Peritraumatic and persistent panic attacks in acute stress disorder

This study examined the prevalence of peritraumatic and persistent panic symptoms following trauma. Survivors of civilian trauma (n=30) with either acute stress disorder (ASD) or no acute stress disorder (non-ASD) were administered the Panic Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed the Impact of Event Scale, Acute Stress Disorder Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Anxiety Sensitivity Index. Panic attacks were experienced by 77% of participants during their trauma, and 47% reported recurrent panic attacks post-trauma. ASD participants demonstrated more panic symptoms during and after their trauma than non-ASD participants. Posttraumatic panic was most strongly associated with anxiety sensitivity. These findings are discussed in terms of cognitive factors that may mediate posttrauma panic and treatment implications for managing posttraumatic anxiety.There is increasing evidence that panic attacks play a role in psychopathological response to trauma. A significant proportion of people with panic disorder report a history of trauma (). Moreover, two-thirds of trauma survivors report panic attacks within the previous 2 weeks (). There is also evidence that people with posttraumatic stress disorder (PTSD) display elevated levels of anxiety sensitivity (). Recent attention has focused on acute panic reactions because of proposals that panic during trauma may condition trauma-related cues to subsequent panic (). There is evidence that panic attacks occur in 53-90% of trauma survivors during the traumatic experience (). Further, people with acute stress disorder (ASD) are more likely to report peritraumatic panic attacks than non-ASD individuals. ASD is a useful framework in which to investigate the role of panic in posttraumatic stress because ASD describes acute responses to trauma that are strongly predictive of chronic PTSD ().This study investigated the relationship between peritraumatic panic and ongoing panic attacks following trauma. Specifically, we indexed panic attacks during trauma and subsequent to trauma in trauma survivors with and without ASD. We also indexed the extent to which distorted interpretations about somatic sensations may be associated with panic attacks following trauma. We considered that the strong evidence that maladaptive appraisals of somatic sensations mediate panic () is directly relevant to posttraumatic panic. We hypothesized that ASD participants would report more peritraumatic and persistent panic than non-ASD participants, and that this panic would be associated with dysfunctional interpretations about somatic stimuli.     

Thought control strategies in acute stress disorder

Intrusive trauma-related thoughts and the means to manage them are a central dynamic in posttraumatic stress. Thought control strategies were investigated in survivors of motor vehicle accidents with either acute stress disorder (ASD; n=20) or no ASD (n=20). Participants completed the Acute Stress Disorder Interview, the Beck Depression Inventory, the Beck Anxiety Inventory, the Impact of Event Scale, and the Thought Control Questionnaire (TCQ) within four weeks of their accident. Although distraction, social control, and reappraisal were the most common strategies in both groups, ASD participants engaged in punishment and worry more than non-ASD participants. Worry and punishment were also strongly associated with severity of intrusive, avoidance, arousal, and depressive symptoms. Findings are discussed in terms of the role of cognitive strategies in resolving posttraumatic stress.     

The generality of cognitive bias in acute stress disorder

Cognitive bias was investigated in acutely traumatised civilians with either acute stress disorder (ASD; n = 26) or no ASD (n = 24). Participants completed the Acute Stress Disorder Interview, the Beck Depression Inventory, the Beck Anxiety Inventory (BAI), the Impact of Event Scale (IES), and an Event Probability Questionnaire and an Event Cost Questionnaire that comprised items pertaining to (a) external harm, (b) somatic sensations and (c) social events. ASD participants exaggerated both the probability of negative external harm, somatic and social events occurring, and the adverse cost of those events more than non-ASD participants. Elevated probability and cost estimates were predicted by BAI and IES-Avoidance scores, respectively. These findings are discussed in the context of different patterns observed in other anxiety disorders, and interpreted in terms of network theories of posttraumatic stress.     

Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder

Although peritraumatic dissociation predicts subsequent posttraumatic stress disorder (PTSD), little is understood about the mechanism of this relationship. This study examines the role of panic during trauma in the relationship between peritraumatic dissociation and subsequent PTSD. Randomized eligible admissions to 4 major trauma hospitals across Australia (n = 244) were assessed during hospital admission and within one month of trauma exposure for panic, peritraumatic dissociation and PTSD symptoms, and subsequently re-assessed for PTSD three months after the initial assessment (n = 208). Twenty (9.6%) patients met criteria for PTSD at 3-months post injury. Structural equation modeling supported the proposition that peritraumatic derealization (a subset of dissociation) mediated the effect of panic reactions during trauma and subsequent PTSD symptoms. The mediation model indicated that panic reactions are linked to severity of subsequent PTSD via derealization, indicating a significant indirect relationship. Whereas peritraumatic derealization is associated with chronic PTSD symptoms, this relationship is influenced by initial acute panic responses.     

Cognitive bias in acute stress disorder

Cognitive bias was investigated in survivors of motor vehicle accidents with either acute stress disorder (ASD; n=17) or no ASD (n=17). Participants completed the acute stress disorder interview, the Beck depression inventory, the Beck anxiety inventory, the impact of event scale, and a probability questionnaire (PQ) and a cost questionnaire (CQ) within four weeks of their accident. ASD participants exaggerated both the probability of negative events occurring, and the adverse cost of those events more than non-ASD participants. IES-Avoidance scores were the only significant predictors of both PQ and CQ scores. Findings are discussed in terms of the role of cognitive errors in posttraumatic adjustment.     

PTSD易感性人格特质、工作记忆能力和创伤期间认知加工对模拟创伤闪回的影响

基于模拟创伤研究范式, 采用道路交通事故影片对159名健康大学生进行模拟创伤, 考察PTSD易感性人格特质(特质焦虑、特质分离和神经质)、工作记忆能力(注意控制和工作记忆容量)和创伤期间认知加工(数据驱动加工和概念加工)对模拟创伤后不同时段闪回的影响。运用结构方程模型分析数据, 结果发现：(1)数据驱动加工正向预测不同时段闪回(即时闪回、一周闪回和触发闪回)的数量、生动性、痛苦度以及一周侵入频率; (2)神经质正向预测触发闪回痛苦度, 注意控制和工作记忆容量负向预测一周侵入频率; (3)概念加工在注意控制与即时闪回痛苦度之间起中介作用。研究结果提示：数据驱动加工是创伤后不同时段闪回的主要影响因素; 概念加工主要作用于早期急性应激反应, 注意控制是其保护因素; 神经质和工作记忆能力对闪回具有较长期的影响, 且工作记忆能力具有一定的保护作用。     

Impaired specific autobiographical memory as a risk factor for posttraumatic stress after trauma

This study tested the proposal that impaired retrieval of specific autobiographical memories is a risk factor for psychological disturbance after trauma exposure. Trainee firefighters (N = 60) were assessed during training (before trauma exposure) on the Autobiographical Memory Test, Clinician Administered PTSD Scale, Beck Depression Inventory (BDI-II), and Traumatic Events Questionnaire. Participants were reassessed 4 years later (N = 46) on the Posttraumatic Diagnostic Scale and BDI-II. All participants had been exposed to multiple traumatic events, and 15% met criteria for posttraumatic stress disorder. Impaired retrieval of specific memories in response to positive cues prior to trauma exposure significantly predicted posttraumatic stress severity after trauma exposure. These findings provide initial evidence that impaired specific retrieval of memories may be a risk factor for posttraumatic stress.     

Cognitive Processing Therapy for Acute Stress Disorder Resulting From an Anti-Gay Assault

This case study describes Cognitive Processing Therapy (CPT) with a 30-year-old gay man with symptoms of acute stress disorder (ASD) following a recent homophobic assault. Treatment addressed assault-related posttraumatic stress disorder symptoms and depressive symptoms. Also addressed were low self-esteem, helplessness, and high degrees of internalized homophobia. Client symptomatology was tracked using the PTSD Symptom Scale and the Beck Depression Inventory over the course of 12 sessions and for a 3-month posttermination session. Symptoms were significantly reduced by the end of the 12-week therapy and were maintained at 3-month follow-up. This case highlights the utility of this therapy in targeting both ASD symptoms and internalized homophobia relating to experiencing a hate crime-related assault. The authors elaborate on theoretical and applied issues in adapting a structured cognitive-behavioral intervention to the treatment of ASD symptoms associated with experiencing a hate crime.     

A Study of Panic Attacks in University Students of Iran

This study examined the parameters of panic, fear, and avoidance among university students in Iran. Data were collected from 347 students using Farsi translations of the Panic Attack Questionnaire, Beck Depression Inventory, Taylor Manifest Anxiety Scale, State-Trait Anxiety Inventory, and Anxiety Sensitivity Index. Thirty-eight percent of participants reported panic attacks in the past year and 21.4% reported panic attacks in the past 4 weeks when prompted by a broad definition of panic. Men and those with unexpected panic reported greater panic severity whereas women with panic attacks reported greater situational fear and avoidance. Panickers who satisfied DSM-III-R panic disorder (PD) criteria reported greater lifestyle restriction and general psychopathology. The findings provide tentative support for cross-cultural similarity in panic phenomenology and the validity of DSM-III-R PD criteria among university students in Iran. The results are discussed by reference to nonclinical panic research and general themes of Iranian culture.     

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.     

Diagnostic, demographic, memory quality, and cognitive variables associated with acute stress disorder in children and adolescents

To date, no studies have investigated factors associated with acute stress disorder (ASD) in children and adolescents. Relationships between ASD and a number of demographic, trauma, cognitive, and trauma memory variables were therefore investigated in a sample (N=93) of children and adolescents involved in assaults and motor vehicle accidents. Several cognitive variables and the quality of trauma memories, but not demographic or trauma variables, were correlated with ASD and also mediated the relationship between peritraumatic threat and ASD. Finally, nosological analyses comparing ASD with indexes of posttraumatic stress disorder in the month posttrauma revealed little support for the dissociation mandate that uniquely characterizes ASD. The results are discussed with respect to assessment and treatment for the acute traumatic stress responses of children and young people.     

Prediction of Posttraumatic Stress Disorder From Peritraumatic Dissociation and Distress Among Men and Women Victims of Violent Crimes

This prospective study evaluated the main and interactive effects of peritraumatic reactions with gender on posttraumatic stress disorder (PTSD) onset, independently of known risk factors. Further, 111 adult victims of violent crime completed the Structured Clinical Interview, the Modified PTSD Symptom Scale, the Peritraumatic Dissociative Experience Questionnaire, and the Peritraumatic Distress Inventory. Hierarchical regressions and chi-square tests were conducted for continuous and categorical measures of PTSD. Extremely elevated scores of peritraumatic dissociation (PD) and peritraumatic distress (PDI) were obtained for both sexes. Greater PDI and PD were related to more PTSD symptoms. No significant interaction effects with gender emerged. These results remained when acute stress disorder was controlled for. Analyses on categorical data produced similar results. Victims of violent crimes recall severe peritraumatic reactions. The more severe these are, the more likely they are to develop significant PTSD symptomatology in the months that follow.     

Generalized anxiety and panic disorders: Response to Cox, Cohen, Direnfeld, and Swinson (1996)

Contrary to the contention of Cox, Cohen, Direnfeld and Swinson (1996, Behaviour Research and Therapy, 34, 949–954) that the Beck Anxiety Inventory (BAI; Beck & Steer, 1993, Manual for the Beck Anxiety Inventory) measures primarily symptoms associated with panic attacks rather than anxiety in general, we propose that the higher level of anxiety found in patients with panic disorders not only is not an artifact of the BAI's symptom content, but patients with panic disorders truly have more anxiety than patients with other types of anxiety disorders. Furthermore, the BAI contains symptoms present in other anxiety disorders, besides panic disorder, and specifically includes 11 symptoms of generalized anxiety disorder (GAD). The BAI and revised Hamilton Anxiety Rating Scale (HARS-R; Riskind, Beck, Brown & Steer, 1987, Journal of Nervous and Mental Disease, 175, 474–479) scores of 274 (69%) outpatients with panic disorders and 123 (31%) outpatients with GAD were found to differentiate these two diagnostic groups equally and significantly. The panic disorder outpatients had higher scores on both the BAI and the HARS-R than did the GAD patients. Thus, Cox et al.'s (1996) speculation about the BAI's yielding spuriously high levels of anxiety in patients with panic disorders revives an important issue relevant to the relation of panic disorder to GAD.     

Further validation of the IDAS: evidence of convergent, discriminant, criterion, and incremental validity

The authors explicated the validity of the Inventory of Depression and Anxiety Symptoms (IDAS; D. Watson et al., 2007) in 2 samples (306 college students and 605 psychiatric patients). The IDAS scales showed strong convergent validity in relation to parallel interview-based scores on the Clinician Rating version of the IDAS; the mean convergent correlations were .51 and .62 in the student and patient samples, respectively. With the exception of the Well-Being Scale, the scales also consistently demonstrated significant discriminant validity. Furthermore, the scales displayed substantial criterion validity in relation to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) mood and anxiety disorder diagnoses in the patient sample. The authors identified particularly clear and strong associations between (a) major depression and the IDAS General Depression, Dysphoria and Well-Being scales, (b) panic disorder and IDAS Panic, (c) posttraumatic stress disorder and IDAS Traumatic Intrusions, and (d) social phobia and IDAS Social Anxiety. Finally, in logistic regression analyses, the IDAS scales showed significant incremental validity in predicting several DSM-IV diagnoses when compared against the Beck Depression Inventory-II (A. T. Beck, R. A. Steer, & G. K. Brown, 1996) and the Beck Anxiety Inventory (A. T. Beck & R. A. Steer, 1990).     

A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder

This study investigated the role of acute arousal in the development of posttraumatic stress disorder (PTSD). Hospitalized motor-vehicle-accident survivors (n = 146) were assessed for acute stress disorder (ASD) within 1 month of the trauma and were reassessed (n = 113) for PTSD 6 months posttrauma. Heart rate (HR) and blood pressure (BP) were assessed on the day of hospital discharge. Participants with subclinical ASD had higher HR than those with ASD and no ASD. Participants who developed PTSD had higher HR in the acute posttrauma phase than those without PTSD. Diagnosis of ASD and resting HR accounted for 36% of the variance of the number of PTSD symptoms. A formula composed of a diagnosis of ASD or a resting HR of > 90 beats per minute possessed strong sensitivity (88%) and specificity (85%) in predicting PTSD. These findings are discussed in terms of acute arousal and longer term adaptation to trauma.     

Gaining Control Over Traumatic Experiences: The Role of Guilt in Posttraumatic Stress Disorder

The present study explores the relationship between guilt, sense of control, and posttraumatic stress disorder. Seventy-eight participants who had experienced a traumatic event completed the following self-report measures online: the Posttraumatic Stress Diagnostic Scale, the Guilt Cognitions subscale of the Trauma-Related Guilt Inventory, the Posttraumatic Cognitions Inventory, and Sense of Control During the Trauma. Results revealed that “behavioral self-blame” that refers to functioning during the trauma, positively correlated with posttraumatic stress symptoms. However, when Sense of Control During the Trauma was introduced into the analysis, this correlation appeared only for participants who had experienced lack of control during the traumatic event. Among the participants who had experienced a sense of control, no such link was found. Results suggest that guilt may be produced to avoid feelings of helplessness following the trauma, because guilt conveys a sense of control.     

Posttraumatic stress disorder in the emergency room: exploration of a cognitive model

Ehlers and Clark (Behav. Res. Ther., 38 (2000) 319) recently proposed a cognitive model of posttraumatic stress disorder (PTSD). In this study, we examined two facets of this model, appraisal and peritraumatic dissociation, in the context of a hospital emergency room. Fifty-one emergency room personnel completed questionnaires measuring posttraumatic stress symptoms, interpretations of traumatic events experienced while working in the emergency room and subsequent intrusive recollections, and peritraumatic dissociation. Twelve percent of participants met formal diagnostic criteria for PTSD, and 20% met PTSD symptom criteria. As predicted, both negative appraisals of the trauma and of intrusive recollections were associated with increased PTSD severity. Although peritraumatic dissociation did not correlate with overall PTSD symptom severity, it was associated with the reexperiencing symptom cluster. Discussion focuses on the factors associated with PTSD in emergency room professionals and implications for intervention.     

Directed forgetting in acute stress disorder

The rationale underpinning the diagnosis of acute stress disorder is that cognitive mechanisms result in avoidant processing of aversive experiences. This study investigated acutely traumatized participants with either acute stress disorder (ASD; n = 15) or no ASD (n = 14) and nontraumatized comparison participants (n = 16). Participants were administered intermixed presentations on a computer screen of positive, neutral, and trauma-related words that were followed by instructions to either remember or forget each word. On a subsequent recall test, ASD participants displayed poorer recall of to-be-forgotten trauma-related words than did non-ASD participants. Severity of psychopathology was negatively correlated with to-be-remembered positive words. These findings are consistent with the proposal that people who develop ASD display an aptitude for superior forgetting of aversive material.     

Acute stress reactions: can biological responses predict posttraumatic stress disorder?

What biological responses characterize those acute trauma reactions that develop into chronic psychiatric disorder? The need to understand the genesis of posttraumatic psychological disorders has resulted in much attention on biological reactions in the initial aftermath of trauma exposure. This review outlines the prevailing biological models of acute stress reaction and critiques the available evidence concerning biological responses to trauma that are associated with subsequent psychological disorder. The roles of peritraumatic dissociation and vulnerability factors for acute stress reaction are also reviewed. The major challenges for research on psychobiological responses to trauma are highlighted.     

Anxiety sensitivity as a predictor of panic disorder symptoms: a prospective 3-year study

Background and Objectives: Anxiety sensitivity (AS) is the fear of anxiety symptoms, a feature proven to be an important vulnerability factor for anxiety pathogenesis. The aim of this study was to examine whether AS (as well as its factors) predicts the onset of panic disorder symptoms when controlling for the contribution of trait anxiety.

Design: We conducted a prospective 3 year follow up study.

Methods: The participants, students at the Humanities and Social Sciences in Zagreb (N?=?1087), completed an Anxiety Sensitivity Index and State-Trait Anxiety Inventory (Trait form) and, after a period of three years, were asked to self-assess criteria for panic disorder (according to the DSM-5).

Results: The predictive validity of AS for the onset of panic disorder symptoms, regardless of trait anxiety, was confirmed. Furthermore, the physical concerns dimension of AS was the only significant predictor of panic disorder symptoms. The optimal cutoff score of 25 on the ASI provides poor to moderate accuracy indices in detecting participants who will manifest panic disorder symptoms in the next three years.

Conclusion: This study contributes to our current understanding of AS as a prospective risk factor for panic disorder symptoms.