Post-traumatic stress disorder: some diagnostic and clinical issues

Recent Developments in Posttraumatic Stress Disorder

The traumatic stress field has expanded dramatically over the last 10 years. This paper provides a review of progress in three areas from the domain of posttraumatic stress responses. First, recent developments in diagnosis are discussed, with particular reference to the proposed diagnostic criteria for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; American Psychiatric Association, in press). Second, a theoretical formulation based on cognitive processing principles is presented and, where available, empirical support for such a conceptualisation is provided. Third, the implications of a cognitive processing paradigm for treatment are discussed briefly, with reference to recent research findings. Suggestions for future development of the field are provided.

The psychological reactions after witnessing a killing in public in a Danish high school

BACKGROUND

School killings attract immense media and public attention but psychological studies surrounding these events are rare.

OBJECTIVE

To examine the prevalence of posttraumatic stress disorder (PTSD) and possible risk factors of PTSD in 320 Danish high school students (mean age 18 years) 7 months after witnessing a young man killing his former girlfriend in front of a large audience.

METHOD

The students answered the Harvard Trauma Questionnaire (HTQ), the Crisis Support Scale (CSS), and the Trauma Symptom Checklist (TSC).

RESULTS

Prevalence of PTSD 7 months after the incident was 9.5%. Furthermore, 25% had PTSD at a subclinical level. Intimacy with the deceased girl; feeling fear, helplessness, or horror during the killing; lack of expressive ability; feeling let down by others; negative affectivity; and dissociation predicted 78% of the variance of the HTQ total scores.

CONCLUSION

It is possible to identify students who are most likely to suffer from PTSD. This knowledge could be used to intervene early on to reduce adversities.

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.

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

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

A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder

Thirty-six patients with PTSD were randomly allocated to individual treatment with imaginal exposure (image habituation training -- IHT), or applied muscle relaxation (AMR) or eye movement desensitization (EMD). Assessment by a blind independent rater and self-report instruments applied pre and posttreatment and at 3-month follow-up indicated that all groups improved significantly compared with a waiting list and that treatment benefits were maintained at follow-up. Despite a failure to demonstrate differences among groups, there was some suggestion that immediately after treatment EMD was superior for intrusive memories.

Posttraumatic stress disorder among Cambodian refugees in New Zealand

The author's objective was to determine the amount of trauma, prevalence and diagnostic features of posttraumatic stress disorder (PTSD), and to study the relationship between PTSD and demographic variables, trauma experiences, coping style and post-migration stresses among adult Cambodian refugees in New Zealand. Information on basic sociodemographic data, trauma experiences, posttraumatic stress symptoms, General Health Questionnaire 28-item version (GHQ-28) scores, coping style, and post-migration stresses were gathered from 223 adult Cambodian refugees living in Dunedin, New Zealand. Most subjects had experienced multiple, severe traumas. The prevalence of PTSD was 12.1%. The most frequently reported posttraumatic stress symptom was recurrent intrusive recollection of trauma. There was a significant association between PTSD and amount of trauma, coping style, and post-migration stresses.

Fearfulness and startle potentiation during aversive visual stimuli

Recent experimental research suggests an association between negative affect and potentiation of the human startle reflex, as well as enhancement of this effect among fearful compared to low fear subjects. In the present study, 32 undergraduates were selected for high or low total Fear Survey Schedule scores. Acoustic startle probes were presented while subjects received warned presentations of aversive and neutral photographic slides. High fear but not low fear subjects showed potentiated short-latency cardiac acceleration and blink magnitude, and reduced blink latency, during aversive compared to neutral slides. These results support the hypothesis that affective modulation of startle is enhanced among high fear compared to low fear subjects. Considered in the context of prior findings, the results suggest that this individual difference effect generalizes across psychophysiological components of the startle reflex and diverse procedures for manipulating affect.