P-173 Large-scale simulation of pregnancy rate improvements using an AI model for embryo ranking

Study question

What is the expected improvement in pregnancy rates using an artificial intelligence (AI) model for embryo ranking compared to manual grading systems?

Summary answer

A large-scale retrospective bootstrapped analysis shows that use of an AI model for embryo ranking can improve pregnancy rates compared to manual grading.

What is known already

Embryo evaluation is one of the most important steps of an in vitro fertilization (IVF) procedure. Recently, artificial intelligence (AI) models have been developed to automate embryo analysis and reduce the subjectivity of manual grading. While models are often evaluated in terms of classification accuracy or area under the curve (AUC), a more relevant metric is improvement in pregnancy rates. Here we evaluate a previously developed model using a large-scale bootstrapped analysis of virtual patient pregnancy rates and compare its performance to manual grading.

Study design, size, duration

Historical, de-identified images of transferred blastocyst-stage embryos and manual morphology grades were collected from 11 IVF clinics in the United States for cycles started between 2015-2020. Images were captured on day 5, 6, or 7 using the inverted microscope prior to biopsy or freeze. A total of 1,776 test set images from 3-fold cross validation were used for this analysis.

Participants/materials, setting, methods

Embryos were matched by age, PGT status, and race to create 16 distinct categories. Virtual patient panels were created within each category using a random selection of 3-5 embryos. Embryos were re-used across different panels, but each individual panel was unique. Three different manual ranking systems were created incorporating the morphology grade and day of image capture. The AI and one randomly chosen manual ranking system independently selected a top embryo for each panel.

Main results and the role of chance

On average, 105,263 unique virtual patient panels were constructed from the 1,776 embryos. Within these panels, the AI model and manual ranking system selected different top embryos from each other in 27,860 cases, or 26% of the time. The average pregnancy rate of the top-ranked embryo using manual grading was 53.1%, and the average pregnancy rate of the top-ranked embryo using the AI model was 59.4%. The average pregnancy rate improvement from using the AI model was 6.3%, with a standard deviation of 0.2% measured across 10 repetitions of the simulation with different random seeds.

Limitations, reasons for caution

The primary limitation is the retrospective nature of this study. Also, this bootstrapped panel study relied on recorded manual morphology grades at the time of embryo transfer or freeze rather than on the actual selection of the top embryo in each panel by an embryologist.

Wider implications of the findings

Our results demonstrate the potential of using an AI model for embryo ranking in terms of improved pregnancy rates. Results from this large-scale bootstrapped retrospective analysis will help inform the design of future clinical validation studies.

Trial registration number

not applicable

Cold atmospheric pressure plasma for treatment of chronic wounds: drug or medical device?

OBJECTIVE

The use of cold atmospheric pressure plasma (CAPP) as a new therapeutic option to aid the healing of chronic wounds appears promising. Currently, uncertainty exists regarding their classification as medical device or medical drug. Because the classification of CAPP has medical, legal, and economic consequences as well as implications for the level of preclinical and clinical testing, the correct classification is not an academic exercise, but an ethical need.

METHOD

A multidisciplinary team of physicians, surgeons, pharmacists, physicists and lawyers has analysed the physical and technical characteristics as well as legal conditions of the biological action of CAPP.

RESULTS

It was concluded that the mode of action of the locally generated CAPP, with its main active components being different radicals, is pharmacological and not physical in nature.

CONCLUSION

Depending on the intended use, CAPP should be classified as a drug, which is generated by use of a medical device directly at the point of therapeutic application.

Virtual reality in the assessment, understanding, and treatment of mental health disorders

Mental health problems are inseparable from the environment. With virtual reality (VR), computer-generated interactive environments, individuals can repeatedly experience their problematic situations and be taught, via evidence-based psychological treatments, how to overcome difficulties. VR is moving out of specialist laboratories. Our central aim was to describe the potential of VR in mental health, including a consideration of the first 20 years of applications. A systematic review of empirical studies was conducted. In all, 285 studies were identified, with 86 concerning assessment, 45 theory development, and 154 treatment. The main disorders researched were anxiety (n = 192), schizophrenia (n = 44), substance-related disorders (n = 22) and eating disorders (n = 18). There are pioneering early studies, but the methodological quality of studies was generally low. The gaps in meaningful applications to mental health are extensive. The most established finding is that VR exposure-based treatments can reduce anxiety disorders, but there are numerous research and treatment avenues of promise. VR was found to be a much-misused term, often applied to non-interactive and non-immersive technologies. We conclude that VR has the potential to transform the assessment, understanding and treatment of mental health problems. The treatment possibilities will only be realized if - with the user experience at the heart of design - the best immersive VR technology is combined with targeted translational interventions. The capability of VR to simulate reality could greatly increase access to psychological therapies, while treatment outcomes could be enhanced by the technology's ability to create new realities. VR may merit the level of attention given to neuroimaging.

A prospective study of pre-trauma risk factors for post-traumatic stress disorder and depression

BACKGROUND

It is unclear which potentially modifiable risk factors best predict post-trauma psychiatric disorders. We aimed to identify pre-trauma risk factors for post-traumatic stress disorder (PTSD) or major depression (MD) that could be targeted with resilience interventions.

METHOD

Newly recruited paramedics (n = 453) were assessed for history of mental disorders with structured clinical interviews within the first week of their paramedic training and completed self-report measures to assess hypothesized predictors. Participants were assessed every 4 months for 2 years to identify any episodes of PTSD and MD; 386 paramedics (85.2%) participated in the follow-up interviews.

RESULTS

In all, 32 participants (8.3%) developed an episode of PTSD and 41 (10.6%) an episode of MD during follow-up. In all but nine cases (2.3%), episodes had remitted by the next assessment 4 months later. At 2 years, those with episodes of PTSD or MD during follow-up reported more days off work, poorer sleep, poorer quality of life, greater burn-out; and greater weight-gain for those with PTSD. In line with theories of PTSD and depression, analyses controlling for psychiatric and trauma history identified several pre-trauma predictors (cognitive styles, coping styles and psychological traits). Logistic regressions showed that rumination about memories of stressful events at the start of training uniquely predicted an episode of PTSD. Perceived resilience uniquely predicted an episode of MD.

CONCLUSIONS

Participants at risk of developing episodes of PTSD or depression could be identified within the first week of paramedic training. Cognitive predictors of episodes of PTSD and MD are promising targets for resilience interventions.

Post-traumatic stress influences the brain even in the absence of symptoms: A systematic, quantitative meta-analysis of neuroimaging studies

Stress affects brain function, and may lead to post-traumatic stress disorder (PTSD). Considerable empirical data for the neurobiology of PTSD has been derived from neuroimaging studies, although findings have proven inconsistent. We used an activation likelihood estimation analysis to explore differences in brain activity between adults with and without PTSD in response to affective stimuli. We separated studies by type of control group: trauma-exposed and trauma-naïve. This revealed distinct patterns of differences in functional activity. Compared to trauma-exposed controls, regions of the basal ganglia were differentially active in PTSD; whereas the comparison with trauma-naïve controls revealed differential involvement in the right anterior insula, precuneus, cingulate and orbitofrontal cortices known to be involved in emotional regulation. Changes in activity in the amygdala and parahippocampal cortex distinguished PTSD from both control groups. Results suggest that trauma has a measurable, enduring effect upon the functional dynamics of the brain, even in individuals who experience trauma but do not develop PTSD. These findings contribute to the understanding of whole-brain network activity following trauma, and its transition to clinical PTSD.

Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors

BACKGROUND

Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems.

METHOD

At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later.

RESULTS

Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction.

CONCLUSIONS

Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.

Perceptual processing advantages for trauma-related visual cues in post-traumatic stress disorder

BACKGROUND

Intrusive re-experiencing in post-traumatic stress disorder (PTSD) comprises distressing sensory impressions from the trauma that seem to occur 'out of the blue'. A key question is how intrusions are triggered. One possibility is that PTSD is characterized by a processing advantage for stimuli that resemble those that accompanied the trauma, which would lead to increased detection of such cues in the environment.

METHOD

We used a blurred picture identification task in a cross-sectional (n=99) and a prospective study (n=221) of trauma survivors.

RESULTS

Participants with acute stress disorder (ASD) or PTSD, but not trauma survivors without these disorders, identified trauma-related pictures, but not general threat pictures, better than neutral pictures. There were no group differences in the rate of trauma-related answers to other picture categories. The relative processing advantage for trauma-related pictures correlated with re-experiencing and dissociation, and predicted PTSD at follow-up.

CONCLUSIONS

A perceptual processing bias for trauma-related stimuli may contribute to the involuntary triggering of intrusive trauma memories in PTSD.

Outreach and screening following the 2005 London bombings: usage and outcomes

BACKGROUND

Little is known about how to remedy the unmet mental health needs associated with major terrorist attacks, or what outcomes are achievable with evidence-based treatment. This article reports the usage, diagnoses and outcomes associated with the 2-year Trauma Response Programme (TRP) for those affected by the 2005 London bombings.MethodFollowing a systematic and coordinated programme of outreach, the contact details of 910 people were obtained by the TRP. Of these, 596 completed a screening instrument that included the Trauma Screening Questionnaire (TSQ) and items assessing other negative responses. Those scoring ≥6 on the TSQ, or endorsing other negative responses, received a detailed clinical assessment. Individuals judged to need treatment (n=217) received trauma-focused cognitive-behaviour therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR). Symptom levels were assessed pre- and post-treatment with validated self-report measures of post-traumatic stress disorder (PTSD) and depression, and 66 were followed up at 1 year.

RESULTS

Case finding relied primarily on outreach rather than standard referral pathways such as primary care. The effect sizes achieved for treatment of DSM-IV PTSD exceeded those usually found in randomized controlled trials (RCTs) and gains were well maintained an average of 1 year later.

CONCLUSIONS

Outreach with screening, linked to the provision of evidence-based treatment, seems to be a viable method of identifying and meeting mental health needs following a terrorist attack. Given the failure of normal care pathways, it is a potentially important approach that merits further evaluation.

Risk factors for post-traumatic stress disorder among UK Armed Forces personnel

BACKGROUND

There is considerable interest in understanding further the factors that increase the risk of post-traumatic stress disorder (PTSD) for military personnel. This study aimed to investigate the relative contribution of demographic variables; childhood adversity; the nature of exposure to traumatic events during deployment; appraisal of these experiences; and home-coming experiences in relation to the prevalence of PTSD 'caseness' as measured by a score of 50 on the PTSD Checklist (PCL) in UK Armed Forces personnel who have been deployed in Iraq since 2003.

METHOD

Data were drawn from the first stage of a retrospective cohort study comparing UK military personnel who were deployed to the 2003 Iraq War with personnel serving in the UK Armed Forces on 31 March 2003 but who were not deployed to the initial phase of war fighting. Participants were randomly selected and invited to participate. The response rate was 61%. We have limited these analyses to 4762 regular service individuals who responded to the survey and who have been deployed in Iraq since 2003.

RESULTS

Post-traumatic stress symptoms were associated with lower rank, being unmarried, having low educational attainment and a history of childhood adversity. Exposure to potentially traumatizing events, in particular being deployed to a 'forward' area in close contact with the enemy, was associated with post-traumatic stress symptoms. Appraisals of the experience as involving threat to one's own life and a perception that work in theatre was above an individual's trade and experience were strongly associated with post-traumatic stress symptoms. Low morale and poor social support within the unit and non-receipt of a home-coming brief (psycho-education) were associated with greater risk of post-traumatic stress symptoms.

CONCLUSIONS

Personal appraisal of threat to life during the trauma emerged as the most important predictor of post-traumatic stress symptoms. These results also raise the possibility that there are important modifiable occupational factors such as unit morale, leadership, preparing combatants for their role in theatre which may influence an individual's risk of post-traumatic stress symptoms. Therefore interventions focused on systematic preparation of personnel for the extreme stress of combat may help to lessen the psychological impact of deployment.

Clinical two-photon microendoscopy

Two-photon medical imaging has found its way into dermatology as an excellent method for noninvasive skin cancer detection without need of contrast agents as well as for in situ drug screening of topically-applied cosmetical and pharmaceutical components. There is an increasing demand to apply the multiphoton technology also for deep-tissue skin imaging as well as for intracorporal imaging. We report on the first clinical use of multiphoton endoscopes, in particular of a miniaturized rigid two-photon GRIN lens endoscope. The microendoscope was attached to the multiphoton tomograph DermaInspect and employed to detect the extracellular matrix proteins collagen and elastin in the human dermis of volunteers and patients with ulcera by in vivo second harmonic generation and in vivo two-photon autofluorescence.

Influence of Nanoencapsulation on Human Skin Transport of Flufenamic Acid

The effect of the inclusion of flufenamic acid in poly(lactide-co-glycolide) nanoparticles on the transport of flufenamic acid into excised human skin was investigated. Penetration and permeation data were acquired using two different in vitro test systems: the Saarbrucken penetration model, where the skin acts as its own receptor medium, and the Franz diffusion cell, where the receptor medium is a buffer solution. For the stratum corneum, no differences were found between nanoencapsulated and free drug. Drug accumulation in the deeper skin layers and drug transport across human epidermis were slightly delayed for the nanoencapsulated drug compared to the free drug after shorter incubation times (<12 h). In contrast, after longer incubation times (>12 h), the nanoencapsulated drug showed a statistically significantly enhanced transport and accumulation (p < 0.05). Additionally, nanoencapsulated flufenamic acid was visualized by multiphoton fluorescence microscopy. Particles were found homogeneously distributed on the skin surface and within the dermatoglyphs, but no nanoparticles were detected within or between the corneocytes.

In vivo Drug Screening in Human Skin Using Femtosecond Laser Multiphoton Tomography

The novel femtosecond laser multiphoton imaging system DermaInspect forin vivotomography of human skin was used to study the diffusion and intradermal accumulation of topically applied cosmetic and pharmaceutical components. Near-infrared 80 MHz picojoule femtosecond laser pulses were employed to excite endogenous fluorophores and fluorescent components of a variety of ointments via a two-photon excitation process. In addition, collagen was imaged by second harmonic generation. A high submicron spatial resolution and 50 ps temporal resolution was achieved using galvoscan mirrors and piezodriven focusing optics together with a time-correlated single-photon counting module with a fast microchannel plate detector. Individual intratissue cells, intracellular mitochondria, melanosomes, and the morphology of the nuclei as well as extracellular matrix elements were clearly visualized due to NAD(P)H, melanin, elastin, and collagen imaging and the calculation of fluorescence lifetime images. Nanoparticles and intratissue drugs were detected by two-photon-excited fluorescence. In addition, hydration effects and UV effects were studied by monitoring modifications of cellular morphology and autofluorescence. The system was used to observe the diffusion through the stratum corneum and the accumulation and release of functionalized nanoparticles along hair shafts and epidermal ridges. The novel noninvasive 4-D multiphoton tomography tool provides high-resolution optical biopsies with subcellular resolution, and offers for the first time the possibility to study in situ the diffusion through the skin barrier, long-term pharmacokinetics, and cellular response to cosmetic and pharmaceutical products.

Enhanced perceptual priming for neutral stimuli occurring in a traumatic context: two experimental investigations

Intrusive memories in posttraumatic stress disorder are often triggered by stimuli that are perceptually similar to those present shortly before or during the trauma. The present study aims to examine the possible role of perceptual priming in this phenomenon. It further investigates whether the degree of perceptual priming is associated with dissociation and whether both perceptual priming and intrusive memories can be reduced through elaboration. Two experiments measured perceptual priming for neutral stimuli that immediately preceded a "traumatic" event. Volunteers (N=46, 92) watched a series of "traumatic" and neutral picture stories, and completed a blurred object identification (perceptual priming) memory task, and a recognition memory task. Participants in Experiment 1 were selected to score either high or low on the Trait Dissociation Questionnaire [Murray, Ehlers, & Mayou (2002). Dissociation and posttraumatic stress disorder: Two prospective studies of motor vehicle accident survivors. British Journal of Psychiatry, 180, 363-368]. They also completed a state dissociation measure in the session. Experiment 2 randomly allocated participants to an experimental condition designed to increase elaboration or to a control condition. This experiment also included a measure of intrusive memories. Both experiments found enhanced perceptual priming for the stimuli that immediately preceded the "traumatic" stories compared to those preceding neutral stories. Participants with high trait dissociation showed relatively stronger perceptual perceptual priming. The degree of perceptual priming for stimuli from the "traumatic" stories also correlated with state dissociation (Experiment 1). Experimental manipulation of the elaboration of the stories showed that elaboration reduced the enhanced perceptual priming effect and the relative probability of reexperiencing symptoms (Experiment 2). The results support the role of perceptual priming in intrusions after traumatic events.

Atopic dermatitis and stress: possible role of negative communication with significant others

Clinical reports have related stressful social interactions to the course of atopic dermatitis (AD). Controlled behavioral observations of interaction patterns of AD patients and their significant others, however, were lacking. In two studies, adult AD patients and their mothers (N1 = 26) or partners (N2 = 67) engaged in a discussion of a mutual problem. Their verbal and nonverbal communication behavior was analyzed with a reliable standardized interactional coding system and compared to that of control dyads (N1 = 18, N2 = 28). Although AD patients and their significant others did not differ from controls in their self-reported satisfaction with the relationship, the behavioral observations showed less positive and more negative communication patterns compared to the control dyads. Negative interactions with significant others may prevent the solution of everyday problems and may add to the patients' stress level.

Unwanted memories of assault: what intrusion characteristics are associated with PTSD?

Intrusive memories are common in the immediate aftermath of traumatic events, but neither their presence or frequency are good predictors of the persistence of posttraumatic stress disorder (PTSD). Two studies of assault survivors, a cross-sectional study (N=81) and a 6-month prospective longitudinal study (N=73), explored whether characteristics of the intrusive memories improve the prediction. Intrusion characteristics were assessed with an Intrusion Interview and an Intrusion Provocation Task. The distress caused by the intrusions, their "here and now" quality, and their lack of a context predicted PTSD severity. The presence of intrusive memories only explained 9% of the variance of PTSD severity at 6 months after assault. Among survivors with intrusions, intrusion frequency only explained 8% of the variance of PTSD symptom severity at 6 months. Nowness, distress and lack of context explained an additional 43% of the variance. These intrusion characteristics also predicted PTSD severity at 6 months over and above what could be predicted from PTSD diagnostic status at initial assessment. Further predictors of PTSD severity were rumination about the intrusive memories, and the ease and persistence with which intrusive memories could be triggered by photographs depicting assaults. The results have implications for the early identification of trauma survivors at risk of chronic PTSD.

Psychological consequences of road traffic accidents for children and their mothers

BACKGROUND

Little is known about the psychological and behavioural consequences of road traffic accidents for children. The study aimed to determine the outcome of road traffic accidents on children and their mothers.

METHOD

A 1-year cohort study of consecutive child attenders aged 5-16 years at an Accident and Emergency Department. Data were extracted from medical notes and from interview and self-report at baseline, 3 months and 6 months.

RESULTS

The children had an excellent physical outcome. Fifteen per cent suffered acute stress disorder; 25% suffered post-traumatic stress disorder at 3 months and 18% at 6 months. Travel anxiety was frequent. Post-traumatic consequences for mothers were common.

CONCLUSION

Psychological outcome was poor for a minority of children and associated with disability, especially for travel. There were significant family consequences. There is a need for changes in clinical care to prevent, identify and treat distressing and disabling problems.

Selective attention in social phobia and the moderating effect of a concurrent depressive disorder

Studies using the modified Stroop colour naming task have provided results consistent with the hypothesis that social phobia is associated with an attentional bias towards negative social-evaluative words. However, these results could also have arisen as a consequence of non-attentional processes. For this reason, the present study uses a modified version of MacLeod et al.'s (J. Abnorm. Psychol. 95 (1986) 15) dot-probe task, which provides a more direct measure of attention. Patients with social phobia (n=28), patients with social phobia and a concurrent depressive disorder (n=33), and non-patients (n=40) were presented with word pairs each consisting of a neutral word and a threat word. The results indicated that patients with social phobia show an attentional bias towards social-threat words while non-patients tend to avoid social-threat words. Patients with social phobia and a concurrent depressive disorder behaved like non-patients, indicating that concurrent depression abolishes the attentional bias. Physical threat words were also included in the study. The main analysis indicated that social phobia is also associated with an attentional bias to physical threat. However, a post hoc analysis (which requires replication) suggested that the physical threat bias might have arisen because some social phobia patients also had another anxiety disorder in which physical concerns are likely to have been prominent. Overall, the results emphasise the importance of assessing comorbidity when investigating attentional biases.

Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study

The present study explored whether cognitive factors specified in the Ehlers and Clark model (Behav. Res. Ther. 38 (2000) 319) of posttraumatic stress disorder (PTSD) predict chronic PTSD in children who had experienced a road traffic accident. Children were assessed at 2 weeks, 3 months, and 6 months after the accident. Data-driven processing during the accident, negative interpretation of intrusive memories, alienation from other people, anger, rumination, thought suppression and persistent dissociation at initial assessment predicted PTSD symptom severity at 3 and 6 months. On the basis of sex and stressor severity variables, 14% of the variance of PTSD symptoms at 6 months could be explained. The accuracy of the prediction increased to 49% or 53% when the cognitive variables measured at initial assessment or 3 months, respectively, were taken into account.

Patients with generalized social phobia direct their attention away from faces

The experiment tested whether patients with social phobia direct their attention to or away from faces with a range of emotional expressions. A modified dot probe paradigm (J. Abnorm. Psychol. 95 (1986) 15) measured whether participants attended more to faces or to household objects. Twenty patients with social phobia were faster in identifying the probe when it occurred in the location of the household objects, regardless of whether the facial expressions were positive, neutral, or negative. In contrast, controls did not exhibit an attentional preference. The results are in line with recent theories of social phobia that emphasize the role of reduced processing of external social cues in maintaining social anxiety.

Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study

The paper presents a 3-year follow-up of a prospective longitudinal study of posttraumatic stress disorder (PTSD) after motor vehicle accidents (J. Abnormal Psychol., 107 (1998) 508). Participants were 546 patients who had been assessed when attending an emergency clinic shortly after a motor vehicle accident, and at 3 months and 1 year afterwards. The prevalence of posttraumatic stress disorder PTSD at 3 years was 11%. Maintaining psychological factors, i.e. negative interpretation of intrusions, rumination, thought suppression and anger cognitions, were important in predicting the persistence of PTSD at 3 years, as were persistent health and financial problems after the accident. Other predictors were female sex, hospital admission for injuries, perceived threat and dissociation during the accident, and litigation.

A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault

The effectiveness of psychological treatments for PTSD is likely to be enhanced by improved understanding of the factors involved in maintaining the disorder. Ehlers and Clark [A cognitive model of persistent posttraumatic stem disorder Behav. Res. Ther. 38 (2000) 319-345] recently proposed a cognitive model of maintenance. The current study aimed to investigate several cognitive factors highlighted in Ehlers and Clark's model using a prospective design. Fifty-seven victims of physical or sexual assault participated in the study. Cognitive factors were assessed within 4 months of assault and victims were followed-up 6 and 9 months after the assault. Cognitive variables which significantly predicted PTSD severity at both follow-ups were: cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking). Relationships between early appraisals, control strategies, and processing styles and subsequent PTSD severity remained significant after statistically controlling for gender and perceived assault severity. These findings support the cognitive model of PTSD proposed by Ehlers and Clark and suggest that effective treatment will need to address these cognitive factors.

Prediction of psychological outcomes one year after a motor vehicle accident

OBJECTIVE

The authors' goal was to identify predictors of 1-year outcomes for consecutive patients in a hospital emergency department following motor vehicle accidents and to describe the prevalence and course of four types of psychiatric outcomes after such accidents.

METHOD

Consecutive patients aged 17-69 years who attended a general hospital emergency department following a motor vehicle accident were identified. Medical information for these patients was extracted from case notes, and the patients completed self-report questionnaires at baseline (soon after the accident), 3 months after the accident, and 1 year after the accident. Measures included a self-report scale for posttraumatic stress disorder (PTSD), the Hospital Anxiety and Depression Scale, and questions about phobic travel anxiety. Logistic regression was used to examine predictors of outcome.

RESULTS

Different frequencies and courses of PTSD, phobic travel anxiety, general anxiety, and depression were reported by a third of the subjects at both 3-month and 1-year follow-up. Many of the subjects reported improvements between 3 and 12 months, but others described late onset of psychiatric outcomes after the accident. There were differences in baseline and 3-month predictors of each type of 1-year outcome.

CONCLUSIONS

The four types of psychiatric outcomes after a motor vehicle accident that were noted overlap, are persistent, and have different early predictors. These findings have implications for the early recognition of psychiatric consequences of motor vehicle accidents that would enable early intervention.

Characterization of clustered MHC-linked olfactory receptor genes in human and mouse

Olfactory receptor (OR) loci frequently cluster and are present on most human chromosomes. They are members of the seven transmembrane receptor (7-TM) superfamily and, as such, are part of one of the largest mammalian multigene families, with an estimated copy number of up to 1000 ORs per haploid genome. As their name implies, ORs are known to be involved in the perception of odors and possibly also in other, nonolfaction-related, functions. Here, we report the characterization of ORs that are part of the MHC-linked OR clusters in human and mouse (partial sequence only). These clusters are of particular interest because of their possible involvement in olfaction-driven mate selection. In total, we describe 50 novel OR loci (36 human, 14 murine), making the human MHC-linked cluster the largest sequenced OR cluster in any organism so far. Comparative and phylogenetic analyses confirm the cluster to be MHC-linked but divergent in both species and allow the identification of at least one ortholog that will be useful for future regulatory and functional studies. Quantitative feature analysis shows clear evidence of duplications of blocks of OR genes and reveals the entire cluster to have a genomic environment that is very different from its neighboring regions. Based on in silico transcript analysis, we also present evidence of extensive long-distance splicing in the 5'-untranslated regions and, for the first time, of alternative splicing within the single coding exon of ORs. Taken together with our previous finding that ORs are also polymorphic, the presented data indicate that the expression, function, and evolution of these interesting genes might be more complex than previously thought.

MHC-linked olfactory receptor loci exhibit polymorphism and contribute to extended HLA/OR-haplotypes

Clusters of olfactory receptor (OR) genes are found on most human chromosomes. They are one of the largest mammalian multigene families. Here, we report a systematic study of polymorphism of OR genes belonging to the largest fully sequenced OR cluster. The cluster contains 36 OR genes, of which two belong to the vomeronasal 1 (V1-OR) family. The cluster is divided into a major and a minor region at the telomeric end of the HLA complex on chromosome 6. These OR genes could be involved in MHC-related mate preferences. The polymorphism screen was carried out with 13 genes from the HLA-linked OR cluster and three genes from chromosomes 7, 17, and 19 as controls. Ten human cell lines, representing 18 different chromosome 6s, were analyzed. They were from various ethnic origins and exhibited different HLA haplotypes. All OR genes tested, including those not linked to the HLA complex, were polymorphic. These polymorphisms were dispersed along the coding region and resulted in up to seven alleles for a given OR gene. Three polymorphisms resulted either in stop codons (genes hs6M1-4P, hs6M1-17) or in a 16-bp deletion (gene hs6M1-19P), possibly leading to lack of ligand recognition by the respective receptors in the cell line donors. In total, 13 HLA-linked OR haplotypes could be defined. Therefore, allelic variation appears to be a general feature of human OR genes.

Social anxiety and self-impression: cognitive preparation enhances the beneficial effects of video feedback following a stressful social task

Negative and distorted images of the observable self are important in the development and maintenance of social phobia. Previous research has shown that video feedback has potential to correct the distorted self-perception [Rapee, R. M. & Hayman, K. (1996). The effects of video feedback on the self-evaluation of performance in socially anxious subjects. Behaviour Research and Therapy, 34, 315-322]. The present experiment investigated whether the construction of a self-image prior to viewing the video may enhance the therapeutic effects of video feedback. High and low socially anxious individuals gave a speech and then viewed the video of their performance. Half of the sample were given cognitive preparation prior to viewing the video. Cognitive preparation involved asking participants to (1) predict in detail what they will see in the video, (2) form an image of themselves giving the speech and (3) watch the video as though they were watching a stranger. Participants who received cognitive preparation prior to the video feedback made higher ratings of their overall performance and of specific aspects of their performance compared to those who were not given cognitive preparation and compared to the same ratings made prior to the video feedback. These results suggest that the therapeutic effects of video feedback can be enhanced by careful cognitive preparation which maximises the perceived discrepancy between self and video images.

Polymorphisms in olfactory receptor genes: a cautionary note

The hundreds of human olfactory receptor (OR) genes are organized into clusters occurring on nearly every chromosome. Although their sequences are not always closely related, they share stretches of considerable similarity, both at the amino acid and nucleotide levels. We demonstrate here that an HLA complex-linked OR sequence, FAT11, for which recently a number of alleles have been claimed within the Hutterites, contains sequences derived from two closely related, linked OR genes, hs6M1-12 and hs6M1-16. Instead of indicating a difference between alleles of a given locus, two of the polymorphisms described for FAT11 (at amino acids 48 and 220 of the deduced protein sequence, respectively) may in fact reflect distinct sequences of hs6M1-12 and a further, closely related HLA-linked OR locus, hs6M1-13P. As a consequence, recombination rates in Hutterites in the region telomeric of HLA-G may have to be reconsidered.

Psychological and perceptual factors associated with arrhythmias and benign palpitations

OBJECTIVE

Little is known about how patients who seek medical help for benign palpitations can be distinguished from those with clinically significant arrhythmias. This study tested whether patients with arrhythmia can be distinguished from those who are aware of sinus rhythm or extrasystoles on the basis of sex, prevalence of anxiety disorders, and heartbeat perception.

METHODS

A consecutive sample of patients referred to a cardiology clinic participated in the study. Patients were diagnosed as having either arrhythmia (N = 62), extrasystoles (N = 75), or awareness of sinus rhythm (N = 47). They were assessed with use of the anxiety disorders and hypochondriasis modules of the Structured Clinical Interview for DSM-IV. Both patients and control subjects (N = 35) answered questionnaires measuring anxiety, fear of bodily sensations, and depression and underwent a heartbeat perception test. The present report focuses on patients who had palpitations but no comorbid cardiovascular disease.

RESULTS

Patients with awareness of sinus rhythm could be distinguished from those with arrhythmia by several variables: female sex, higher prevalence of panic disorder, poor performance on the heartbeat perception test, report of palpitations when doing the test, higher heart rates, lower levels of physical activity, and (as trends) a greater prevalence of panic attacks, fear of bodily sensations, and depression. In contrast, patients with arrhythmias rarely reported palpitations when doing the test but were more likely to perceive their heartbeats accurately than patients with sinus rhythm and control subjects. Performance on the heartbeat perception test was intermediate in patients with extrasystoles; these patients also had an intermediate prevalence of panic disorder and intermediate depression scores.

CONCLUSIONS

Measures of panic disorder and a simple heartbeat perception test could complement medical assessment in the diagnosis of patients who seek medical help for palpitations. The results also have implications for the treatment of patients with benign palpitations.

Dysfunctional meaning of posttraumatic intrusions in chronic PTSD

The paper suggests that the negative idiosyncratic meaning of posttraumatic intrusions (e.g., 'I am going crazy') and cognitive strategies intended to control the intrusions play a major role in maintaining posttraumatic stress disorder. Two studies of 159 and 138 motor vehicle accidents survivors showed that the dysfunctional meaning of intrusions explained a proportion of the variance of the intrusion-related distress, strategies used to end the intrusions, and PTSD severity that was not explained by intrusion frequency, accident severity, or by general catastrophic thoughts when anxious. Rumination, thought suppression, and distraction when having intrusions showed substantial correlations with PTSD severity, as did avoidance of reminders of the accident. The results have implications for the treatment of chronic PTSD.

Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial

BACKGROUND

Psychological debriefing is widely used for trauma victims but there is uncertainty about its efficacy. We have previously reported a randomised controlled trial which concluded that at 4 months it was ineffective.

AIMS

To evaluate the 3-year outcome in a randomised controlled trial of debriefing for consecutive subjects admitted to hospital following a road traffic accident.

METHOD

Patients were assessed in hospital by the Impact of Event Scale (IES), Brief Symptom Inventory (BSI) and questionnaire and re-assessed at 3 months and 3 years. The intervention was psychological debriefing as recommended and described in the literature.

RESULTS

The intervention group had a significantly worse outcome at 3 years in terms of general psychiatric symptoms (BSI), travel anxiety when being a passenger, pain, physical problems, overall level of functioning, and financial problems. Patients who initially had high intrusion and avoidance symptoms (IES) remained symptomatic if they had received the intervention, but recovered if they did not receive the intervention.

CONCLUSIONS

Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims.

Posttraumatic stress disorder following political imprisonment: the role of mental defeat, alienation, and perceived permanent change

An interview study of 81 former political prisoners investigated whether posttraumatic stress disorder (PTSD) is related to the way individuals process the prison experience. In contrast to participants without PTSD, those with chronic or remitted PTSD were more likely to perceive mental defeat and an overall feeling of alienation from other people. Chronic PTSD was also related to perceived negative and permanent change in their personalities or life aspirations. The groups did not differ in their attempts to gain control during imprisonment. Evidence for a relationship between political commitment and PTSD was mixed. The results suggest that mental defeat, alienation, and permanent change are related to PTSD after interpersonal trauma and may need to be addressed in treatment.

A cognitive model of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or its sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualization, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies have provided preliminary support for several aspects of the model.

Heartbeat perception in panic disorder: a reanalysis

This article describes a reanalysis of seven studies on heart beat perception (HBP) in panic disorder. The pooled sample had 709 participants from eight diagnostic categories. Accurate HBP was uncommon, but more prevalent among panic disorder patients than among healthy controls, depressed patients, patients with palpitations and individuals with infrequent panic attacks. No differences were found between panic disorder patients and patients with other anxiety disorders. Accurate perceivers had higher anxiety sensitivity scores than inaccurate perceivers. The data remain inconclusive as to whether perceived heart rate is correlated with anxiety in inaccurate perceivers. Physical exercise, distraction, variations in instructions and treatment each influenced HBP. However, the influence was different than previously thought. Finally, it is suggested that HBP may be understood in terms of schema-guided information processing.

PTSD symptoms, response to intrusive memories and coping in ambulance service workers

OBJECTIVES

To examine the relationship of coping strategies and responses to intrusive memories with post-traumatic stress disorder (PTSD) and other psychiatric symptoms in ambulance service workers.

METHOD

Fifty-six ambulance service workers describe the most distressing aspects of their work and completed questionnaires designed to measure their coping strategies in dealing with distressing incidents. They also described their intrusive memories of particularly distressing incidents and completed a questionnaire designed to measure their interpretation of these intrusions and their responses to them. In addition, they completed the Post-traumatic Stress Symptom Scale (PSS; Foa, Riggs, Dancu & Rothbaum, 1993) and the General Health Questionnaire (GHQ; Goldberg & Hiller, 1979).

RESULTS

Of the participants, 21% met DSM-III-R criteria for PTSD, and 22% met GHQ screening criteria for psychiatric symptoms. Wishful thinking and mental disengagement when confronted with critical incidents at work, negative interpretations of intrusive memories, and maladaptive responses to these memories (rumination, suppression and dissociation) correlated with PTSD severity.

CONCLUSION

The results are consistent with the hypothesis that coping strategies and responses to intrusive memories that prevent emotional processing of the distressing event maintain PTSD. They also support Ehlers & Steil's (1995) hypotheses about the role of negative interpretations of post-traumatic intrusions in PTSD. A substantial subgroup of emergency service personnel may need support in processing distressing incidents at work and may benefit from information that normalizes post-traumatic symptoms such as intrusions.

Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault

Cognitive factors hypothesised to influence the development and maintenance of PTSD were investigated. 92 assault victims completed questionnaires assessing a range of cognitive variables. Factors relating to onset of PTSD were investigated by comparing victims who did and who did not suffer PTSD. Factors relating to maintenance of PTSD were investigated by comparing victims who had recovered from PTSD with victims who had persistent PTSD. Cognitive factors associated with both onset and maintenance of PTSD were: appraisal of aspects of the assault itself (mental defeat, mental confusion, appraisal of emotions); appraisal of the sequelae of the assault (appraisal of symptoms, perceived negative responses of others, permanent change); dysfunctional strategies (avoidance/safety seeking) and global beliefs impacted by assault. Cognitive factors that were associated only with the onset of PTSD were: detachment during assault; failure to perceive positive responses from others and mental undoing. Relationships between the cognitive variables and PTSD remained significant when variations in perceived and objective assault severity were statistically controlled. The cognitive factors identified in the study may contribute to PTSD directly, by generating a sense of ongoing threat, or indirectly, by motivating cognitive and behavioural strategies that prevent recovery, or by affecting the nature of the traumatic memory.

Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents

A prospective longitudinal study assessed 967 consecutive patients who attended an emergency clinic shortly after a motor vehicle accident, again at 3 months, and at 1 year. The prevalence of posttraumatic stress disorder (PTSD) was 23.1% at 3 months and 16.5% at 1 year. Chronic PTSD was related to some objective measures of trauma severity, perceived threat, and dissociation during the accident, to female gender, to previous emotional problems, and to litigation. Maintaining psychological factors, that is, negative interpretation of intrusions, rumination, thought suppression, and anger cognitions, enhanced the accuracy of the prediction. Negative interpretation of intrusions, persistent medical problems, and rumination at 3 months were the most important predictors of PTSD symptoms at 1 year. Rumination, anger cognitions, injury severity, and prior emotional problems identified cases of delayed onset.

Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents

A prospective longitudinal study assessed 967 consecutive patients who attended an emergency clinic shortly after a motor vehicle accident, again at 3 months, and at 1 year. The prevalence of posttraumatic stress disorder (PTSD) was 23.1% at 3 months and 16.5% at 1 year. Chronic PTSD was related to some objective measures of trauma severity, perceived threat, and dissociation during the accident, to female gender, to previous emotional problems, and to litigation. Maintaining psychological factors, that is, negative interpretation of intrusions, rumination, thought suppression, and anger cognitions, enhanced the accuracy of the prediction. Negative interpretation of intrusions, persistent medical problems, and rumination at 3 months were the most important predictors of PTSD symptoms at 1 year. Rumination, anger cognitions, injury severity, and prior emotional problems identified cases of delayed onset.

Predicting response to exposure treatment in PTSD: the role of mental defeat and alienation

Not all patients with posttraumatic stress disorder benefit from exposure treatment. The present paper describes two cognitive dimensions that are related to inferior response to exposure in rape victims. First, individuals whose memories during relieving of the trauma reflected mental defeat or the absence of mental planning showed little improvement. Second, inferior outcome was correlated with an overall feeling of alienation or permanent change following the trauma. These results are based on blind ratings of transcripts of exposure treatment sessions from 10 women with good outcome and 10 women with inferior outcome. Patients in the two groups were matched for initial symptom severity and were comparable in many aspects of the assault. Patients who experienced mental defeat, alienation, or permanent change may require cognitive restructuring in addition to exposure.

Dysfunctional cognitions and adult psychological functioning in child sexual abuse survivors

Two studies explored the relationship between cognitions and long-term symptoms in adult child sexual abuse (CSA) survivors. In Study 1, an American sample of 43 survivors completed questionnaires assessing attributional style and dysfunctional beliefs in cognitive themes affected by victimization, as well as measures of posttraumatic symptoms. Survivors' attributions of negative events were more internal, stable, and global than those of 29 comparison subjects without a history of CSA. However, only the globality scale was significantly related with severity of long-term symptoms. High correlations between dysfunctional beliefs concerning safety, trust, esteem, or intimacy, and posttrauma symptoms were found. The latter finding was replicated in Study 2 with a German sample of 35 CSA survivors, even when controlling for frequency of abuse.