Neural valuation of rewards and punishments in posttraumatic stress disorder: a computational approach

Posttraumatic stress disorder (PTSD) is associated with changes in fear learning and decision-making, suggesting involvement of the brain's valuation system. Here we investigate the neural mechanisms of subjective valuation of rewards and punishments in combat veterans. In a functional MRI study, male combat veterans with a wide range of posttrauma symptoms (N = 48, Clinician Administered PTSD Scale, CAPS-IV) made a series of choices between sure and uncertain monetary gains and losses. Activity in the ventromedial prefrontal cortex (vmPFC) during valuation of uncertain options was associated with PTSD symptoms, an effect which was consistent for gains and losses, and specifically driven by numbing symptoms. In an exploratory analysis, computational modeling of choice behavior was used to estimate the subjective value of each option. The neural encoding of subjective value varied as a function of symptoms. Most notably, veterans with PTSD exhibited enhanced representations of the saliency of gains and losses in the neural valuation system, especially in ventral striatum. These results suggest a link between the valuation system and the development and maintenance of PTSD, and demonstrate the significance of studying reward and punishment processing within subject.

COVID-19 Traumatic Disaster Appraisal and Stress Symptoms Among Health Care Workers: Insights From the Yale Stress Self-assessment

OBJECTIVE

To determine to what extent did health care workers experience the pandemic as a severe stress event.

METHODS

This cross-sectional evaluation of 8299 health care workers, representing a 22% response rate, utilized machine learning to predict high levels of escalating stress based on demographics and known predictors for adverse psychological outcomes after trauma.

RESULTS

A third of health care workers experienced the pandemic as a potentially traumatic stress event; a greater proportion of health care workers experienced high levels of escalating stress. Predictive factors included sense of control, ability to manage work-life demands, guilt or shame, age, and level of education. Gender was no longer predictive after controlling for other factors. Escalating stress was especially high among nonclinical academics and clinical private practitioners.

CONCLUSION

Findings suggest adverse effects on total worker health, care quality, professionalism, retention, and acute and chronic mental health.

A prospective study of transdiagnostic psychiatric symptoms associated with burnout and functional difficulties in COVID-19 frontline healthcare workers

OBJECTIVE

Frontline healthcare workers (FHCWs) responding to the COVID-19 pandemic develop posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and generalized anxiety disorder (GAD) symptoms. Such symptoms are associated with burnout, occupational and relational difficulties. In the current study, we examined the prospective association between acute transdiagnostic COVID-19-related PTSD, MDD, and GAD symptoms at pandemic outset, and burnout and functional difficulties several months later in FHCWs in New York City.

METHODS

Wave 1 symptoms of COVID-19-related PTSD, MDD, and GAD, were assessed in 787 FHCWs from April 14 to May 11th, 2020. Burnout and occupational difficulties were assessed at wave 1 and wave 2, approximately 7 months later.

RESULTS

After adjusting for wave 1 burnout, wave 1 MDD symptoms, particularly sleep difficulties, loss of interest, and feeling tired/having little energy, collectively explained 42% incremental variance in this outcome. After adjusting for wave 1 work difficulties, MDD and PTSD symptoms, particularly feeling tired/having little energy, loss of interest, and negative expectations of self/world, collectively explained 42% incremental variance in this outcome. After adjusting for wave 1 relationship difficulties, MDD, GAD, and PTSD symptoms, particularly depressed mood, irritability, and appetite disturbance, explained 26% incremental variance in this outcome.

CONCLUSIONS

Results highlight psychiatric symptoms assessed during the acute phase of the COVID-19 pandemic that may help predict burnout and work and relationship difficulties in FHCWs. Early interventions aimed at ameliorating transdiagnostic symptoms of MDD, PTSD, and GAD may help mitigate risk for burnout and functional difficulties in this population.

Psychological Consequences Among Residents and Fellows During the COVID-19 Pandemic in New York City: Implications for Targeted Interventions

PURPOSE

To examine the psychological impact of the COVID-19 pandemic on medical trainees (residents and fellows) working at Mount Sinai Hospital (MSH) in New York City (NYC), the initial epicenter of the United States pandemic.

METHOD

The authors administered a survey to 991 trainees in frontline specialties working at MSH in NYC between April and May 2020. The instrument assessed symptoms of major depressive disorder, generalized anxiety disorder, COVID-19-related posttraumatic stress disorder, and burnout. Psychiatric screens were aggregated into 1 composite measure, and meeting criteria on any of the 3 scales was considered a positive screen for psychiatric symptoms. The survey also assessed COVID-19-related exposures, worries, coping strategies, and desired interventions. Multivariable logistic regressions were conducted to identify factors associated with psychiatric symptoms and burnout.

RESULTS

Of the 560 respondents (56.6% response rate), 29.7% screened positive for psychiatric symptoms and 35.8% screened positive for burnout. History of a mental illness, COVID-19-related duties and personal/career worries, and coping by substance use were associated with increased likelihood of screening positive for psychiatric symptoms. Positive emotion-focused coping and feeling valued by supervisors were associated with decreased likelihood. Internal medicine and surgical specialties, a history of mental illness, increased duty hours, duty-related worries, personal/career worries, coping via self-blame and venting, and coping via substance use were associated with higher odds of burnout. Feeling valued by supervisors was associated with decreased burnout odds. The most common crisis-related needs included access to personal protective equipment, food provisions, and financial support.

CONCLUSIONS

Psychological distress and burnout affected approximately one-third of trainees sampled during the height of the pandemic in NYC. As the pandemic surged beyond NYC, these findings suggest that interventions should include addressing basic needs, promoting leadership affirmation, moderating duty hours, supporting trainees financially, and enhancing mental health support.

Resilience in the age of COVID-19

Resilience is broadly defined as the ability to bounce back from adversity or trauma. Recent advances in resilience research have shifted away from merely describing individual characteristics towards focusing on the complex interactions between individuals and their dynamic personal, community and cultural contexts. It is clear that resilience involves both neurobiological and cultural processes. Neurobiological contributions include genes, epigenetics, stress-response systems, the immune system and neural circuitry. Culture helps to elucidate collective systems of belief and accepted positive adaptations. Importantly, resilience can also be affected by evidence-based interventions and deliberate practice on the part of the individual. This review seeks to understand resilience as a complex and active process that is shaped by neurobiological profiles, developmental experiences, cultural and temporal contexts, and practical training. It uses the COVID-19 pandemic as a case example to better understand individual and group responses to tragedy. We suggest practical recommendations to help populations around the world cope and recover from the global threat of COVID-19.

Mindfulness as a mediator between trauma exposure and mental health outcomes: Results from the National Health and Resilience in Veterans Study

OBJECTIVE

Exposure to traumatic life events is associated with increased risk of posttraumatic stress disorder (PTSD) and other mental health problems such as suicidal ideation (SI), alcohol use disorder (AUD), and decreased quality of life (QOL). Mindfulness, which involves attending to the present moment, may help individuals cope with traumatic events by increasing acceptance of trauma-related experiences and decreasing trauma-related negative affect and avoidance of trauma reminders. The current study evaluated whether mindful attention to the present moment mediated the association between number of lifetime traumas and mental health.

METHOD

The sample consisted of 1,268 trauma-exposed U.S. veterans who participated in the National Health and Resilience in Veterans Study, a nationally representative study of U.S. veterans. On average, the sample was 60.6 years of age (SD = 15.2, range = 20-94), predominantly male (89.8%), Caucasian (75.0%), and noncombat veterans (59.2%).

RESULTS

Path analyses revealed that mindfulness partially mediated the relation between number of lifetime traumas and PTSD symptoms (β = -.55), AUD (β = -.17), and QOL (β = .38), and fully mediated the relation between number of lifetime traumas and SI (β = -.36).

CONCLUSIONS

The relationship between lifetime trauma burden and various mental health issues of relevance to U.S. veterans may be mediated by mindfulness, or the ability to pay attention to the present moment. Interventions that bolster mindfulness may help mitigate the negative impact of cumulative traumas in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trauma- and Stress-Induced Craving for Alcohol in Individuals Without PTSD

AIMS

The main objective of the study was to compare the differences in craving following trauma and stress scripts in individuals with alcohol dependence (AD) who have experienced trauma but did not meet criteria for post-traumatic stress disorder (PTSD).

METHODS

Twenty-eight men and women who participated in a treatment trial were included in this study before starting treatment. All had to meet criteria for AD and had experienced trauma at some point of their lives but were never diagnosed with PTSD. All participants had one laboratory session and were exposed to stress, trauma and neutral scripts randomly assigned. Main measures of craving, anxiety and mood were administered before, during and after each script.

RESULTS

Stress and trauma scripts induced significantly more craving and anxiety than the neutral scripts. Interestingly, stress scripts produced stronger craving and anxiety than the trauma scripts but only with some measures. Stress and trauma scripts produced significantly more fear, anger and sadness and significantly lower ratings of joy and relaxation than the neutral script. Again, there were no differences between stress and trauma scripts for any of the emotional subscales.

CONCLUSIONS

Trauma scripts did not result in stronger craving than stress scripts. These findings suggest that trauma in the absence of PTSD diagnosis does not lead to stronger craving for alcohol.

Neural computations of threat in the aftermath of combat trauma

By combining computational, morphological, and functional analyses, this study relates latent markers of associative threat learning to overt post-traumatic stress disorder (PTSD) symptoms in combat veterans. Using reversal learning, we found that symptomatic veterans showed greater physiological adjustment to cues that did not predict what they had expected, indicating greater sensitivity to prediction errors for negative outcomes. This exaggerated weighting of prediction errors shapes the dynamic learning rate (associability) and value of threat predictive cues. The degree to which the striatum tracked the associability partially mediated the positive correlation between prediction-error weights and PTSD symptoms, suggesting that both increased prediction-error weights and decreased striatal tracking of associability independently contribute to PTSD symptoms. Furthermore, decreased neural tracking of value in the amygdala, in addition to smaller amygdala volume, independently corresponded to higher PTSD symptom severity. These results provide evidence for distinct neurocomputational contributions to PTSD symptoms.

Posttraumatic Stress Disorder: an integrated overview and neurobiological rationale for pharmacology

Thirty years of research on the biology of posttraumatic stress disorder now provides a foundation for hypotheses related to the mechanisms underlying the pharmacotherapy of this disorder. Only two medications, sertraline and paroxetine, are approved by the U.S. Food and Drug Administration for the treatment of PTSD. While these medications are somewhat effective, other treatment mechanisms must be explored to address the unmet need for effective treatment. This article provides a concise summary of advances in our understanding of the neurobiology of PTSD that suggest novel approaches to pharmacotherapy.

Real-Time fMRI Neurofeedback with War Veterans with Chronic PTSD: A Feasibility Study

Many patients with post-traumatic stress disorder (PTSD), especially war veterans, do not respond to available treatments. Here, we describe a novel neurofeedback (NF) intervention using real-time functional magnetic resonance imaging for treating and studying PTSD. The intervention involves training participants to control amygdala activity after exposure to personalized trauma scripts. Three combat veterans with chronic PTSD participated in this feasibility study. All three participants tolerated well the NF training. Moreover, two participants, despite the chronicity of their symptoms, showed clinically meaningful improvements, while one participant showed a smaller symptom reduction. Examination of changes in resting-state functional connectivity patterns revealed a normalization of brain connectivity consistent with clinical improvement. These preliminary results support feasibility of this novel intervention for PTSD and indicate that larger, well-controlled studies of efficacy are warranted.

PTSD: from neurobiology to pharmacological treatments

Posttraumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder characterized by symptoms of re-experience, avoidance, and hyperarousal that can arise immediately or many years after exposure to a traumatic event and injury. Although extensive research has been done over the past 30 years, the etiology of PTSD remains largely unknown. Several neurobiological systems have been implicated in the pathophysiology and vulnerability for developing PTSD; however, first-line pharmacotherapies are limited. Less than 30% achieve full remission, and even then, approved pharmacological treatments often take weeks for therapeutic effect. This article aims to review the pathophysiology of PTSD within multiple neurobiological systems and how these mechanisms are used as pharmacologic targets of treatment, as well as their potential for future targets of intervention.

What I have changed my mind about and why

This paper is based upon a panel discussion "What I Have Changed My Mind About and Why" held on 5 November in New Orleans, Louisiana (USA), as part of the ISTSS 2015 annual meeting "Back to Basics: Integrating Clinical and Scientific Knowledge to Advance the Field of Trauma." The panel was chaired by Professor Dr. Rachel Yehuda of the Icahn School of Medicine at Mount Sinai and the James J. Peters Veterans Affairs, and included five clinician-scholars who exchanged thoughts about what they have changed their minds about over the years: Dr. David Spiegel, Dr. Steven Southwick, Dr. Lori Davis, Dr. Thomas Neylan, and Dr. John Krystal. This paper provides a summary of the salient points made by each expert and the questions and discussion that ensured. Major issues raised included the increasingly clear limitations to the fear-based model that has advanced the field. While treatments for PTSD have improved, there are some aspects of trauma exposure that cannot be entirely repaired. Research providing an evidence base to treatment has led to overly specific treatment guidelines that may obscure more general principles of effective treatment. Treatment might be viewed as a way to increase the plasticity of the brain in the context of processing social cues. A variety of novel and integrative therapies include comprehensive holistic care, exercise, returning to competitive work, logotherapy, mindfulness, enhancing well-being and resilience, and medications with novel mechanisms, such as ketamine.

Prazosin for Veterans with Posttraumatic Stress Disorder and Comorbid Alcohol Dependence: A Clinical Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is an important and timely clinical issue particularly for combat veterans. Few pharmacologic options are available to treat PTSD, particularly among military personnel, and they are not based on rational neurobiology. The evidence for noradrenergic dysregulation in PTSD is strong, and the alpha-adrenergic agonist prazosin is one of the most promising medications to treat sleep disturbances associated with PTSD as well as PTSD symptoms among both veterans and civilians. Evidence also implicates noradrenergic dysregulation in the pathophysiology of alcohol dependence (AD); prazosin also may have efficacy in treating this disorder. The use of prazosin represents a rational and compelling approach for the treatment of PTSD and comorbid AD. Given the high rates of comorbid AD in trauma survivors with PTSD, and the enormous impact that these comorbid disorders have on psychosocial function and well-being, finding effective treatments for this population is of high clinical importance.

METHODS

Ninety-six veterans with PTSD and comorbid AD were randomized to receive prazosin (16 mg) or placebo in an outpatient, randomized, double-blind, clinical trial for 13 weeks. Main outcomes included symptoms of PTSD, sleep disturbances, and alcohol use.

RESULTS

Symptoms of PTSD improved over time, but contrary to the hypothesis, there was no medication effect on PTSD symptoms, or on sleep. Alcohol consumption also decreased over time, but there were no significant differences in outcomes between medication groups.

CONCLUSIONS

Prazosin was not effective in treating PTSD symptoms, improving sleep, or reducing alcohol consumption overall in this dually diagnosed group. This does not support the use of prazosin in an actively drinking population and suggests that the presence of a comorbid condition affects the efficacy of this medication. This study highlights the importance of conducting clinical trials in "real-world" patients, as results may vary based on comorbid conditions.

Perspective: I believe what I remember, but it may not be true

A growing number of research findings have challenged the conception that memory for traumatic events is highly accurate or even indelible in nature. Research involving soldiers indicates that realistic levels of high stress decrease the accuracy of eyewitness memory. In addition, recent findings from several studies show quite clearly that memories for stressful events - including those from combat trauma - are malleable and vulnerable to alteration by exposure to misinformation. Under high stress, our brains facilitate the formation of "gist" memories that allow us to avoid future dangers but which may not contain the detail and precision demanded by the judicial system. Although mental health professionals ought to play a role in educating the courts about mental illness and trauma, it is unwise for them to become advocates for the idea that traumatic memories are indelible, factual accounts of events.

Misinformation can influence memory for recently experienced, highly stressful events

A large body of research has demonstrated that exposure to misinformation can lead to distortions in human memory for genuinely experienced objects or people. The current study examined whether misinformation could affect memory for a recently experienced, personally relevant, highly stressful event. In the present study we assessed the impact of misinformation on memory in over 800 military personnel confined in the stressful, mock POW camp phase of Survival School training. Misinformation introduced after the negatively affected memory for the details of the event (such as the presence of glasses or weapons), and also affected the accuracy of identification of an aggressive interrogator. In some conditions more than half of the subjects exposed to a misleading photograph falsely identified a different individual as their interrogator after the interrogation was over. These findings demonstrate that memories for stressful events are highly vulnerable to modification by exposure to misinformation, even in individuals whose level of training and experience might be thought to render them relatively immune to such influences.

Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study

BACKGROUND

More than 50,000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities.

METHODS

In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27,449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud).

FINDINGS

9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders.

INTERPRETATION

9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population.

FUNDING

Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health.

Stories behind the symptoms: a qualitative analysis of the narratives of 9/11 rescue and recovery workers

A qualitative study of the experiences of rescue and recovery workers/volunteers at Ground Zero following the terrorist attacks of 9/11/01 is reported. Information was extracted from a semi-structured clinical evaluation of 416 responders who were the initial participants in a large scale medical and mental health screening and treatment program for 9/11 responders. Qualitative analysis revealed themes that spanned four categories- occupational roles, exposures, attitudes/experiences, and outcomes related to the experience of Ground Zero. Themes included details regarding Ground Zero roles, grotesque experiences such as smells, the sense of the surreal nature of responding, and a turning to rituals to cope after leaving Ground Zero. These findings personalize the symptom reports and diagnoses that have resulted from the 9/11 responders' exposure to Ground Zero, yielding richer information than would otherwise be available for addressing the psychological dimensions of disasters. This work shows that large scale qualitative surveillance of trauma-exposed populations is both relevant and feasible.

Enduring mental health morbidity and social function impairment in world trade center rescue, recovery, and cleanup workers: the psychological dimension of an environmental health disaster

BACKGROUND

The World Trade Center (WTC) attacks exposed thousands of workers to hazardous environmental conditions and psychological trauma. In 2002, to assess the health of these workers, Congress directed the National Institute for Occupational Safety and Health to establish the WTC Medical Monitoring and Treatment Program. This program has established a large cohort of WTC rescue, recovery, and cleanup workers. We previously documented extensive pulmonary dysfunction in this cohort related to toxic environmental exposures.

OBJECTIVES

Our objective in this study was to describe mental health outcomes, social function impairment, and psychiatric comorbidity in the WTC worker cohort, as well as perceived symptomatology in workers' children.

METHODS

Ten to 61 months after the WTC attack, 10,132 WTC workers completed a self-administered mental health questionnaire.

RESULTS

Of the workers who completd the questionnaire, 11.1% met criteria for probable post-traumatic stress disorder (PTSD), 8.8% met criteria for probable depression, 5.0% met criteria for probable panic disorder, and 62% met criteria for substantial stress reaction. PTSD prevalence was comparable to that seen in returning Afghanistan war veterans and was much higher than in the U.S. general population. Point prevalence declined from 13.5% to 9.7% over the 5 years of observation. Comorbidity was extensive and included extremely high risks for impairment of social function. PTSD was significantly associated with loss of family members and friends, disruption of family, work, and social life, and higher rates of behavioral symptoms in children of workers.

CONCLUSIONS

Working in 9/11 recovery operations is associated with chronic impairment of mental health and social functioning. Psychological distress and psychopathology in WTC workers greatly exceed population norms. Surveillance and treatment programs continue to be needed.

Cognitive-behavioral theory and preparation for professionals at risk for trauma exposure

Military personnel, emergency first responders, and others whose work environments include exposure to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). To help prevent negative sequelae, there is a strong need to identify well-operationalized, empirically supported, theoretically framed models of healthy adaptation to potentially traumatic events. Cognitive-behavioral theories (CBTs) describe etiological factors in trauma, guide research that has identified risk for PTSD, and help develop interventions that can effectively reduce posttrauma symptomatology. In this article, the authors draw on CBT and empirical research on post-traumatic stress to propose possible cognitive-behavioral mechanisms in trauma adaptation. They then suggest directions for future research, including areas for prevention interventions for at-risk professionals.

Social support and resilience to stress: from neurobiology to clinical practice

Numerous studies indicate social support is essential for maintaining physical and psychological health. The harmful consequences of poor social support and the protective effects of good social support in mental illness have been well documented. Social support may moderate genetic and environmental vulnerabilities and confer resilience to stress, possibly via its effects on the hypothalamic-pituitary-adrenocortical (HPA) system, the noradrenergic system, and central oxytocin pathways. There is a substantial need for additional research and development of specific interventions aiming to increase social support for psychiatrically ill and at-risk populations.

Accuracy of eyewitness identification is significantly associated with performance on a standardized test of face recognition

OBJECTIVES

This study assessed the relationship between Eyewitness Accuracy regarding a person met under conditions of high stress and performance on a standardized, neutral test of memory for human faces.

METHOD

Fifty-three U.S. Army personnel were exposed to interrogation stress. Forty-eight hours later, participants were administered the Weschler Face Test and then asked to identify the one interrogator who they had encountered 48 h earlier.

RESULTS

A significant positive relationship was observed between performance on the Weschler Face Test and performance on the Eyewitness task. Inaccurate eyewitnesses exhibited more False Negative errors when performing the Weschler Face Test.

DISCUSSION

Trait ability to remember human faces may be related to how accurately people recall faces that are associated with highly emotional circumstances. Detection probability methods, such as ROC curve analyses, may be of assistance to forensic examiners, the police, and the courts, when assessing the probability that eyewitness evidence is accurate.

Relation between cardiac vagal tone and performance in male military personnel exposed to high stress: three prospective studies

Vagal tone has been proposed both as an index of emotion regulation and cognitive ability. To assess the relation between vagal tone and emotion regulation and cognitive ability, the present research prospectively measured vagal tone (measured either as high-frequency spectral power or respiratory sinus arrhythmia) in healthy participants exposed to high stress. The participants were active duty military personnel (men) enrolled in high intensity military training: Survival School (Experiments 1 and 3) and Combat Diver Qualification Course (Experiment 2). We consistently observed a significant relationship between low vagal tone and superior performance. The data suggest that vagal suppression is associated with enhanced performance under conditions of high stress and that this enhanced performance may be related to emotion regulation and cognitive functioning.

Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare

CONTEXT

In the 1980-1988 Iran-Iraq War, extensive use of chemical weapons resulted in high rates of morbidity and mortality. While much is known about the physical consequences of chemical warfare, there is a paucity of information about the long-term effects of chemical attacks on mental health.

OBJECTIVE

To assess the long-term psychological impact of chemical warfare on a civilian population.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional randomized survey conducted in July 2004 of 153 civilians in 3 towns exposed to warfare in northwestern Iran: Oshnaviyeh (low-intensity conventional warfare), Rabat (high-intensity conventional warfare), and Sardasht (both high-intensity conventional warfare and chemical weapons).

MAIN OUTCOME MEASURES

Full or partial posttraumatic stress disorder (PTSD) diagnosis, anxiety symptoms, and depressive symptoms were assessed using Farsi versions of the Clinician-Administered PTSD Scale, Hamilton Scale for Anxiety, and Beck Depression Inventory, respectively.

RESULTS

Overall participation rate was 93%. Respondents had a mean age of 45 years and were all of Kurdish ethnicity. Among individuals exposed to both high-intensity warfare and chemical weapons, prevalence rates for lifetime PTSD, current PTSD, major anxiety symptoms, and severe depressive symptoms were 59%, 33%, 65%, and 41%, respectively. Among the low-intensity warfare group, the corresponding rates were 8%, 2%, 18%, and 6%, respectively, while intermediate rates were found among those exposed to high-intensity warfare but not to chemical weapons (31%, 8%, 26%, and 12%, respectively). Compared with individuals exposed to low-intensity warfare, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (odds ratio [OR], 18.6; 95% confidence interval [CI], 5.8-59.4), current PTSD (OR, 27.4; 95% CI, 3.4-218.2), increased anxiety symptoms (OR, 14.6; 95% CI, 6.0-35.6), and increased depressive symptoms (OR, 7.2; 95% CI, 3.3-15.9). Exposure to high-intensity warfare but not to chemical weapons was also significantly associated with lifetime PTSD (OR, 5.4; 95% CI, 1.7-17.6), compared with those in the low-intensity warfare group. Further, compared with individuals exposed to high-intensity warfare alone, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (OR, 3.4; 95% CI, 1.5-7.4), current PTSD (OR, 6.2; 95% CI, 2.0-20.1), increased anxiety symptoms (OR, 5.6; 95% CI, 2.5-12.6), and increased depressive symptoms (OR, 3.7; 95% CI, 1.8-7.2).

CONCLUSION

Exposure to chemical warfare is an extreme traumatic event that has long-lasting adverse consequences on mental health.

Developing an Agenda for Translational Studies of Resilience and Vulnerability Following Trauma Exposure

Here we outline a translational research agenda for studies of resilience, defined as the process of adapting well in the face of adversity or trauma. We argue that an individual differences approach to the study of resilience, in which the full range of behavioral and biological responses to stress exposure is examined can be applied across human samples (e.g., people who have developed psychopathology versus those who have not; people who have been exposed to trauma versus those who have not) and even, in some cases, across species. We delineate important psychological resilience-related factors including positive affectivity and optimism, cognitive flexibility, coping, social support, emotion regulation, and mastery. Key brain regions associated with stress-related psychopathology have been identified with animal models of fear (e.g., extinction and fear conditioning; memory reconsolidation) and we describe how these regions can be studied in humans using neuroimaging technology. Finally, we cite recent research identifying neuroendocrine markers of resilience and recovery in humans (e.g., neuropeptide Y [NPY], dehydroepiandrosterone [DHEA]) that can also be measured, in some cases, in other species. That exposure to adversity or trauma does not necessarily lead to impairment and the development of psychopathology in all people is an important observation. Understanding why this is so will provide clues for the development of therapeutic interventions for those people who do develop stress-related psychopathology, or even for the prevention of adverse outcomes.

Brain derived neurotrophic factor (BDNF) gene variants and Alzheimer's disease, affective disorders, posttraumatic stress disorder, schizophrenia, and substance dependence

Genetic variation at the locus encoding the brain derived neurotrophic factor (BDNF) has been implicated in some neuropsychiatric disorders such as Alzheimer's disease (AD), affective disorders (AFDs), schizophrenia, and substance dependence. We therefore performed a mutation scan of the BDNF gene to identify novel gene variants and examined the association between BDNF variants and several neuropsychiatric phenotypes in European American (EA) subjects and controls. Using denaturing high performance liquid chromatography (dHPLC), we identified a novel variant (G-712A) in the putative promoter region. This variant and two previously reported BDNF SNPs (C270T and Val66Met) were genotyped in 295 patients with AD, 108 with AFDs, 96 with posttraumatic stress disorder (PTSD), 84 with schizophrenia, 327 with alcohol and/or drug dependence, and 250 normal control subjects. No association was found between these three BDNF gene variants and AD, AFDs, PTSD, or schizophrenia. However, there was a nominally higher frequency of the G-712A G-allele and the G/G genotype in subjects with substance dependence than in controls (Allele: chi(2) = 4.080, df = 1, P = 0.043; Genotype: chi(2) = 7.225, df = 2, P = 0.027). Although after correction for multiple testing, the findings are not considered significant (threshold P-value was set at 0.020 by the program SNPSpD), logistic regression analyses confirmed the modest association between SNP G-712A and substance dependence, when the sex and age of subjects were taken into consideration. The negative results for AFDs, PTSD, and schizophrenia could be due to the low statistical power. Further study with larger samples is warranted.

Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels

BACKGROUND

Exposure to uncontrollable stress reduces baseline plasma neuropeptide-Y levels in animals. We previously reported that baseline plasma neuropeptide-Y levels, as well as neuropeptide-Y responses to yohimbine, were lower in combat veterans with posttraumatic stress disorder, but we were unable to determine whether this was attributable to posttraumatic stress disorder or trauma exposure. The current report addresses this issue.

METHODS

A) Baseline plasma neuropeptide-Y levels were measured in 8 healthy combat veterans compared to 18 combat veterans with posttraumatic stress disorder and 8 healthy nontraumatized subjects; and B) Baseline plasma neuropeptide-Y levels, trauma exposure, and posttraumatic stress disorder symptoms were assessed in 41 active military personnel.

RESULTS

Plasma neuropeptide-Y was negatively associated with trauma exposure but not posttraumatic stress disorder symptoms in active duty personnel. Baseline neuropeptide-Y was reduced in combat veterans with and without posttraumatic stress disorder.

CONCLUSIONS

Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels. Future studies must determine if neuropeptide-Y reactivity differentiates trauma-exposed individuals with and without posttraumatic stress disorder.

A functional neuropeptide Y Leu7Pro polymorphism associated with alcohol dependence in a large population sample from the United States

BACKGROUND

Quantitative trait locus studies, and observations in animals manipulated for the neuropeptide Y (NPY) gene suggest that variation within this gene may contribute to alcoholism. A recent population study suggested that the Pro7 allele of a functional NPY polymorphism (Leu7Pro) may be associated with increased alcohol consumption. We tested whether the Pro7 allele is associated with alcohol dependence in European Americans (EA).

METHODS

The design was a population study comparing the Leu7Pro allele frequencies in alcohol-dependent subjects and controls. Population stratification potential and diagnostic specificity was studied by genotyping individuals from additional populations and psychiatric diagnostic classes. We studied 2 independently collected samples of EA alcohol-dependent subjects (sample 1, n = 307; sample 2, n = 160) and a sample of psychiatrically screened EA controls (n = 202); 8 population samples, including African Americans and European Americans (total n = 551); and 4 samples of individuals with Alzheimer disease, schizophrenia, posttraumatic stress disorder, and major depression (total n = 502). The main outcome measure was the difference in Leu7Pro allele frequencies between alcohol-dependent subjects and controls.

RESULTS

The frequency of the Pro7 allele was higher in the alcohol-dependent subjects (sample 1, 5.5%; sample 2, 5.0%) compared with the screened EA controls (2.0%) (sample 1 vs controls, P=.006; sample 2 vs controls, P=.03). The attributable fraction (excess morbidity) in similarly affected populations, owing to the Pro7 allele, was estimated to be 7.3%. The frequency of the Pro7 allele was equal or lower in the population samples, as compared with the screened EA controls (0%-2.2%), with 1 exception (Bedouins). We found no significant evidence that the association of the Pro7 allele with alcohol dependence was due to an association with a comorbid psychiatric disorder.

CONCLUSIONS

These results suggest that the NPY Pro7 allele is a risk factor for alcohol dependence. This is only the second specific genetic mechanism ever identified that modulates risk for alcohol dependence.

Marked lability in urinary cortisol levels in subgroups of combat veterans with posttraumatic stress disorder during an intensive exposure treatment program

OBJECTIVE

The objective of this study was to obtain longitudinal data on lability of cortisol levels in posttraumatic stress disorder (PTSD) because previous studies have largely been based on sampling at a single time point and have yielded varying results.

METHODS

This study measured urinary cortisol levels at admission, midcourse, and discharge during a 90-day hospitalization period in male Vietnam combat veterans with PTSD (N = 51).

RESULTS

Although there were no significant differences in the mean +/- SEM urinary cortisol levels between the admission (59.4 +/- 3.0 microg/d), midcourse (55.6 +/- 3.9 microg/d), and discharge (53.4 +/- 3.4 microg/d) values, marked lability of cortisol levels in individual patients was observed over time, with changes ranging from +93 to -58 microg/d from admission to midcourse. In addition, this hormonal lability defined discrete subgroups of patients on the basis of the longitudinal pattern of cortisol change during exposure treatment, and there were significant psychometric differences in the level of social functioning between these subgroups.

CONCLUSIONS

The findings do not support the concept of either a static "hypocortisolism" or "hypercortisolism" in PTSD, but rather suggest a psychogenic basis for cortisol alterations in PTSD in relation to psychosocial stress and indicate a central regulatory dysfunction of the hypothalamic-pituitary-adrenal axis characterized by a dynamic tendency to overreact in both upward and downward directions. The longitudinal findings fit with recent observations that cortisol elevations occur when acutely superimposed stressful conditions emotionally engage patients and overwhelm the usually dominating disengaging coping mechanisms associated with suppression of cortisol levels in PTSD. The findings emphasize the importance of longitudinal data in studies of the hypothalamic-pituitary-adrenal axis in PTSD.

Scoring accuracy using the comprehensive system for the Rorschach

The Comprehensive System (CS; Exner, 1974, 1978) for scoring Rorschach responses is the most widely taught and most widely accepted system in use today. The complexity and labor- intensive nature of the CS makes the issue of scoring accuracy a central concern. Twenty-one graduate psychology students and 12 professionals scored 20 Rorschach responses drawn from normal and clinical protocols. In general. accuracy scores for both students and professionals were below acceptable levels. Accuracy scores were clearly better for the code categories of Location, DQ, Pairs, Popular, and Z than for Determinants, FQ, Content, and Special Scores. Responses from clinical protocols were subject to more error. The results suggest that high levels of scoring errors may exist in the field use of the CS. Training standards may need to be devised to insure scoring competence.

The affective and memorial components of distinctiveness-based illusory correlations

Two studies were conducted to test a model of the distinctiveness-based illusory correlation (IC) phenomenon that suggests there are two components operating with ICs: cognitive memorial, and affective. In Expt 1 (N = 118), two stimulus arrays were developed that were equivalent in regards to valence (good or bad extremity) but differed in regards to the affect dimension (high or low emotional intensity). Consistent with predictions drawn from the proposed model, the magnitude of the IC effect was higher in the high emotional intensity than in the low emotional intensity condition, but only significantly so on the measures (estimation and general evaluation) that have been hypothesized to be most sensitive to the affective component. In Expt 2 (N = 52), the affective qualities were matched and the valence properties varied in two stimulus arrays. As predicted, the IC effect differed significantly between conditions only on the measure (assignment) thought to be most sensitive to the memorial component. The results are discussed in terms of the implications of the findings for the proposed mechanisms of illusory correlation.

The role of marital interaction in chronic pain and depressive symptom severity

Several investigators have noted the moderating role of the spouse in determining the severity and disability associated with the experience of chronic pain. In this study, pain-contingent responses from spouses, but not global marital satisfaction, accounted for a significant proportion of the variance in reported pain severity. Global marital satisfaction predicted depressive symptom severity. The interaction between global marital satisfaction and the reported frequency of punishing responses to pain behavior added significantly to the prediction of depressive symptoms. Similarly, the interaction between marital satisfaction and degree of spouse solicitousness significantly predicted pain severity. These results are consistent with evolving literatures on the important relationship between marital distress, aversive communication and depression on the one hand, and the potentially deleterious role of the solicitous spouse in the maintenance of chronic pain on the other.

No association between D2 dopamine receptor (DRD2) "A" system alleles, or DRD2 haplotypes, and posttraumatic stress disorder

BACKGROUND

Association studies between marker alleles at the D2 dopamine receptor gene (DRD2) and various psychiatric illnesses have produced conflicting results. Reports of allelic associations were originally made with alcoholism, but were then extended to other psychiatric disorders, including posttraumatic stress disorder (PTSD).

METHODS

We studied allele frequency of the DRD2 TaqI "A," "B," and "D" system markers in 52 European-American subjects with diagnoses of PTSD (based on structured interviews).

RESULTS

Frequency of the A1 allele in this sample was .15, not significantly different from the .19 allele frequency seen in 87 control subjects. We were thus unable to replicate the previous reports of allelic association between the DRD2 TaqI "A1" allele and PTSD. There were also no significant differences in allele frequency for the "B" or "D" systems. We then computed three marker (TaqI "A," "B," and "D" system) haplotypes for the sample; DRD2 haplotype frequencies also did not differ between control subjects and subjects with PTSD.

CONCLUSIONS

We conclude that DRD2 alleles are not associated with PTSD in this sample, and that genetic variation at the DRD2 locus is not likely to be an important contributor to risk for this disorder.

Comparison of outcome between homogeneous and heterogeneous treatment environments in combat-related posttraumatic stress disorder

This study compared treatment outcome at discharge, and 4, 8, and 12 month follow-up between an inpatient program consisting of a mixture of Vietnam combat veterans with posttraumatic stress disorder (PTSD) and general psychiatric patients (N = 42), and the same program at a later period, consisting of only Vietnam combat veterans with PTSD (N = 33). Veterans rated the homogeneous environment higher in satisfaction, support, order, clarity, and amount of discussion of combat, and lower in hostility, than the heterogeneous condition. However, veterans showed no improvement in condition at 12 month follow-up, with the exception of decreased violence, replicating earlier studies. No differences in outcome were found between homogeneous or heterogeneous treatment environments. This study underscores the enduring nature of chronic posttraumatic stress disorder in the veteran population.