+RISK, STRESS AND DISTRESS

Stress and distress

Resilience and Risk

4 chapter 4

Wednesday, July 30, 2008
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Wednesday, December 03, 2008

I need to write this tonight.  I have avoided my computer all day today after the revelation that I had last night when I again looked at the baby picture I have of myself at 11 ½ months old, enlarged from a picture I found in my “nonexistent” baby book, that I have hanging on my bedroom wall.  When I first discovered the picture and studied it over 2 years ago, I wanted to have that picture where I could see it (I have to shut my eyes while I write now, changing my alpha brain wave state) to remind myself of what I thought was my ability, still, at that age, to feel unbounding joy.

In the picture I am dressed in a frilly dress, hair curled, taken out for pictures.  Obviously not a time my mother would have abused me, not out in the open.  I have thought about that picture in terms of dissociation, that the happy baby and the hurt and terrified baby were even then two different people.  But I have thought that somehow maybe I could “get back” that kind of joy, that ability to feel as happy as I appear in that photograph.

But last night when I stopped in front of that picture and studied that little face, what I saw there, mirrored back to me, scared me as if it had suddenly turned into a demon with demon eyes.

The truth is that the intensity that I cannot modulate and cannot regulate that is inside me every living day is in the eys of that baby.  I now know that what is showing, though not “craziness,” is a visible sign of the brain damage already present before I was a year old.

I should not be surprised that I see that intensity now in those eyes, and see it for what it truly is.  Knowing what I know now is a testimony to the hard work and research I have done these past years as I have been working on this book.  The intensity in those eyes is painful.  The degree of emotion in that tiny body is painful, whether it looks happy or not.  No baby should every feel that INTENSITY of emotion.  Schore talks about that, that too much excitement is damaging to an infant’s growing brain and nervous system, whether the intensity is from a positive or a negative emotion.

It is a mother’s job to modulate an infant’s emotions by mirroring back the infant’s correct emotions, and doing it correctly.  My emotional dysregulation is showing in that picture.  I see it now, screaming back at me.  Screaming out to me.

I can see that intensity could just as well be terror or pain, even though in the photograph the emotion is supposedly happy.  I can see my dysregulated limbic brain and over stimulated nervous system in those eyes.  I am grateful that there were any happy times for me at all, because without them I wouldn’t have had any happy neurons that moved into place and stayed there as my brain grew.  I have always known I had my brother John to help me with that.  But I can look into that picture and see mirrored back to me the same agony that I feel exactly today, 56 years later.

No baby should ever feel any feeling that intensely.  There’s a part of me that says there’s a demon in that baby’s eyes.  One could say that of insanity, the kind of insanity or mania that makes a person shine too brightly.  One could also say that of the diamone that Hillman writes about – that seed that is supposed to come into an infant’s life, a young child’s life, a child’s life, gradually – with balance and grace so that the child is not either lost to itself or overwhelmed.

That baby looking back at me had been overwhelmed and over stimulated long before that picture was taken.  I feel echoes of intensity resonating back and forth between my body today and my little body in the picture.  And it’s also a sense of knowing.  Knowledge, that kind of Knowledge and knowing that comes with a capital “K.”

This new discovery of mine, looking at the picture, into the mirror of time – like seeing something that is forbidden to see, the damage in the brain and developing mind of an infant that enters the world blameless.  I have great pain still inside of me that I brush away even now, not wanting to get sucked into that terrible storm yet again.  And the hardest thing might be to look into the face of evil and realize that it is very real, that it doesn’t come from some devil, that some people, my mother included, have a threshold for inflicting pain on a helpless infant and child that is matched only by her inability to feel empathy or compassion for it.

I have to remind myself of all I have studied and learned and come to understand – how my mother represents an evolutionary throw back to a time when circumstances appeared so bad to her, on the unconscious level, that those evolutionary forces were put into play that were (and are) about not having offspring, not letting them all survive….blah blah blah, along with the 14,000 plus years that she should have been sentenced to serve in prison for what she did to me for 18 years.

There is a level where no amount of research or study or reasoning in the world, no amount of trying to understand my mother’s childhood, or her genes, or how the early deprivation, abuse and stress in her life changed the way her genes manifested, changed the way her mind developed right along with her brain, so that she became a monster, a demonic monster.  Unreasoning cruelty, unbelievably evil.  Mentally ill we can call it.  What scares me most is that I see expression in that little baby Linda’s eyes, shining back at me, an unnatural shine for any baby that age to have in her eyes, as if that look was literally put into me so that my eyes matched my mother’s.

On this personal level, “I don’t want to write this book,” screams inside of me.  I want to run and run and run.  Away.  How could I not have seen that look in those eyes before now?  It’s like a veil has been lifted, and I want to put it back.  I want to hide the picture now, take if down off my wall, never look at it again.  Which could be a choice I might want to make, but why?  The truth of that baby’s eyes is in me now, I cannot erase it by taking a picture off of a wall.

This would be one of those “get on with it” moments, one of those “get over it” moments.  “How can it matter in the least what you see in that baby’s eyes, what happened to that baby to put that look in her eyes.  You’ve got to be kidding me, spending even a second worrying about your babyhood?”

That look is a direct indication of the damage that was done to my developing brain by the time I was 11 ½ months old.  I can’t erase the changed brain structure, circuitry and operations of the brain that grew in and out of that terrible abuse.  It is in me, not as a little inner child, but as me the adult that suffered then and had that suffering built into every fiber of my body for the rest of my life.

That’s the reality that hits me now when I look through the levels and through the veil at that picture.  No more magical thinking that I was OK still at that age.  I was not.

An ode to suffering.  An end to suffering.

Looking at her, like staring straight into the sun.  I want to save her.  I want her to be able to now write words that others can read that will lighten their suffering, somehow.  That would mean I want her to be a sort of savior.  Me a savior.  I would save so many tiny babies from their suffering, if I could.

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DISTURBED IMMUNE SYSTEM IN PTSD

Altemus, Dhabhar & Yang 2006

Abstract – NY

“Disturbed regulation of both the hypothalamic-pituitary-adrenal (HPA) axis and sympathoadrenomedullary system in posttraumatic stress disorder (PTSD) suggests that immune function, which is modulated by these systems, may also be dysregulated.”

…………….2 measures of immune system:  delayed-type hypersensitivity (DTH) and skin barrier function recovery——–previous studies show these both are enhanced in women with PTSD—contrast with effects of acute stress in healthy controls which was associated with suppression of DTH responses and skin barrier function recovery

…circulating numbers of lymphocyte subtypes were assessed – no difference between PTSD and healthy controls

RESULTS:

“…suggest that cell-mediated immune function is enhanced in individuals with PTSD, a condition that imposes chronic physiological and mental stress on sufferers.  These findings contrast with suppression of DTH and skin barrier function recovery in healthy volunteers in response to acute psychological stress.”

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Mason et al 1986

Abstract

The findings suggest a possible role of defensive organization as a basis for the low, constricted cortisol levels in PTSD and paranoid schizophrenic patients.

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Heim et al, 2000

Abstract

“… a role for CRF receptor antagonists in the prevention and treatment of psychopathological conditions related to early-life stress

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Flesher et al 2001

Abstract

Kent State

70 MVA victims – assessed for PTSD one month after accident

…….amnesic patients displayed lower NE/cortisol ratios than non-amnesics, were less likely than non-amnesics to develop PTSD, and displayed fewer PTSD symptoms than non-amnesics

CONCLUSION:

“Amnesics may physiologically experience a motor vehicle accident differently from non-amnesics and have lower subsequent PTSD incidence.  These results provide partial support for the hypothesis that amnesia for a traumatic even can serve as a buffering function in the development of subsequent PTSD among MVA victims.”

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Heim et al 1998

Abstract – Germany

“These findings suggest that a lack of protective properties of cortisol may be of relevance for the development of bodily disorders in chronically stressed or traumatized individuals

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protective stress factor – neuropeptide Y (NPY)

Yehuda, Brand & Yang 2006

Abstract

Mt Sinai

Role of plasma neuropeptide Y (NPY) as a protective stress factor

Plasma NPY measured in 11 nonexposed veterans, 11 combat-exposed veterans without PTSD, 12 veterans with current PTSD

“A significant group difference in plasma NPY…was observed, reflecting higher NPY levels in exposed veterans without PTSD than in nonexposed but comparable levels in veterans with current PTSD.”

“Among those without current PTSD, veterans with past PTSD had higher NPY levels than those without past PTSD….”

“After controlling for all other variables, NPY levels were significantly predicted by extent of symptom improvement and lower combat exposure and significant at a trend level with positive coping.”

CONCLUSION:

Plasma NPY levels may represent a biologic correlate of resilience to or recovery from the adverse effects of stress.”

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Ghika 2008

Abstract – CHCVs, Division of Neurology, Avenue Grand Champsec 80, CH-1951 Sion (VS), Switzerland.

Paleoneurology: Neurodegenerative diseases are age-related diseases of specific brain regions recently developed by homo sapiens.

Bipedal locomotion and fine motility of hand and larynx of humans introduced musculoskeletal adaptations, new pyramidal, corticostriatal, corticobulbar, nigrostriatal, and cerebellar pathways and expansions of prefrontal, cingular, parieto-temporal and occipital cortices with derived new brain capabilities.

All selectively degenerate in aged homo sapiens following 16 syndromic presentations:

1) Parkinsonism: nigrostriatal control for fast automatic movements of hand, larynx, bipedal posture and gait (“simian gait and hand”).

(2) Frontal (highest level) gait disorders (lower body parkinsonism, gait apraxia, retropulsion): prefrontostriatal executive control of bipedal locomotion.

(3) ataxia: new synergistic coordination of bipedal gait and fine motility.

(4) Dyskinesias (chorea, dystonia, tremor…): intrusions of simian basal ganglia motor subroutines.

(5) motoneuron diseases: new proximo-distal and bulbar motoneurons, preserving older ones (oculomotor, abdominal…)

(6) Archaic reflexes: prefrontal disinhibition of old mother/tree-climbing-oriented reflexes (sucking, grasping, Babinski/triple retraction, gegenhalten), group alarms (laughter, crying, yawning, grunting…) or grooming (tremor=scratching).

(7) Dysautonomia: contextual regulation (orthostatism…).

(8) REM sleep disorders of new cortical functions.

(9) Corticobasal syndrome: melokinetic control of hand prehension-manipulation and language (retrocession to simian patterns).

(10) Frontal/temporal lobe degeneration: medial-orbitofrontal behavioral variant: self monitoring of internal needs and social context: apathy, loss of personal hygiene, stereotypia, disinhibition, loss of concern for consequences of acts, social rules, danger and empathy; dorsolateral executive variant: inadequacy to the context of action (goal, environmental changes…); progressive non-fluent aphasia: executive and praxic processing of speech; temporal variant: abstract concepts for speech, gestures and vision (semantic dementia, progressive nonfluent aphasia)

(11) Temporomesial-limbic-paralimbic-associative cortical dementias (Alzheimer’s disease, Lewy body, progressive amnesia): processing of explicit cognition: amnesic syndrome, processing of hand, larynx and eye: disorientation, ideomotor apraxia, agnosia, visuospatial processing, transcortical aphasia.

(12) Focal posterior atrophy (Benson, progressive apraxia): visuomotor processing of what and where.

(13) Macular degeneration: retinal “spot” for explicit symbols.

(14) “Psychiatric syndromes”: metacognition, self monitoring and regulation of hierarchical processing of metacognition: hallucinations, delusions, magic and mystic logic, delusions, confabulations; drive: impulsivity, obsessive-compulsive disorders, mental automatisms; social interactions: theory of mind, autism, Asperger.

(15) Mood disorders: control on emotions: anxio-depressive and bipolar disorders, moria, emotional lability.

(16) Musculoskeletal: inclusion body myositis: muscles for bipedal gait and fine motility. Paget’s disease: bones for bipedal gait and cranium.

Understanding of the genetic mechanisms underlying the evolution of these recent human brain regions and paleoneurology may be the key to the focal, asymmetrical or systemic character of neurodegeneration, the pathologic heterogeneity/overlap of syndromic presentations associating gait, hand, language, cognition, mood and behavior disorders.

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Yehuda, Flory et al 2006

Abstract

Bronx VA

“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 [DEA]) 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.”

In talking about prevention we must include the entire possible range of the trauma spectrum, including epigenetics, infant “learning” etc that build platforms that cannot entirely be altered under any circumstances, e.g., Teicher’s altered brain.

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Yehuda, Brand Golier & Yang, 2006

Abstract

Mt. Sinai

Healing steroid hormones DHEA and DHEAS

Increased plasma dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) have been demonstrated in PTSD

Documented beneficial effects of these steroids in enhancing mood and cognition, as well as neuroprotection, suggest their presence in PTSD may be associated with defensive rather than maladaptive effects.”

Study “…examined DHEA, DHEAS, cortisol, and the DHEA/cortisol ratio in 40 male veterans with or without PTSD, and determined their relationships to PTSD symptom severity and symptom improvement.”

RESULTS:

PTSD group showed significantly higher plasma DHEA and on-significantly higher ………..DHEAS levels as well as a significantly lower cortisol/DHEA ratio

………..DHEA and DHEAS levels could be predicted by symptom improvement and coping

………..whereas the DHEA/cortisol ratio was predicted by severity of childhood trauma and current symptom severity

CONCLUSION:

“…greater symptom improvement was related to DHEA levels, may suggest for a role for these hormones in modulating recovery from PTSD

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Rasmusson et al 2004

Abstract – Yale & VA

Increased adrenal cortisol responses to adrenocorticotropic hormone (ACTH)1-24 and increased pituitary ACTH and adrenal cortisol response to corticotropin-releasing factor in premenopausal women with chronic PTSD compared to healthy nontraumatized subjects

……………this pattern of hypothalamic-pituitary-adrenal axis (HPA) hyper-reactivity previously seen in healthy individuals treated with the antiglucocorticoid mifepristone

……………….investigated whether endogenous plasma levels of antiglucocorticoids such as dehydroepiandrosterone (DHEA) and progesterone were increased in premenopausal women with PTSD at baseline or in response to adrenal activation by ACTH1-24

……………..”This work suggests that an increased capacity for DHEA release in response to extreme adrenal activation may influence the pattern of HPA axis adaptation to extreme stress, as well as mitigate the severity of PTSD and negative mood symptoms in premenopausal women with PTSD.

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Olff et al 2007

Abstract

Amsterdam, The Netherlands

PTSD associated with dysregulation of the neuroendocrine system

…study examined effects of psychotherapy in 21 PTSD patients with and without coexisting depression on levels of

six stress-related hormones

+ cortisol

+ dehydroepiandrosterone (DHEA)

dehydroepiandrosterone-sulfate (DHEA-S)

prolactin

thyrotropin (TSH)

free thyroxin (fT4)

……………………..after brief eclectic psychotherapy (BEP) responders showed significant increase occurred in levels of cortisol and DHEA

…………………nonresponders both hormones decreased

…..differences only found after controlling for depressive symptoms

CONCLUSION:……………INTERACTION WITH DEPRESSION

“…effective psychotherapy for PTSD may alter dysregulations in the Hypothalamus-pituitary-adrenal (HPA-axis, but comorbid depressive symptoms should be taken into account.”

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Yehuda & LeDoux 2007

Abstract

Mt Sinai and VA – am getting this article

Majority of trauma-exposed persons do not develop PTSD – examination of typical effects of a stressor will not identify the critical components of PTSD risk or pathogenesis

………..PTSD represents a specific phenotype associated with a failure to recover from the normal effects of trauma

research must focus on identifying pre-and posttraumatic risk factors that explain the development of the disorder and the failure to reinstate physiological homeostasis

……..well, plenty of us who were severely abused from birth do not have a normal state of physiological homeostasis to be reinstated to!

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TOLERANCE THRESHOLD

I found it helpful to think about the concept of thresholds in the mind by literally considering a doorway.  If the threshold is low, it means that you don’t have to step up to get in the door, and that the doorway itself is as large as it can be, thus letting in a larger amount of “stuff” than a doorway with a high threshold.  A higher threshold would mean that you would actually have to step up and over to go through the doorway.  The actual space of entry would be smaller, and less “stuff” could fit through easily.

So a low threshold means more gets through.  A high threshold means less gets through.

As you can imagine, there are many, many factors that influence what our tolerance to trauma is, and what amounts to a stressful event of any kind varies according to many factors.

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Forte, 2006, abstract

Studying stress of “mobbing” or being harassed in the workplace

vs

being a victim of a hold-up

This reminds me of bullying, and this happens not only at school but in the workplace.  My neighbor has been going through that.  There are consequences to a person experiencing this kind of traumatic stress.  It happened to me at Gateway and I walked off the job rather than face it.  My dysregulated emotional brain could not make heads or tails of it – I had no clear idea what was going on.  It is subtle and can be erosive and devastating – to children and adults

“We then suggest, as a first hypothesis, that the nature of the victimization process, resulting from specific aggressive scenarios, would determine different psychological, physiological and relational consequences, apprehended under the generic expression of tolerance threshold.”

Lazarus and Folkman’s “transactional model of stress” – “…which postulates that stress would rise from the perception people get of the transaction between the requirements of the situation and their own resources.  These modulators would correspond to the social evaluation of the stressor and the adjustment strategies adopted by the victims.”

“We then postulate the fact that these interfering variables would determine a connection between the type of victimization and the series of signs and symptoms generated.  In other words, the aversive modes would refer to a process of significance via these interpolated socio-cognitive factors, thus forming a trace of the traumatic event according to the tolerance threshold expressed.  More precisely, our assumption consists in postulating that the insidious and latent aspect of harassment which is supposed to support a dispositional attribution of the harasser’s intrigues as well as the preferential adoption of coping strategies centered on emotional control, would lower the victims’ tolerance threshold further, than a visible and instantaneous hold-up which is supposed to condition an essentially situational perception and the adoption of strategies mainly directed towards the problem.”

“…through the filter of the people’s subjectivity, it clearly determined the meaning granted by the victim to the aversive situation.”

In accordance with the general assumption, the results show that the victims reveal a dominating presence of mobbing signs related to depression and anxiety symptomatology with an acute emotional threshold.”

:Hold-up victims also show undoubted but significantly less harmful consequences.  These victims have turned out to be more centred on the anxious pole and the social and family fields.”

“Moreover, while the victims of harassment unanimously evoke the emergence of a break-up in dynamics conveying a freeze of the social matrix, some of the victims of armed attacks express “secondary benefits” through the setting-up of gregarious dynamics on professional as well as on family level.”

“The social evaluation tends to be a first explanatory inference as for the expressed tolerance level….a different perception  of the attacker….supposing a personal motivation marked with intrigues concealed behind an apparent legitimacy, draws a very personological profile of the harasser.  This majority of intrinsic determinants reveals an increase in the causal weight of the harasser; at the same time, it disregards the possible influence of extrinsic factors.  In that respect, the harasser is seen as the only instigator of the attacks, which consequently worsens his/her responsibility and culpability.  No difference appears between the harasser himself and the hypothetical causes of the aversive situation; the harasser is seen as the source of the attacks and the attacks as concretization of the harasser’s state of mind.  On the basis of this report, the victims of harassment tend to amalgamate [unite, merge into a single body] the personality and the situation.”

“The victims of armed attacks, as for them, are characterized by a more situational evaluation of the stressor, revealing an apparent will to segment the aversive situation:  on the one hand the act, and the other the attacker, as though, eventually, the latter was but one element depending on a specific situation.  The majority enunciation of extrinsic factors supposes an obvious intention to diffuse the hold-up man’s responsibility over contextual attributes.”

“The second inference lies in the strategies used to adjust to the situation.  Whatever the type of victimization, the passive coping system reveals as dominating.  However, this tendency seems to be more moderate with hold-up victims, who tend to counterbalance the strategies centered on emotional control with strategies directed towards an active resolution of the problem.”

See notes in contents, must get complicated in similar ways with accidents versus illnesses like cancer, when you don’t know if you are at fault or not!

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Richards & Freeman 2003

Australian book about bullying in the workplace, problem seen to be reaching critical mass in their country.  What about in ours?

Doctors and medical staff are not exception.  Can happen with program administrators, in our schools and universities…law enforcement

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MacDonald et al 2008

Report from Kessler, Sonnega, Bromet

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Dorahy & Paterson 2006

Northern Ireland

1916 Irish Nationalists resurgence of militant resistance to British rule

1921 landmass of Ireland divided – 26 counties gained independence from Britain and became the Republic of Ireland and 6 counties in the northeast remained politically attached to Great Britain, known as Northern Ireland

fighting for a united Ireland free from British rule

fighting by others to retain Northern Ireland’s union with Great Britain

in 1960s violence reached greater intensity and ferocity with start of what is referred to as “the Troubles.”

Article examines many manifestations of trauma in Northern Ireland, familial and interpersonal, social and political

Attention given to growing study of dissociation in Northern Ireland, case examples illustrating human cost of trauma and dissociation

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Hepp et al, 2006

Swiss study

“To date, for Europe, no epidemiological data on PTSD in adults in the general population exist.”  Hepp et al, 2006, 151

the initial screening sample in 1978 for the Zurich Cohort Study included 4547 young adults age 19-20 – from this cohort a subsample of 591 selected understood to represent 2599 persons in the general population – in 1993 407 of these were interviewed and in 1999 367 were interviewed —  “Information about PTE was obtained by asking the participants whether they had experienced or witnessed an event or events that involved actual or threatened death, serious injury or a threat to the physical integrity of self or others….Several typical events were proposed and participants were asked whether any of these or similar events had happened to them.  In 1999, participants were asked in addition whether they had felt intense fear, helplessness, or horror….Participants could report multiple events.”  Hepp et al, 2006, 153

1999 interviews 34.9% reported a total of 179 lifetime potential traumatic experience (PTE)

…… 33.3% of men, 36.1% of women

………..of these, 71.1% reported one, 18% reported two, 10.9% reported three or more

“… lifetime prevalence of PTE was 28%; it showed no gender difference…..Women experienced assaultive violence 2.8 times more often than men, whereas men tended to experience more life-threatening illnesses and witnessed more death or injury to others.”  Hepp et al, 2006, 154

…none met all the remaining criteria (other than exposure to PTE) for PTSD;

…….01.3%  (.26% males; 2.21% females) met criterion for subthreshold PTSD without the criteria of +duration or +impairment

……..03.4% (2.4% males; 4.4% females) met the criterion for +re-experiencing

…….  0.77% (o.41% males; 1.2% females) met the criterion of +avoidance

..01.3% (0.14% males; 2.5% females) met the criterion for +hyperarousal  – Hepp et al, 2006, 154

“Of the 11 subthreshold PTSD subjects in 1999, eitht (72.7%) had experienced an assaultive trauma, whereas the 117 subjects who reported PTE but no PTSD symptomatology, only 25 (21.4%) had a history of assaultive traumas.  Unexpected or threatened death of a close friend or relative led in one case to a subthreshold PTSD.”  Hepp et al, 2006, 155

1993 interviews 31.9% reported a total of 147 lifetime PTE

………28.7% of men, 34.9% of women

……..28.3% reported one, 2.9% reported two, and 0.7% reported three or more PTE

…………………none met all criteria for PTSD,1.90% met the criteria for subthreshold PTSD  – Hepp et al, 2006, 154

…….9.8%(8.6% males; 10.9% females) met criterion of +re-experiencing

………1.7% (2.6% for males; 0.99% for females) met criterion of + avoidance

…….1.6% (2.2% males; 0.99% females) met criterion of +hyperarousal

“Only two subjects met subthreshold PTSD criteria at both the 1993 and 1999 interviews).”  Hepp et al, 2006, 155

“… lifetime prevalence of exposure to PTE was 26.6%; there was no gender difference.”  Hepp et al, 2006, 154

COMORBIDITY

On assessed symptom levels not part of PTSD diagnostic criterion, “…a comparison between participants exposed to PTE with and without subthreshold PTSD revealed significantly higher levels for the 11 subthreshold PTSD participants…for depression…and vegetative irritability [related to nervous system:  fatigue, sleep, appetite, digestion]….subthreshold PTSD subjects met the diagnostic criteria for major depression, agoraphobia and benzodiazepine [psychoactive sedative] abuse/dependence significantly more often.”  Hepp et al, 2006, 155

Subthreshold PTSD cases were [significantly] more often divorced or separated…, reported more chronic illnesses…and had a lower educational level…and a lower socio-economic status…compared with those who reported PTE without subthreshold PTSD.”  Hepp et al, 2006, 156

discussion

information was gained from “a well-characterized representative age cohort in Switzerland at two points in time” through 2 face-to-face interviews “performed by clinically trained psychiatric residents and clinical psychologists.”  Hepp et al, 2006, 156

“The lifetime prevalence of exposure to PTE is age-dependent….”  Hepp et al, 2006, 156

…….in this study at age 40/41 prevalence for PTE was 28%

………in National Comorbidity Study (NCS) was 60.7% for males, 51.2% for females

………..in Detroit Area Survey lifetime exposure to any PTE was 89.6% with mean number of PTE of 5.3 for males and 4.3 for females – total of 37.7% reported at least one episode of assaultive violence

……..in Australian study nearly identical to NCS

…..in Canada prevalence of traumatic exposure was 81.3% for males and 74.2% for females, with about half exposed to PTE reporting multiple events — Hepp et al, 2006, 156

“Although the overall rate of traumatic exposure showed no gender difference in our sample, women experienced assaultive violence 2.8 times more frequently than men did.  In view of the above-cited epidemiological studies, this is a unique result.  A possible explanation for the lack of a higher prevalence in men could be that Swiss men are less at risk of traumatic exposure on account of the relatively low crime rate and the absence of combat-related traumas; whereas, for women, the risk of violence, especially sexual violence, is rather comparable to that in other countries.  After controlling for trauma and sociodemographic factors, women have consistently been shown to be at higher risk of developing PTSD following traumatic exposure [14.15]; our results confirm this for PTSD symptoms.”  Hepp et al, 2006, 156

“The most striking result of our study is that no subjects met the full criteria for PTSD according to the DSM-IV.  Only 11 subjects met the criteria for subthreshold PTSD-syndrome…representing a…prevalence of 1.30%. Similarly, in the interview carried out in 1993, no participant was diagnosed with a PTSD according to DSM-III-R.”  Hepp et al, 2006, 156

“In contrast to international epidemiological data, PTSD in the Swiss general population seems to be a very rare condition….There are several possible explanations.  First of all, we assessed the 12-month prevalence and not lifetime prevalence rates for PTSD.  A further explanation would be the relatively low prevalence of exposure to PTE; however, given a prevalence of PTE exposure of 28%, one would still expect a certain proportion of subjects to develop PTSD.  A more plausible explanation could be that Switzerland has not been actively involved in warfare for 150 years and has not seen major natural disasters in the past decades.  In the United States, for example, the prevalence of combat-related traumatic experience was 6.4% for males, and the prevalence of traumatic experiences related to natural disasters was 18.9% for males and 15.2% for females (NCS study) [28].  A further explanation could be the relatively low rate of physical violence in Switzerland.  This hypothesis is supported by the relatively low average homicide rate of 2.6 per 100,000 from 1990 to 1996 in Switzerland compared to the European average of 7.2 per 100,000 for the same period (http://www.europeansourcebook.org).  Indeed, males in our study had a very low prevalence of exposure to assaultive violence.  Moreover, only Swiss citizens were recruited for this study in 1978.  Given that today the Swiss population comprises approximately 21% non-Swiss citizens, the results may not mirror today’s situation characterized (156) by a high rate of immigrants and refugees from conflict regions.”  Hepp et al, 2006, 157

“In fact, our results are in line with earlier data on Swiss accident victims, showing that only 5% of seriously injured patients referred to an intensive care unity (ICU) immediately after the accident developed a full PTSD; in a 1-year follow-up, the PTSD persisted in only 2%….These results again contrast with the international studies, where the conditional risk for motor vehicle accidents was distinctly higher….A recent study showed that there was no increase in psychiatric inpatient admissions in Switzerland in the aftermath of global or local disasters [24].”  Hepp et al, 2006, 157

“Most of the eight subthreshold PTSD subjects in 1999 with a history of assaultive violence were women, explaining the relatively high proportion of women in the subthreshold PTSD group.”  Hepp et al, 2006, 157

“Subjects with subthreshold PTSD had the highest comorbidity levels with significantly more diagnoses of major depression, agoraphobia and benzodiazepine abuse.  The high comorbidity in PTSD patients is a well-known phenomenon….In addition, subjects with exposure to PTE without PTSD symptoms also had higher levels of comorbidity than non-traumatized subjects.  It is possible that, after exposure to PTE, some people develop specific symptoms, such as re-experiencing…whereas others develop uncharacteristic posttraumatic syndromes such as depression, anxiety, somatization and substance abuse.”  Hepp et al, 2006, 157

limitations of study

“…the study was restricted to Swiss citizens in a period of relatively low influx of refugees and immigrants from conflict regions.”  Hepp et al, 2006, 157

Which is why I think this study is crucially important because it might show what is possible for a group of citizens to accomplish if warfare and related conflict traumas are not a part of the population.

Conclusions

The prevalence of exposure to PTE in Switzerland at age 40/41 was relatively low.  Women experienced more assaultive violence than men.  Surprisingly, we found not a single case of full PTSD in our sample, and even the prevalence of subthreshold PTSD was very low.  The fact that Switzerland has not been involved in war for 150 years, has not experienced any major natural disasters in recent decades, the relatively low crime rate and the virtual absence of terrorism, in addition to the political and economic stability may well contribute to a sense of security which, to some extent, protects Swiss citizens from developing PTSD in the aftermath of traumatic experiences.”  Hepp et al, 2006, 157

In other words, this study was done on people who live in a benevolent environment.

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European Sourcebook of Crime and Criminal Justice Statistics, 3rd edition published in June 2006 covers 2000-2003 for 37 countries, limited edition – www.europeansourcebook.org

Minimum age for consideration in conviction statistics 2003 varies between countries, with Switzerland, Cyprus, France, Greece down to age 7, Scotland age 8, and the other countries ranging from age 12 to 16

Ireland in all statistics showed its troubled climate

Persons convicted per 100,000 for rape is less than 2 people in Switzerland, and rates have decreased 2000-2003 down 16%

Rates for persons convicted for completed intentional homicide per 100,000 — Remain at less than 0.5 in Switzerland with no change during the years included

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Giaconia  et al, 1995

Reported adolescents are equally at risk for development of PTSD following having a parent sent to prison as they are having experienced a rape

384 adolescents – ongoing longitudinal study, when they turned 18 evaluated lifetime traumatic events and symptoms – more than two fifths of adolescents experienced at least one PTE by age 18 years; PTSD developed in 14.5% of these AFFECTED youths or 6.3% of the total sample – these youths demonstrated widespread impairment including overall behavioral-emotional problems, interpersonal problems, academic failure, suicidal behavior, and health problems, and increased risk for additional disorders.

Striking finding:  Youths who experienced traumas but did not develop PTSD also showed deficits in many of these areas when compared to non-trauma peers –

Conclusion:  prompt intervention is needed!

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Copeland et al, 2007

Differing from other psychiatric disorders, PTSD requires an initiating stressor

Subjective appraisal of event is important to development of PTSD, includes wide variety of traumatic exposures that lead to increased risk:

“Efficient treatment and prevention strategies require knowledge of the conditional risk for PTSD, given different event categories across the full range of potentially vulnerable groups.”  Copeland et al, 2007, p 577

The Great Smoky Mountains Study – random selection from pop of 20,000 children in western North Carolina – ages 9, 11, and 13 years of age  — final sample 790boys and 630 girls  —

[No differences found between Native American and white]

Analysis of 3 areas of information:  (1) psychiatric disorders (2) potentially traumatic events (PTE) and associated posttraumatic stress (PTS) symptoms (3) risk factors

As part of the assessments – [interesting]

“Coping mechanisms such as normal, obsessional, and compulsive suppression are explored; questions are asked about autonomic effects such as panic attacks; (578) and other associated features are queried (eg. “omen formation” and engagement in dangerous activities).”  Copeland et al, 2007, p 578

results:

“We derived the following 3 categories of PTS symptoms:  (1) meeting all diagnostic criteria for DSM-IV PTSD; 2) endorsing at least 1 symptom each of painful recall, hyperarousal, and avoidance symptoms but not meeting full PTSD criteria (subclinical PTSD); and (3) reporting painful recall only.”  Copeland et al, 2007, p 579

“Full-blown DSM-IV PTSD was rare across all sex, age, and ethnic groups.  Painful recall and subclinical PTSD were more common, with cumulative rates of 9.1% and 2.2% respectively, by 16 years of age in the full sample.  Subclinical PTSD was more common in adolescence than childhood….Rates of painful recall and subclinical PTSD did not differ across sex or ethnic groups.  Because full-blown PTSD was so rate, the few cases were included in the painful recall and subclinical PTSD groups, but not analyzed separately.”  Copeland et al, 2007, p 579

I know for a fact that these studies would never in a million years obtain access to any truly terrifying family.  Our stories do not appear in these kinds of reports.  So I would say they are looking at the middle range of normal, considering the variations at top and bottom….

PTEs grouped into broad categories of violence, sexual trauma, other injury or trauma, witness to trauma, and learning about trauma.

By age 16 – 32.2% reported no PTE,

…………….30.8% reported exposure to 1 PTE and

…………….37% reported exposure to multiple events –

most common events were witnessing or learning about a traumatic event – “so-called “vicarious” events”  Copeland et al, 2007, p 580

I don’t believe overall that vicarious events harm children – they are a fact of life, and offer experience, practice, and learning coping skills to deal with traumas through life

Averaging 3-month and lifetime prevalence, about 10% exposed to trauma reported painful recall, about 3% reported subclinical PTSD

………..highest rates of both were associated with violent events or sexual trauma

“In addition to event characteristics, a lifetime history of multiple trauma exposures strongly predicted higher rates of painful recall and subclinical PTSD.”  Copeland et al, 2007, p 580

rates of impairments were generally double the rates of having painful recall, impairments such as disruption of important relationships, school problems, physical problems, exacerbation of emotional problems –…

…………21.9% children with PTE reported impairment, increased with number of PTEs

………..20.4% those with 1 PTE, 49.6% for those with 2 or more PTEs

Children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.  This effect was significant for all diagnostic groups except substance use disorders.  Higher levels of PTS-related symptoms were associated with higher levels of psychiatric disorders, with rates of 52.6% and 59.5% for painful recall and subclinical PTSD, respectively.”  Copeland et al, 2007, p 581

“…the dose-dependent relation between trauma and psychiatric disorders was similar to that observed for trauma and PTS symptoms.  This pattern, significant for most diagnostic groups, was most pronounced for depressive disorders.”  Copeland et al, 2007, p 582

“Overall, 8.2% of the studied individuals reported painful recall and 1.4% reported subclinical PTSD in response to their first trauma exposure.”  Copeland et al, 2007, p 582

“Overall, most children experienced few PTS symptoms in response to their initial trauma exposure, and those experiencing PTS symptoms were also at highest risk of psychiatric morbidity.”  Copeland et al, 2007, p 582

comment

“The analyses of longitudinal data from a community-based sample of children and adolescents showed that,

first, although exposure to traumatic events was almost commonplace, full-blown DSM-IV PTSD was rare across middle childhood and adolescence.  Symptoms of PTS, including painful recall and subclinical PTSD, were more common, but very far from being expectable sequelae.

Second, children displaying PTS symptoms in response to trauma exposure were more likely to be older, to have a history of exposure to trauma, to have a history of anxiety, and to come from an adverse family environment.

Third, higher levels of trauma exposure were related to higher levels of most types of psychopathology, particularly anxiety and depressive disorders, as well as other impairments.

Finally, the prognosis after a first lifetime trauma exposure was generally favorable.”  Copeland et al, 2007, p 582

.”…[study suggests that] different symptom clusters and different levels of symptoms are needed to predict impairment in childhood samples.  Although the present study did not intend to evaluate the current DSM-IV PTSD criteria, the findings suggest that the current criteria, when applied to children, may not be developmentally sensitive or that childhood PTSD is rare.” Copeland et al, 2007, p 582

“Psychopathology is strongly interrelated with trauma and trauma symptoms.  Across childhood, the children (582) who experienced trauma are often those with anxiety, depressive, and disruptive behavior disorders, a finding supported in the present study…..Our study indicated some specificity in the role of psychopathology as risk for trauma and trauma exposure.  Past depression best predicted first trauma, but it was a history of anxiety disorders that best predicted PTS symptoms in response to trauma exposure.  Both of these disorders are also common sequelae of trauma exposure, with rates increasing dramatically immediately after the first trauma exposure.  This relationship is strongest in individuals who also display some PTS symptoms (ie, at least painful recall).”  Copeland et al, 2007, p 583

“…the study may underestimate lifetime rates of traumatic events because interviews began when children were already in middle childhood.”  Copeland et al, 2007, p 583

“Severe events such as sexual abuse may be under-reported….mandated reporting requirements might suppress reporting for physical and sexual abuse, events associated with higher rates of PTS symptoms.”  Copeland et al, 2007, p 583

conclusion

“Few children exposed to trauma develop PTSD, and the few who display PTS symptoms can be identified through information about their age, trauma history, anxiety history, and family environment.  Children exposed to traumatic events also displayed higher rates of depression, anxiety disorders, and other impairments.”  Copeland et al, 2007, p 583

This article is free online – very carefully collected data, as reliable and as accurate as possible – yet looking at their table 2, I see things reported that I would have like to have seen the authors discuss in detail, particularly with the lifetime prevalence of some of the specific traumas the children were exposed to

2.4% – violent death of a love one, of which 39.9% suffered from painful recall – 14.1% with subclinical PTSD

14.5% violent death of sibling/peer with painful recall at 12% – very low, only 0.6% subclinical PTSD

interesting 0.1% exposure to war/terrorism, 0% having painful recall

victim of physical violence  3.1% with 13% painful recall and 9.1% subclinical PTSD

physical abuse by relative 7.2% with 13.5% painful recall and 2.2% subclinical PTSD

sexual trauma reports – were there official interventions on these?

Sexual abuse 10.9% — that is HIGH, considering that the worst of the worst were probably not reported and/or did not participate – only 8.4% of these reporting painful recall – 3.4% with subclinical PTSD

Rape 1.2% with 33.2% painful recall and 17.1% with subclinical PTSD

Coercion (sexual trauma) 4.3% with 21.9% painful recall and 7.9% subclinical PTSD

Rape and violent death of a loved one showed the most troubled response

It is hard to know how to interpret this information.  I sincerely doubt that using adult criteria for an adult diagnosis of PTSD is relevant for assessing trauma impact on children – and yet I would think that children’s resilience helps them to cope – and also assuming that most of these children are in environments where they have access to someone who cares for them.

It also makes me wonder about the children that are outside the radar in terms of abuse.  It is highly unlikely that a parent that is abusing a child would willing cooperate with this face-to-face interview technique.  At best this study is measuring the most likely “norm” of a community sample

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Yehuda, Bryand, Marmar & Zohar 2005

Abstract

“…ability to predict those who will develop pathologic responses…is essential for developing appropriate strategies for mounting a mental health response in aftermath of terrorism and for facilitating the recovery of individuals and society.”

……………I hate the word pathologic in application to those who have been dealt a hand that prevents them from responding to stress “like everyone else.”

“…it is essential to remove the barriers to collecting data in the aftermath of trauma by creating a culture of education in which the academic community can communicate to the public what is and is not known so that survivors of trauma and terrorism will understand the value of their participation in research to the generation of useful knowledge, and by maintaining the acquisition of knowledge as a priority for the government and those involved in the immediate delivery of services in the aftermath of large-scale disaster or trauma”

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Yehuda & Hyman, 2005

Abstract————I am getting this article

“…the psychological responses to terrorism exert significant effects on mental and physical health and on society.  We present a research agenda…to address the troubling gaps in our knowledge about the longterm effects of terrorism on brain, behavior, and physical health, the risk factors for predicting who will be most affected by terrorism, and interventions that might promote resilience at an individual and population level.”

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Hamblen 2008

National Center for PTSD FactSheet

PTSD has different age-specific features – may not present in children same as adults

Experience of “an event that involved a threat to one’s own or another’s life or physical integrity and that this person responded with intense fear, helplessness, or horror.  There are a number of traumatic events that have been shown to cause PTSD in children and adolescents…..natural and man made disasters such as floods; violent crimes such as kidnapping, rape or murder of a parent, sniper fire, and school shootings; motor vehicle accidents such as automobile and plane crashes; severe burns; exposure to community violence; war; peer suicide; and sexual and physical abuse.”  Hamblen 2008, 1

“…studies have shown that as many as 100% of children who witness a parental homicide or sexual assault develop PTSD.  Similarly, 90% of sexually abused children, 77% of children exposed to a school shooting and 35% of urban youth exposed to community violence develop PTSD.”  Hamblen 2008, 1

3 risk factors that increase children’s risk factors for developing PTSD, affecting children’s report of distress:

+ 1  severity of the traumatic event –most severe equal highest levels of symptoms

+ 2  parental reaction to the traumatic event – family support and parental coping

+ 3  physical proximity to the traumatic event – distance equals less distress

interpersonal traumas such as rape and assault are more likely to result in PTSD than other types of traumas – no doubt tied to 2 and 3 above being compromised

…prior experience of traumatic events increases risk

…girls are more likely than boys to develop PTSD

..young children – may report more generalized fears such as stranger or separation anxiety [tied to attachment]; avoidance of situations that may or may not be related to the trauma; sleep disturbances; preoccupation with words or symbols that may or may not be related to the trauma; may display repeated themes of trauma in their play; may lose some acquired developmental skills as result of traumatic experience

elementary school-age children – may not experience flashbacks or amnesia for the trauma, but do experience “time skew” and “omen formation” which are not typically seen in adults –

“Time skew refers o a child mis-sequencing trauma related events when recalling the memory.  Omen formation is a belief that there were warning signs that predicted the trauma.  As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas.”  Hamblen 2008, 2

“School-aged children…exhibit posttraumatic play or reenactment of the trauma in play, drawings, or verbalizations.  Posttraumatic play is different from reenactment in that …[it] is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety.  An example of posttraumatic play is an increase in shooting games after exposure to a school shooting.  Posttraumatic reenactment, on the other hand, is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).”  Hamblen 2008, 2

Adolescents and teens – more closely resemble adult PTSD, but more likely “to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives….[and] are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.”  Hamblen 2008, 2

Associated symptoms along side PTSD in children and adolescents suffering the affects of sexual abuse:

“…problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, and substance abuse.  These problems are often seen in children and adolescents who have experienced other types of traumas as well.  Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.”  Hamblen 2008, 2

Any adult who reads this information and has never thought about early exposure to traumas that contribute to increased risk of developing a PTSD, along with related symptoms, might find themselves looking at themselves in a mirror of their past.  It is never too late to validate reality.

Besides PTSD symptoms, associated symptoms, there are psychiatric disorders commonly found in children and adolescents who have been traumatized:

“One commonly co-occurring disorder is major depression.  Other disorders include substance abuse; other anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.”  Hamblen 2008, 2

I would think that depression, or “hypoactivity,” that is directly attributable to trauma that leads to PTSD should be included under the PTSD diagnosis – not sure why the hypoarousal is considered separately from the hyperarousal –both from nervous system reactions

Interesting that this website mentions that some children show a natural remission of PTSD symptoms – even in studies like the one just reviewed by Copeland are not making that distinction – because they can’t.  It won’t be until the PTSD reappears sometimes many years later following yet another traumatic event exposure that going back and doing a thorough history all the way back through childhood as far as possible and as accurately as possible – can reveal that the PTSD has lain their dormant all those years – symptoms may not just go away, as Copeland’s study suggests.  It would take a very long range study to follow these same children for another 50 years to be able to find the pattern of remission followed by reoccurrence of PTSD.

It reminds me of a pot of water brought as close to the boiling point as possible and then the heat is turned down or off – the boiling point happens later on – like it’s an incremental process?

This website advocates Cognitive-Behavioral Therapy (CBT) as an adult treatment approach that has been shown to be most affective and safe for treating children and contains an informative brief description of the process.

..child directly discusses the traumatic event (exposure) – “Although there is some controversy regarding exposing children to the events that scare them, exposure-based treatments seem to be most relevant when memories or reminders of the trauma distress the child.  Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences.  Through this procedure, they learn that they do not have to be afraid of their memories.”  Hamblen 2008, 3

..anxiety management techniques such as relaxation and assertiveness training

..correction f inaccurate or distorted trauma related thoughts

..challenging children’s false beliefs such as, “the world is totally unsafe.”

The problem with this approach is that it is very short sighted to use with anyone who has an extensive history of insecure attachment that has altered the way their nervous system and brain operates on a continual basis.  These people’s BODIES know that the world is totally unsafe because that is the world they were in that built their brain in the first place.

I can see that this approach would be best suited to children with secure attachment histories as a way to prevent a single, or a few traumas, from changing the basically sound and safe perception of themselves and the world into a malevolently based pattern – to stop the traumatic reactions in their tracks before they take over the child’s life.  For some, that has already happened, and this distinction needs to be made before an appropriate treatment can be implemented on any level.

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Seedat et al, 2004

Africa

1140 Cape Town, South African and 901 Nairobi, Kenyan students participated mean age 15.8 years and in grade 10 – chosen in each city to be representative of the ethnic and socio-economic make-up of the population in the year 2000

completed anonymous self-report questionnaires under supervision in their classrooms – voluntary participation – used age adjusted assessment tools

more than 80% of the 2041 respondents reported lifetime exposure to at least one DSM-IV trauma — mean number of trauma exposures was 2.49, comparisons between countries was not significant

for both countries most common PTEs were

63% witnessing community violence

35% being robbed or mugged

33% witnessing a family member being hurt or killed

Significantly more in the Kenyan group had witnessed violence, been physically hurt or beaten by a family member, or been sexually assaulted  Seedat et al, 2004, p 170

Symptoms of PTSD

+ (a)  avoidance of activities, places or people that aroused recollections of the trauma

33.3% South African group (SA)

53.2% Kenya group (Kenya)  Seedat et al, 2004, p 170

+ (b)  avoidance of thoughts, feelings or conversations associated with the trauma

32.4% SA

50.5% Kenya

+ ( c) irritability or outbursts of anger

31.1% SA

23.1% Kenya

+ (d) intense psychological distress at exposure to trauma reminders

21.3% SA

28.0% Kenya

“The South African students had higher scores across all the three symptom clusters of re-experiencing, avoidance and hyperarousal, and more PTSD symptoms, than Kenyan respondents:  SA, 4.9…Kenya, 2.3….

In the whole group, 14.5%…of adolescents met the symptom criteria for full PTSD, and an additional 10%…met symptom criteria for partial PTSD.

Notably, 22% of South African adolescents had a full PTSD diagnosis compared with only 5% of Kenyan adolescents…,

and 12% [SA] met the symptom criteria for partial PTSD compared with 8% in the Kenyan group….”  Seedat et al, 2004, p 171

relationship between trauma exposure and PTSD symptoms:

Remained significant for each country that PTSD endorsed more traumas on the Trauma Checklist, and by gender

Total for both countries full symptoms:  PTSD positive – 3.5 traumas —  PTSD negative – 2.3 traumas

KENYA  – PTSD positive – 2.9 traumas— PTSD negative – 2.4 traumas

SA – PTSD positive – 3.6 traumas — PTSD negative – 2.2 traumas

Males:      PTSD positive – 3.7 traumas — PTSD negative – 2.5 traumas

Females:  PTSD positive – 3.2 traumas — PTSD negative – 2.2 traumas

Those with full PTSD endorsed a higher number of traumas 3.7 than those with partial-symptom PTSD 2.9 or no PTSD 2.3

Gender and trauma exposure

Boys – 2.7 – as a whole had more trauma exposures than girls – 1.9

witnessed community violence: Boys 67% – significantly more likely than girls – 60%

been robbed or mugged:  Boys 39% – significantly more likely than girls – 33%

been beaten by someone not a family member:  Boys 26% -sig more likely than girls 15%

to have been victim of sexual assault: Boys 19%- sig more likely than girls 13%

“’sexual assault’ was operationalized in the survey as ‘any unwanted and forceful sexual experience that made (171) you feel uncomfortable’.  When responses for boys and girls were analyzed by country, these differences remained significant in the Kenyan sample but not in the south African sample…” Seedat et al, 2004, p 172

boys and girls did not differ in symptom clusters or in rate of full symptom PTSD

lifetime exposure

Asian (SA) 86%, of those, 32% PTSD

Asian (Kenya) 60%, of those, 0% PTSD

Black (SA) 75%, of those, 34% PTSD

Black (Kenya) 85%, of those, 5% PTSD (majority race in Kenya)

Mixed Race (Colored) (SA) 85%, of those, 29% PTSD (majority race in South Africa)

Mixed Race (Colored) (Kenya) —–

White (SA) 86%, of those, 20% PTSD

White (Kenya) 100%, of those, 0% PTSD  Seedat et al, 2004, p 172

3 traumas most likely to be rated most frightening or upsetting:

sexual assault – physical assault by a family member – serious accidents

same risk of PTSD following sexual assault:  24% of girls and 25% of boys

traumas that constituted independent predictors for PTSD were:  sexual assault; witnessing family members injured, beaten, hurt or killed; being in a bad accident; being robbed or mugged; being beaten or physically hurt by a family member; witnessing violence in the street, neighborhood or school.  Seedat et al, 2004, p 172

“Physical attack by someone outside the family…and natural disaster…were not independently predictive of a PTSD symptom diagnosis.”  Seedat et al, 2004, p 172

depression

mild depression with no significant differences between countries

except in Kenya where girls reported more depressive symptoms and significantly higher scores than boys

number of PTSD symptoms correlated significantly with total depression scores overall and within each country; significant gender difference also found

full symptom PTSD also had higher depression scores than those with partial-symptom and those with no PTSD

substance use

more South African than Kenyan adolescents reported smoking ten or more cigarettes a day (SA –5.3%, Kenya – 1.7%) and using cannabis (SA –8.7%, Kenya 4.6%).  As a whole more boys (8.7%) than girls (4.6%) reported cannabis use, no significant gender use for cigarettes or alcohol.  Use of these substances did not correlate significantly with PTSD symptoms.  Seedat et al, 2004, p 173

negative life events over previous year

(SA) 9.2 negative life events – (Kenya) 8.3

included such things as doing much worse than expected on a test, breaking up with a boyfriend/girlfriend, pregnancy, legal difficulties

Negative life event exposure was not significantly associated with PTSD symptoms

DISCUSSION

PTSD and trauma

Whole group:  14.5% met criteria for full PTSD; 10.3% fulfilled partial criteria for PTSD

(14.8% of those exposed to more than one trauma met full PTSD; 11.4%of those traumatized met partial PTSD criteria)

“These rates are strikingly similar to rates previously documented in trauma samples.  In a study by Giaconia et al (1995), 14.5% of affected youths (6.3% of the total sample) met DSM-III-R criteria for PTSD (American Psychiatric Association, 1987), while Lipschitz et al (2000) found that 14.4% and 11.6% of traumatized girls met DSM-IV symptom criteria for full and partial PTSD, respectively.  Both countries [in this study] had high rates of trauma exposure, with 83% of South African adolescents and 85% of Kenyan adolescents reporting at least one DSM-IV trauma in their lifetime, echoing the findings of other local (South African) and international studies….”  Seedat et al, 2004, p 173

The most striking finding was the discrepancy in the rate of PTSD between South African and Kenyan adolescents in the context of equally high rates of trauma exposure (and even higher for specific types of trauma in the Kenyan sample).  The lower rate of PTSD in Kenya adolescents is difficult to explain.”  Seedat et al, 2004, p 173

“Our assessments did not measure the severity or chronicity of trauma exposure or past PTSD, variable that may contribute to PTSD risk.  For example, difference in toxicity of exposure between the samples (much higher levels of exposure to violent crime in South African adolescents) may be operant here, accounting to some extent for the differences inn PTSD rates.” Seedat et al, 2004, p 173

possible cultural factors  in way concept of trauma are operationalized

questionnaires were not culturally validated for the various ethnic groups

SA was far more culturally diverse composition

Kenya relatively homogeneous – 97% Black, compared with only 20% of South Africans

Gender

Surprising finding was absence of gender difference in overall rate and presentation of PTSD (as per Silva 2000)

More boys in this study than girls had experienced sexual trauma, surprise finding

“Sexual abuse [for both genders], compared with all other traumas, was also associated with the highest risk of PTSD.”  Seedat et al, 2004, p 173

depression but not substance abuse was correlated with depression

study limitations – PTSD criteria not based on functional impairment – age of onset and duration of PTSD were not documented, nor was symptom chronicity –

exposure to trauma was measured as a count of trauma types, rather than as the number of exposures or severity of exposure to a particular trauma.  This might have contributed to the failure to detect significant differences between the samples, particularly as cumulative and toxic trauma exposure is associated with a higher PTSD risk.  It does not, however, account for higher rates of PTSD in the South African students, despite higher rates of exposure in Kenyan youth to both sexual assault and physical assault by a family member, as these are traumas that are likely to be repeated.  Further, these traumas were most likely to e associated with a PTSD full-symptom diagnosis.  This discrepancy is one for which we do not have an adequate explanation.”  Seedat et al, 2004, p 174

This would seem to go against Silva’s (2000) findings about threats within the home contributing to higher risk of PTSD in children.

to be eligible all had to read and write English at 10th grade level, although English was not the home language of the majority of respondents

survey questionnaires were not culturally validated

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Silva et al, 2000

Psychiatric clinic sample of 100 inner-city child and adolescent referrals ages 3 to 18 mean 9.9

59 had experienced a PTSD criteria trauma – 22% who had been traumatized met full criteria for PTSD; 32% had partial symptoms of PTSD; 46% had no symptoms of PTSD

witnessing domestic violence or being physically abused predicted severity of TSD

traumatic experience interacts with factors within the child and in the family to contribute to development of PTSD; especially traumas that threaten family integrity appear to make strong contribution

gender made no significant difference in terms of interaction of traumatic experience including sexual abuse with PTSD full, or in difference in number of PTSD symptoms

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Dillenburger 2007

Belfast, Northern Ireland

Politically motivated violence – 37 years – ceasefires 1994 to 1995 – ongoing violent incidents relatively common – range of services developed to help people cope – assessed psychological health of people who use these service – 10 years after ceasefire psychological health remains compromised in terms of death, individual, social and cultural contexts –

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Elliott et al,2006

Northern Ireland

Need to get this article

“Can there be a societal form of PTSD?  Do other individual constellations have a societal parallel?  Are there implications for psychotherapists?  The answer is ‘yes’; but this must be systematically demonstrated….This paper describes some of the work of the Irish Institute for Psycho-Social Studies in studying the Protestant community in Northern and Southern Ireland, and particularly a paramilitary-dominated community in Belfast…..shows powerful parallels between the experience and attitudes of this community and the experience of individual PTSD….For psychotherapists there are important implications about the existence of cultural pathology in a client’s psyche – and perhaps the psychotherapist’s!”

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Bell et al, 2007

Northern Ireland

Sample 643 adults seeking compensation for “Nervous Shock” – 23% diagnosed with PTSD – tended to be older, included more females, had more depressive symptoms, had more severe prolonged disturbance – “…The findings document our experience of PTSD in the special context of Northern Ireland and suggest it may be a more useful term in describing psychological reaction to violence than the nebulous concept of “Nervous Shock” used at present by our courts.”

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Edwards et al, 2003

Abstract

atlanta

members of a health maintenance organization (HMO) – 8,667 adult members

completed measures of childhood exposure to family dysfunction including items on physical and sexual abuse, witnessing of maternal battering, and emotional abuse in the childhood family environment – with current mental health assessment

RESULTS:

[this is not representative of the general population as many members do not have access to health care or participate in HMOs]

prevalence:  sexual abuse 21.6% —  physical abuse 20.6% —- witnessing of maternal violence 14%

among respondents reporting any of the maltreatment types, 34.6% reported more than one type of maltreatment

lower mean mental health scores were associated with higher numbers of abuse categories

both an emotionally abusive family environment and interaction of emotionally abusive family environment with various maltreatment types had significant effect on mental health scores

CONCLUSIONS:  “Childhood physical and sexual abuse, as well as witnessing of maternal battering, were common among the adult members of an HMO in this study.  Among those reporting any maltreatment, more than one-third had experienced more than one type of maltreatment.  A dose-response relation was found between the number of types of maltreatment reported and mental health scores.  In addition, an emotionally abusive family environment accentuated the decrements in mental health scores.  Future research examining the effects of childhood maltreatment on adult mental health should include assessments of a wide range of abusive experiences, as well as the family atmosphere in which they occur.”

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Saleptsi et al, 2004

Abstract

Germany

192 patients with diagnoses of alcohol-related disorders (n=45), schizophrenic disorders (n=52), affective disorders (n=54), and personality disorders (n=41) — Patients were recruited from four psychiatric hospitals in Germany, Switzerland, and Romania – 63 controls with no history of mental illness –

completed 42-item self-rating scale (Traumatic Antecedents Questionnaire, TAQ)

TAQ assesses personal positive experiences (competence and safety) and negative experiences (neglect, separation, secrets, emotional, physical and sexual abuse, trauma witnessing, other traumas, and alcohol and drugs abuse) during four developmental periods beginning from early childhood to adulthood.

RESULTS:

Amount of positive experiences did not differ significantly between groups except personality disorders with lower safety scores

Negative experiences appeared more frequently in patients than in controls

Patients with alcohol-related and personality disorders reported more negative events than the ones with schizophrenic and affective disorders

Emotional neglect and emotional abuse reported more frequently than physical and sexual abuse, with negative experiences encountered more often in late childhood and adolescence than in early childhood

CONCLUSIONS: emphasis that emotional neglect and abuse are the most prominent negative experiences

Adolescence is a more ‘sensitive’ period for negative experiences as compared to early childhood

High amount of reported emotional abuse with alcohol-related disorders

High amount of reported physical abuse occurs in personality disorders

++++

Golier et al, 2003

Abstract

Bronx

Examined relationship of BPD to PTSD with respect to the role of trauma and its timing

Assessed 180 outpatients with a diagnosis of one or more personality disorders

RESULTS:

Rates for early and lifetime trauma were high for the group as a whole

……..Compared to subjects without BPD (34.3%), BPD (52%) group had significantly higher rates of childhood/adolescent physical abuse and were twice as likely to develop PTSD

…………..associations with both trauma and PTSD were not unique to BPD

…paranoid personality disorder subjects had an even higher rate of comorbid PTSD than subjects without same, as well as elevated rates of physical abuse and assault in childhood/adolescence and adulthood

CONCLUSIONS:  associations of personality disorder with early trauma and PTSD were evident, but modest in BPD and were not unique to this type of personality disorder

Results do not substantial or distinct enough to support singling out BPD from the other personality disorders as a trauma-spectrum disorder or variant of PTSD.

++++

Bierer et al, 2003

Abstract

Mt Sinai School of Medicine, NY

Evaluated self-rated indices of sustained childhood abuse and neglect in outpatient sample of well-characterized personality disorder in 182 subjects

……….five dimensions of childhood trauma exposure (emotional, physical, and sexual abuse, and emotional and physical neglect) assessed with Childhood Trauma Questionnaire

24% reported past suicide attempts

78% met dichotomous criteria for some form of childhood trauma – majority reported emotional abuse and neglect

the dichotomized criterion for global trauma severity was predictive of cluster B, borderline, and antisocial personality disorder diagnoses

trauma scores were positively associated with cluster A, negatively with cluster C, not significantly associated with cluster B diagnoses

among specific diagnoses comprising cluster A, paranoid disorder alone was predicted by sexual, physical, and emotional abuse

within cluster B, only antisocial personality disorder showed significant associations with trauma scores with specific prediction by sexual and physical abuse

……..for BPD there were gender interactions for individual predictors, with emotional abuse being the only significant trauma predictor, and only in men

history of suicide gestures was associated with emotional abuse in the entire sample and in women only

………self-mutilatroy behavior was associated with emotional abuse in men

CONCLUSION:

“The results suggest that childhood emotional abuse and neglect are broadly represented among personality disorders, and associated with indices of clinical severity among patients with borderline personality disorder.”

“Childhood sexual and physical abuse are highlighted as predictors of both paranoid and antisocial personality disorders.”

“These results help qualify prior observations of the association of childhood sexual abuse with borderline personality disorder.”

++++

Spertus et al, 2003

Abstract

NY

255 women were assessed on a variety of scales when presenting to their primary care physician for a visit

examined unique contributions of emotional abuse and neglect variables on symptom measures while controlling for childhood sexual and physical abuse and lifetime trauma exposure

RESULTS:

“A history of emotional abuse and neglect was associated with increased anxiety, depression, posttraumatic stress and physical symptoms, as well as lifetime trauma exposure.”

Physical and sexual abuse and lifetime trauma were also significant predictors of physical and psychological symptoms.”

“…emotional abuse and neglect predicted symptomatology in these women even when controlling for other types of abuse and lifetime trauma exposure.”

CONCLUSIONS:

Long-standing behavioral consequences may arise as a result of childhood emotional abuse and neglect, specifically, poorer emotional and physical functioning, and vulnerability to further trauma exposure.”

++++++++++++++++++++++++++++++

mothers infants WTC

Yehuda et al, 2005

Abstract

Mt. Sinai School of Medicine and Bronx Veterans Affairs Med Center

38 mothers directly exposed to the World Trade Center collapse during pregnancy, collected salivary cortisol samples from themselves and their 1-yr-old babies at awakening

RESULTS:

Lower cortisol levels were observed in both mothers and babies of mothers who developed PTSD in response to 9/11 compared with mothers who did not develop PTSD and their babies.

……lower cortisol levels were most apparent in babies born to mothers with PTSD exposed in their third trimesters

CONCLUSIONS:

“The data suggest that effects of maternal PTSD related to cortisol can be observed very early in the life of the offspring and underscore the relevance of in utero contributors to putative [commonly accepted] biological risk for PTSD.”

If they controlled for exact location during 9/11 then these differences in the infants cannot be accounted for by exposure to pollution

++++

Yehuda, Bell, Bierer, Schmeidler 2008

Abstract

117 men and 167 women recruited from community evaluated using comprehensive psychiatric battery to identify traumatic life experiences and lifetime psychiatric diagnoses

211 of these were adult offspring of Holocaust survivors with 73 Jewish controls – subdivided by mother, father, neither, or both parents met criteria for lifetime PTSD

RESULTS:

Maternal PTSD specifically associated with PTSD in adult offspring of Holocaust survivors, but not other psychiatric diagnoses did not show specific effects associated with maternal PTSD

CONCLUSIONS:

“The tendency for maternal PTSD to make a greater contribution than paternal PTSD to PTSD risk suggests that classic genetic mechanisms are not the sole model of transmission, and paves way for the speculation that epigenetic factors may be involved.  In contrast, PTSD in any parent contributes to risk for depression, and parental traumatization is associated with increased anxiety disorders in offspring.”

++++

Engel et al, 2005

abstract

Mt Sinai School of Medicine

Impact of extreme trauma on the birth outcomes of women highly exposed to the WTC

187 women who were pregnant and living or working within close proximity to the WTC on 9/11

52 women completed at least one psychological assessment prior to delivery

both posttraumatic stress symptomatology (PTSS) and moderate depression were associated with longer gestational durations, although only PTSS was associated with decrements in infant head circumference at birth

“The impact of stress resulting from extreme trauma may be different from that which results from ordinary life experiences, particularly with respect to cortisol production.”

“As prenatal PTSS was associated with decrements in head circumference, this may influence subsequent neurocognitive development.”

++++

Lederman et al, 2004

Abstract

Columbia U, NY

Assessed impact of gestational timing of the disaster and distance from the WTC in the 4 weeks after 9/11 on birth outcomes of 300 nonsmoking women who were pregnant at the time of event – recruited at delivery

……concern:  prenatal exposure to pollutants from WTC disaster on fetal growth and subsequent health and development of exposed children

“Term infants born to women who were pregnant on 11 September 201 and who were living within a 2-mile radius of the WTC during the month after the event showed significant decrements in term birth weight…and birth length…compared with infants born to the other pregnant women studied, after controlling for sociodemographic and biomedical risk factors.  The decrements remained significant with adjustment for gestational duration….Women in the first trimester of pregnancy at the time of the WTC event delivered infants with significantly shorter gestation…and a smaller head circumference…compared with women at later stages of pregnancy, regardless of the distance of their residence or work sites from the WTC.  The observed adverse effects suggest an impact of pollutants and/or stress related to the WTC disaster and have implications for the health and development of exposed children.”

++++

Brand et al 2006

Abstract

Bronx

Examination of effect of in utero maternal stress as determined by PTSD symptom severity and maternal cortisol levels on behavioral outcomes in the infant

98 pregnant women directly exposed to WTC collapse “…provided salivary cortisol samples and completed PTSD symptom questionnaire and a behavior rating scale to measure infant temperament, including

distress to limitations, and response to novelty.

Mothers who developed PTSD in response to 9/11 had lower morning and evening salivary cortisol levels, [how do they know they didn’t have this before 9/11?  I guess it makes no difference any more…they have PTSD]compared to mothers who did not develop PTSD.

“Maternal morning cortisol levels were inversely related to their rating of infant distress [see the article that states parental assessment of children may reflect maternal PTSD rather than accurately reporting on the infant] and response to novelty (i.e., loud noises, new foods, unfamiliar people).

“Also, mothers who had PTSD rated their infants as having greater distress to novelty than did mothers without PTSD.”

CONCLUSION:

Longitudinal studies are needed to determine how the association between maternal PTSD symptoms and cortisol levels and infant temperament reflect genetic and/or epigenetic mechanisms of intergenerational transmission.”

++++

++++++++++++++++++

Yehuda et al 1998

abstract

Mt Sinai

Impact of Holocaust on the second generation – examined 100 adult offspring on prevalence of stress and exposure to trauma, current and lifetime posttraumatic stress disorder (PTSD), and other psychiatric diagnoses compared to 44 controls

RESULTS:

“…although adult offspring of Holocaust survivors did not experience more traumatic events, they had a greater prevalence of current and lifetime PTSD and other psychiatric diagnoses than the demographically similar comparison subjects.  This was true in both community and clinical subjects.”

CONCLUSIONS:

“The findings demonstrate an increased vulnerability to PTSD and other psychiatric disorders among offspring of Holocaust survivors, thus identifying adult offspring as a possible high-risk group within which to explore the individual differences that constitute risk factors for PTSD.”

++++

Yehuda, Teicher et al 2007

Abstract

Mt Sinai

“Lower cortisol levels in posttraumatic stress disorder (PTSD) may reflect a preexisting vulnerability associated with developing the disorder after trauma exposure. “

“Because offspring of trauma survivors with PTSD have a greater prevalence of PTSD after their own life events than offspring of trauma survivors without PTSD and offspring of nonexposed persons, examination of patterns of basal cortisol secretion in such offspring provides an opportunity to test this hypothesis.”

Raw hormonal data analyzed

RESULTS:

Offspring with parental PTSD displayed lower mean cortisol levels, reflected by the circadian mesor and reduced cortisol amplitude, compared with offspring without parental PTSD and children of nonexposed parents.  This effect seemed to be specifically related to the presence of maternal PTSD.”

CONCLUSIONS:

Low cortisol levels and other chronobiological alterations in offspring are associated with the risk factor of maternal PTSD, raising the possibility that these alterations are acquired via glucocorticoid programming either from in utero exposures or in response to maternal behaviors early in life.”

[what other chronobiological alterations?]

++++

Yehuda, Blair, Labinsky & Bierer, 2007

Abstract

Mt Sinai and Bronx VA

Cortisol negative feedback inhibition in adult offspring of Holocaust survivors with and without PTSD

RESULTS:

Enhanced cortisol suppression in response to dexamethasone was associated primarily with parental PTSD status, with minimal contribution of subjects’ own trauma-related symptoms.”

CONCLUSION:

Enhanced cortisol negative feedback inhibition may be associated with PTSD because it is related to the PTSD risk factor of parental PTSD.”

++++

EARLY DAMAGE

Heim et al 1997

Abstract

…genetic contribution to the vulnerability for mood and anxiety disorders – major depressive disorder (MDD) and post-traumatic stress disorder (PTSD)

…also preeminent role of earl adverse life events in pathogenesis of these disorders postulated

Corticotropin releasing factor (CRF) – is major regulator of the mammalian stress response

……………may be seminal neurobiological substrate mediating effects of early life stress on subsequent psychopathology

………………………central administration of CRF produces many of physiological and behavioral effects of stress, anxiety and depression

….clinical studies provide evidence for increased activation of CRF neuronal systems in MDD and PTSD

………..similar hyperactivity of CRF neurons and sensitization of the pituitary-adrenal stress response observed in animals exposed to stress in early life

We propose that early adverse life events might render the human individual vulnerable to the effects of stress later in life, resulting in an increased risk for developing psychopathology via long-lived alterations in CRF-containing neural circuits.”

++++

Long et al 2008

Abstract – U of SD, Vermillion

Abstract – will call this article in

ongoing controversy about definition of DSM-IV posttraumatic stress disorder (PTSD) traumatic stressor criterion (A1) and PTSD construct

……sample of 119 college students completed the PTSD Symptom Scale separately in relation to both Criterion A1 and non-Criterion A1 stressful events

….”Contrary to what was expected, analyses revealed that non-Criterion A1 events were associated with greater likelihood of “probable” PTSD diagnoses and a greater PTSD symptom frequency than Criterion A1 events.”

……..”Symptom frequency relationships, however, were moderated by the order in which the measures were administered.”

.. “The non-Criterion A1 PTSD scores were only higher when non-Criterion A1 measures were presented first in the administration order.”

…… “Similar patterns of differences in PTSD scores between stressor types were also found across the three PTSD symptom criteria.”

++++

Van Hooff et al 2008

Abstract – Australia

“Considerable controversy exists with regard to the interpretation and definition of the stressor “A1” criterion for Post Traumatic Stress Disorder (PTSD).  At present, classifying an event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life event) is determined by the rater’s subjective interpretation of the diagnostic criteria.  This has implications in research and clinical practice.”

“Utilizing a sample of 860 Australian adults, this study is the first to provide a detailed examination of the impact of event categorization on the prevalence of trauma and PTSD.”

“Overall, events classified as non-traumatic were associated with higher rates of PTSD.  Unanimous agreement between raters occurred for 683 (79.4%) events.  As predicted, the categorization method employed (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD diagnostic criteria.”

++++

Bedard-Bulligan & Zoellner 2008

Abstract – U of Washington, Seattle

Study examined predictive utility of Criterion A events, examining the stressor (A1) and subjective emotional response (A2) components of definition of a traumatic event

“Across all samples, the current Criterion A requirements did not predict much better than chance.  Specifically, A2 reports added little to the predictive ability of an A1 stressor, though the absence of A2 predicted the absence of PTSD-related symptoms, their duration, and impairment.  Notably, the combination of three A1 and A2 criteria showed the best prediction.  Confronted events also showed less predictive ability than experienced events, with more variable performance across samples.”

These results raise fundamental questions about the threshold or “gate” that Criterion A ought to play in our current nosology.”

++++

Breslau & Kessler 2001

Abstract – Detroit

DSM-IV two-part definition of PTSD widened variety of A1 stressors and added a subjective component A2

…effects of the revised stressor criterion on estimates of exposure and PTSD in community sample of 2181 persons evaluated

…… “The enlarged definition of stressors in A1 increased the total number of events that can be used to diagnose PTSD by 59%.”

….. “The majority of A1 events (76.6% involved the emotional response in A2.  Females were more likely than males to endorse A2….”

……. “Of all PTSD cases resulting from the representative sample of events, 38% were attributable to the expansion of qualifying events in A1.”

……. “The identification of exposures that lead to PTSD were not improved materially by A2 however, events that did not involve A2 rarely resulted in PTSD.”

CONCLUSIONS

“Compared to previous definitions, the wider variety of stressors in A1 markedly increased the number of events experienced in the community that can be used to diagnose PTSD.”

….. “Furthermore, A2 might be useful as a separate criterion, an acute response necessary for the emergence of PTSD, and might serve as an early screen for identifying a subset of recently exposed persons at virtually no risk for PTSD.”

++++

Gold et al 2005

Abstract – PA

Ongoing controversy over PTSD Criterion A1 — Explored relation between definition of traumatic stressor in DSM-IV and psychological symptomatology

…..454 college undergraduates completed measures of psychopathology and exposure to trauma

……the group who reported a traumatic event that was inconsistent with the Criterion A1 definition of a traumatic event reported significantly greater severity of PTSD symptomatology than those who reported a Criterion A1 PTSD event

…..In addition, significantly more people in the DSM trauma-incongruent group met criteria for PTSD than those in the DSM trauma-congruent group.”

…… “Nearly two-thirds of the DSM trauma-incongruent group identified the death or illness of a loved on as their traumatic experience.”

Obvious implications with allostatic load or overload

++++

Yao et al 2003

Abstract – translated – French article – part one of 3 parts

PTSD characterized by intense fear, helplessness or horror, resulting from exposure to a traumatic event

…….clinically manifested with three main syndromes:

reexperiencing,

avoidance behavior and numbing of emotion,

physiological hyperarousal

Post-Traumatic Checklist Scale (PCLS) – brief self-report questionnaire for evaluating severity of three main syndromes of PTSD, can be divided into three sub-scales corresponding to the three main syndromes of the disorder

…………PCLS – aim of study is to validate the French version – 53 patients

.. “The results of our study confirm that the PCLS possesses good empirical and discriminating validity and a good sensitivity.  The fact that the PTSD patients reported significantly higher total scores on the PCLS and its three subscores than other anxiety disorder subjects and non-clinical subjects indicates that the PCLS differentiates well the patients presenting PTSD from other anxiety disorder subjects and non-clinical subjects.  The PCLS total score also correlates significantly with the other measures of psychopathology used in the study, such as measures of phobia…depression…and distress.  This may be explained by the fact that some PTSD symptoms overlap with those of depression and of anxiety or phobia  The PCLS showed anxiety or phobia. The PCLS showed a satisfactory test-retest reliability. The PCLS is therefore a valid and effective measurement of PTSD.  It may be a useful tool for screening and assessing PTSD in clinical practice and research in psychiatry.”

++++++++++++++++++++++

NATURAL DISASTERS

++++

Acierno et al 2007

Abstract – SC

6 to 9 months after 2004 hurricanes – assessment of prevalence of and major risk factors associated with posttraumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive episode – random population sample of 1452 hurricane-affected adults

RESULTS

Posthurricane prevalence for PTSD – 3.6%; generalized anxiety disorder 5.5%; major depressive episode 6.1%

Risk factors varied except for previous exposure to traumatic events which increased risk of all negative outcomes

CONCLUSIONS

“Storm exposure variables and displacement were associated primarily with PTSD.  Notably, high social support in the 6 months preceding the hurricanes protected against all types of disorders.”

++++

Mellman et al 1996

Abstract – Florida

“The nature of psychiatric morbidity in previously non-ill subjects from the area most affected by Hurricane Andrew was investigated at 6-12 months posthurricane.”

…….N=61 – 51% met criteria for a new-onset disorder, including PTSD in 35%, major depression (MD) in 30%, other anxiety disorders in 20%

……..56% had significant symptoms persisting beyond 6 months

……….”Having sustained “severe damage” was the risk factor most strongly associated with outcome.”

….data underscores range of psychiatric morbidity related to a natural disaster, and suggests a relationship to chronic stressors.  Of course I can’t access the article to find out what they are saying is a chronic stressor – meaning stressors other than the obvious hurricane related ones?

++++

Mohamed & Rosenheck 2008

Abstract

BACKGROUND: Although increasing numbers of war veterans are seeking treatment for posttraumatic stress disorder (PTSD) at the U.S. Department of Veterans Affairs (VA), information on the role of psychotropic pharmacotherapy in their treatment has not been available. METHOD: Records of psychotropic prescriptions for all VA patients diagnosed with ICD-9 PTSD (N = 274,297) in fiscal year 2004 (October 1, 2003, to September 30, 2004) were examined. Descriptive statistics and multivariable logistic regression were used to identify veteran characteristics and measures of service use that were associated with receipt of any psychotropic medication and, among users of such medications, with use of each of 3 medication classes: antidepressants, anxiolytics/sedative-hypnotics, and antipsychotics. RESULTS: Most veterans diagnosed with PTSD received psychotropic medication (80%), and among these, 89% were prescribed antidepressants, 61% anxiolytics/sedative-hypnotics, and 34% antipsychotics. Greater likelihood of medication use was associated with greater mental health service use and comorbid psychiatric disorders. Among comorbidities, medication-appropriate comorbid diagnoses were the most robust predictors of use of each of the 3 medication subclasses, i.e., depressive disorders were associated with antidepressant use, anxiety disorders with anxiolytic/sedative-hypnotic use, and psychotic disorders with antipsychotic use. Use of anxiolytics/sedative-hypnotics and antipsychotics in the absence of a clearly indicated diagnosis was substantial. CONCLUSIONS: Diverse psychotropic medication classes are extensively used in the treatment of PTSD in the VA. While disease-specific use for both PTSD and comorbid disorders is common, substantial use seems to be unrelated to diagnosis and thus is likely to be targeted at specific symptoms (e.g., insomnia, anxiety, nightmares, and flashbacks) rather than diagnosed illnesses. A new type of efficacy research may be needed to determine symptom responses to psychotropic medications as well as disorder responses, perhaps across diagnoses.

++++

Reuber et al 2005

Abstract – UK

“Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation.”

“Current concepts explain functional [unexplained] symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention.  Predisposition, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation.  The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric cormorbidity.”

“Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general Practioners.  Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help for the government.”

++++

Bremner et al 2003b

Abstract – GA

Preclinical studies show that animals with a

history of chronic stress exposure have increased hypothalamic-pituitary-adrenal (HPA) axis reactivity following reexposure to stress.

Patients with posttraumatic stress disorder (PTSD) have been found to have normal or decreased function of the HPA axis, however no studies have looked at the HPA response to stress in PTSD.

The purpose of this study was to assess cortisol responsivity to a stressful cognitive challenge in patients with PTSD related to childhood abuse. Salivary cortisol levels, as well as heart rate and blood pressure, were measured before and after a stressful cognitive challenge in patients with abuse-related PTSD (N=23) and healthy comparison subjects (N=18). PTSD patients had 61% higher group mean cortisol levels in the time period leading up to the cognitive challenge, and 46% higher cortisol levels during the time period of the cognitive challenge, compared to controls.

Both PTSD patients and controls had a similar 66-68% increase in cortisol levels from their own baseline with the cognitive challenge. Following the cognitive challenge, cortisol levels fell in both groups and were similar in PTSD and control groups.

PTSD patients appeared to have an increased cortisol response in anticipation of a cognitive challenge relative to controls.

Although cortisol has been found to be low at baseline, there does not appear to be an impairment in cortisol response to stressors in PTSD.

++++

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