEDLINE, Embase, PsycINFO, CENTRAL, and SCOPUS. We then performed an exploratory random effects meta-analysis.

RESULTS

Studies on rTMS applied to the right DLPFC included 64 adults with PTSD. The pooled Hedges g effect size for pre and post changes in clinician-rated and self-reported PTSD symptoms were, respectively, 1.65 (P < 0.001) and 1.91 (P < 0.001), indicating significant and large-sized differences in outcome favouring active rTMS. Also, there were significant pre and post decreases with active rTMS in overall anxiety (Hedges g = 1.24; P = 0.02) and depressive (Hedges g = 0.85; P < 0.001) symptoms. Dropout rates at study end did not differ between active and sham rTMS groups. Regarding rTMS applied to the left DLPFC, there is only one study published to date (using a high frequency protocol), and its results showed that active rTMS seems to be superior overall to sham rTMS.

CONCLUSIONS

Our exploratory meta-analysis shows that active rTMS applied to the DLPFC seems to be effective and acceptable for treating PTSD. However, the small number of subjects included in the analyses limits the generalizability of these findings. Future studies should include larger samples and deliver optimized stimulation parameters.

Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007.

OBJECTIVES

To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD).

SEARCH METHODS

For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms.

DATA COLLECTION AND ANALYSIS

We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects.

MAIN RESULTS

We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution.

AUTHORS' CONCLUSIONS

The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

Nature and correlates of post-traumatic stress symptomatology in lung transplant recipients

BACKGROUND

The burden of post-traumatic stress disorder (PTSD) symptoms may be associated with worse outcomes after transplantation. Little is known about the prevalence and correlates of PTSD symptoms in lung transplant recipients.

METHODS

We conducted a cross-sectional study of lung transplant recipients between April 2008 and February 2010 at a single center. The PTSD Checklist was used to determine the burden of PTSD symptomatology (total score) and percent of subjects with a provisional PTSD diagnosis (validated algorithms). We assessed the relationship between PTSD symptom burden and patient characteristics with multivariable logistic modeling.

RESULTS

We enrolled 210 subjects (response rate 91%). Most patients were female (50%), and Caucasian (89%). The median age was 59 (interquartile range [IQR] 48 to 63) years and the median time between transplant and follow-up was 2.4 (IQR 0.7 to 5.3) years. Clinically significant PTSD symptomatology was observed in 12.6% (8.4% to 17.9%) of subjects. Subjects were more likely to endorse symptoms of re-experiencing (29.5%) and arousal (33.8%) than avoidant symptoms (18.4%). Multivariable linear regression showed higher PTSD symptom scores among recipients who were: younger (p < 0.001); without private insurance (p = 0.001); exposed to trauma (p < 0.001); or diagnosed with bronchiolitis obliterans syndrome (p = 0.005).

CONCLUSIONS

Overall prevalence of PTSD (12.6%) in our study was two times higher than the general population. Patient characteristics found to be associated with an increased burden of PTSD symptoms may be useful to consider in future interventions designed to reduce this comorbidity.

Critical incidents among intensive care unit nurses and their need for support: explorative interviews

AIMS

This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit.

BACKGROUND

Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety. Unresolved problems may also cause poor behaviour towards patients. In response, nurses reduce work hours or even resign. Social support alleviates emotional problems, but little is known about actual support perceived.

DESIGN

This study is a qualitative explorative study.

METHOD

Thematic analysis of semi-structured interviews was performed among a purposive sample of 12 intensive care nurses in a university hospital in The Netherlands.

FINDINGS

Four main themes have been identified in critical incidents: high emotional involvement in patient-related incidents (in contrast to major life-threatening events as such), avoidable incidents, sub-standard patient care and intimidation. Themes discerned in nurses' reactions after critical incidents were physical reactions, emotional reactions and cognitive/behavioural reactions. After critical incidents, nurses talked with colleagues, friends or relatives, but would have appreciated additional support.

CONCLUSIONS

Incidents under emotionally demanding circumstances are among the most difficult situations, but may not be recognized as critical incidents by colleagues. Both adequate and inadequate coping strategies, with long-lasting problems after critical incidents, were reported. Feelings of anger, shame and powerlessness, may have hindered recovery. Talking to colleagues was perceived to be helpful, but intensive care nurses' need for support was insufficiently met.

RELEVANCE TO CLINICAL PRACTICE

Managers should acknowledge the effects of critical incidents on intensive care nurses and take preventive measures: reducing critical incidents, improving open communication, imposing a buddy-system for collegial support, and timely evaluating the necessity of professional help.

Effects of a post-shock injection of the kappa opioid receptor antagonist norbinaltorphimine (norBNI) on fear and anxiety in rats

Exposure of rats to footshocks leads to an enduring behavioral state involving generalized fear responses and avoidance. Recent evidence suggests that the expression of negative emotional behaviors produced by a stressor is in part mediated by dynorphin and its main receptor, the kappa opioid receptor (KOR). The purpose of this study was to determine if a subcutaneous injection of the long-acting KOR antagonist norbinaltorphimine (norBNI; 15.0 and 30.0 mg/kg) given 2 days after an acute exposure of rats to footshooks (5×2 s episodes of 1.5 mA delivered over 5 min) attenuates the expression of lasting fear and anxiety. We report that exposure of rats to acute footshock produced long-lasting (>4 weeks) fear (freezing) and anxiety (avoidance of an open area in the defensive withdrawal test). The 30 mg dose of norBNI attenuated the fear expressed when shock rats were placed in the shock context at Day 9 but not Day 27 post-shock. The same dose of norBNI had no effect on the expression of generalized fear produced when shock rats were placed in a novel chamber at Days 8 and 24. In contrast, the 30 mg dose of norBNI produced consistent anxiolytic effects in shock and nonshock rats. First, the 30 mg dose was found to decrease the latency to enter the open field in the defensive withdrawal test done 30 days after the shock exposure. Second, the same high dose also had anxiolytic effects in both nonshock and shock rats as evidence by a decrease in the mean time spent in the withdrawal box. The present study shows that systemic injection of the KOR antagonist norBNI had mixed effect on fear. In contrast, norBNI had an anxiolytic effect which included the attenuation of the enhanced avoidance of a novel area produced by a prior shock experience.

Brief Treatment of Symptoms of Post-Traumatic Stress Disorder (PTSD) by Use of Accelerated Resolution Therapy (ART(®))

Post-Traumatic Stress Disorder (PTSD) is a prevalent, disabling anxiety disorder. This prospective cohort study reports on a new exposure-based therapy known as Accelerated Resolution Therapy (ART(®)) that incorporates the use of eye movements administered in a brief treatment period (1-5 one-hour sessions within three weeks). Eighty adults aged 21-60 years with symptoms of PTSD were recruited from the Tampa Bay area. The ART-based psychotherapy was designed to minimize anxiety and body sensations associated with recall of traumatic memories and to replace distressing images with favorable ones. Participants' mean age was 40 years, 77% were female, and 29% were Hispanic. Participants underwent a median of three ART sessions, 66 of 80 (82.5%) completed treatment, and 54 of 66 (81.8%) provided 2-month follow-up data. Mean scores pre- and post-ART and at 2-month follow-up were: PTSD Checklist: 54.5 ± 12.2 vs. 31.2 ± 11.4 vs. 30.0 ± 12.4; Brief Symptom Inventory: 30.8 ± 14.6 vs. 10.1 ± 10.8 vs. 10.1 ± 12.1; Center for Epidemiologic Studies Depression Scale: 29.5 ± 10.9 vs. 11.8 ± 11.1 vs. 13.5 ± 12.1; Trauma Related Growth Inventory-Distress scale: 18.9 ± 4.1 vs. 7.4 ± 5.9 vs. 8.2 ± 5.9 (p < 0.0001 for all pre-ART vs. post-ART and 2-month comparisons). No serious adverse events were reported. ART appears to be a brief, safe, and effective treatment for symptoms of PTSD.

The lived experience of patients with uncertain medical diagnosis following a serious injury: a qualitative study

PURPOSE

This paper examines the lived experience of uncertain medical diagnosis in patients with a serious injury.

METHOD

Data reported in this article are from the qualitative component of a multi-method study. Nineteen participants were purposively selected from a longitudinal quantitative study (n = 2856) undertaken in five regions of New Zealand, investigating the outcomes of injury. This article reports results from qualitative interviews taking place approximately 6 months after the injury event.

RESULTS

The results section focuses on the lived experience of the injured patient who does not have a definite diagnosis. It describes the difficulty of persuading both health professionals and the workplace to take ongoing injury effects seriously, when the diagnosis cannot be clearly articulated. Issues associated with health professionals as gatekeepers to resources are raised, and also the potential for extended uncertainty to stigmatise the patient. Finally, the emotional impact of injury is discussed as an issue that is not often recognised.

CONCLUSION

Vague diagnostic labels attached to serious but invisible injury potentially reduce legitimate access to rehabilitation and the sick role. The socio-cultural context within which medicine is administered produces specific tensions in the clinical encounter. It is hypothesised that patients with uncertain diagnosis may be particularly at risk of the emergence of disability.

A review of United Kingdom Armed Forces' approaches to prevent post-deployment mental health problems

There is now an abundance of research which has demonstrated that military personnel who deploy on operations are at increased risk of suffering a variety of mental health difficulties in the immediate and long-term post-deployment period. One consequence of these research findings has been the development of a variety of programmes which attempt to mitigate the increased psychological risk and to assist personnel who are returning from a deployment to make a smooth transition home. Using a three-tiered prevention model, this article reviews some of the key post-deployment issues facing the UK Armed Forces and highlights the recent interventions which have been put in place to promote successful adjustment in the early post-deployment period. The paper is based upon research identified through a thorough literature search for studies which focused on this area and included a recognized measure of mental health as an outcome. The paper focuses on three main areas; psychological decompression, psycho-education and screening. The current philosophical approaches to post-deployment mental health problems of some of the UK's coalition partners are also discussed.

Asylum seekers, refugees, and the politics of access to health care: a UK perspective

The UK government has recently consulted on proposals to prohibit access to health care for some asylum seekers. This discussion paper considers the wider ethical, moral, and political issues that may arise from this policy. In particular, it explores the relationship between immigration and health and examines the impact of forced migration on health inequalities. It will be argued that it is both unethical and iniquitous to use health policy as a means of enforcing immigration policy. Instead, the founding principle of the NHS of equal access on the basis of need should be borne in mind when considering how to meet the needs of this population.