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.     

Exposure to War Trauma, War-Related PTSD, and Psychological Impact of Subsequent Hurricane

This study explored the impact of psychological outcomes to war on response to subsequent natural disaster. Participants were 312 military personnel, 66% of whom saw Gulf War duty. All were exposed to the 1992 Hurricane Andrew. Troops were compared on reported traumatic events, hurricane impact responses, and psychological symptoms in subgroups defined by war or no war exposure prior to hurricane and by presence or absence of war-related posttraumatic stress disorder (PTSD). Data were gathered in face-to-face clinical assessments. War trauma prior to hurricane was associated with more reported traumatic events, greater fears for safety during the hurricane, and heightened psychological symptoms. Troops with preexisting war-related PTSD showed more adverse psychological hurricane sequelae and reported more traumatic events, higher depression, anxiety, anger, PTSD symptoms, and physical symptoms, and lower self-esteem than those free of diagnoses. Results point to the negative influence of exposure to one traumatic event on the experience of and response to a subsequent stressor.     

Sequential Temporal Dependencies in Associations Between Symptoms of Depression and Posttraumatic Stress Disorder: An Application of Bivariate Latent Difference Score Structural Equation Modeling

Depression and posttraumatic stress disorder (PTSD) are highly comorbid conditions that may arise following exposure to psychological trauma. This study examined their temporal sequencing and mutual influence using bivariate latent difference score structural equation modeling. Longitudinal data from 182 emergency room patients revealed level of depression symptom severity to be positively associated with changes in PTSD intrusion, avoidance, and hyperarousal over 3 time intervals, beginning shortly after the traumatic event. Higher scores on depression anticipated increases (or worsening) in PTSD symptom severity. The pattern of influence from PTSD symptom severity to change in depression symptom severity simply followed the general trend toward health and well-being. Results are discussed in terms of the dynamic interplay and associated mechanisms of posttrauma depression and PTSD symptom severity.     

Psychological Distress and Symptoms of Posttraumatic Stress Disorder in Jewish Adolescents Following a Brief Exposure to Concentration Camps

We investigated the psychological impact of an organized visit to Polish concentration camps on Jewish-American adolescents. Eighty-seven adolescents who participated in a B'nai B'rith memorial visit to concentration camps in Poland completed measures of general psychological adjustment and posttraumatic stress disorder (PTSD) at four time-points: pretest, posttest, 6-month follow-up and 12-month follow-up. Measures included the SCL-90-R, the Mississippi Scale for PTSD, and the Impact of Events Scale (IES) for PTSD. On the SCL-90-R, changes in somatization, interpersonal sensitivity, obsessive-compulsive tendencies, depression, anxiety, and phobic anxiety were observed over time, with peak symptom scores at posttest and 6-month follow-up. Scores on the Mississippi Scale for PTSD and the IES Intrusion subscale also increased at 6-months. Predictors of PTSD symptoms on the Mississippi Scale included previous psychiatric treatment and SCL-90-R symptoms of paranoia, depression, and psychosis. Elevated psychotic symptoms on the SCL-90-R predicted PTSD symptoms on the IES. Jewish adolescents with preexisting symptoms of generalized distress or psychoticism appeared at increased risk for PTSD symptoms following exposure to Holocaust stimuli. This study contributes a prospective, multi-measure assessment of trauma reactions in adolescents.     

Is the centralization of potentially traumatic events always negative? An expansion of the Centrality of Events Scale

The autobiographical memory model of posttraumatic stress disorder (PTSD) argues that centralizing a traumatic event into one's life story is a maladaptive process associated with increased PTSD symptoms. Current measures of event centralization make no reference to whether individuals centralize the event in a positive or negative way. This study examined 400 undergraduate participants using a modified version of the Centrality of Events Scale composed of 2 factors measuring both positive and negative event centralization. Exploratory factor analysis confirmed the 2‐factor structure. Negative event centralization was associated with PTSD symptoms to a greater degree than was positive event centralization, and negative event centralization mediated the relationship between neuroticism and PTSD symptoms. Combined, these results suggest that the effect of event centralization is dependent on the valence with which the individual centralizes the event. The relationship shown between negative event centralization and PTSD symptoms supports the autobiographical memory model of PTSD.     

A review of acute stress reactions among victims of violence:

This article reviews research pertaining to the psychological trauma occurring in the immediate aftermath of interpersonal violence. The literature surveyed includes studies of victims and observers of various forms of interpersonal violence: rape, threats by a patient, legal execution, terrorist attack, ambush, and assassination, mass shootings, and other forms of homicide. The empirical evidence indicates that individuals commonly experience disruptive psychological symptoms immediately following violence. Further, there is evidence that acute stress reactions can lead to posttraumatic stress disorder (PTSD). The limited amount of research conducted on treatment interventions on acute stress reactions to violence indicates that there is not one best intervention. However, the high prevalence of acute stress reactions among victims immediately following interpersonal violence, coupled with evidence that acute stress symptoms predict PTSD, underscore the importance of providing early intervention to victims of interpersonal violence.     

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.     

灾后孤儿创伤后应激障碍的发生发展及其认知神经机制

灾后孤儿亲历双重重大创伤, 是创伤后应激障碍(post-traumatic stress disorder, PTSD)的高发群体; 同时, 巨大创伤对其认知功能和行为模式也带来一定程度的影响。本研究拟以灾后孤儿这一特殊群体为研究对象, 考察“PTSD发生发展及其认知神经机制”, 具体如下：(1) 采用序列研究设计, 展开灾后孤儿PTSD流行病学调查, 描述其PTSD发生发展、变化的轨迹和时程特点; (2) 展开横断研究, 考察灾后孤儿认知发展特点, 并通过结构方程模型, 揭示其PTSD发生发展的心理行为机制; (3) 采用眼动和脑电技术展开比较研究, 考察罹患PTSD孤儿的认知神经机制。本研究的研究结果将对今后的灾后孤儿安置及心理援助提供科学建议; 为有针对性地提供心理干预、制定心理干预的总体规划提供科学依据; 力争为今后孤儿的创伤心理的诊断、干预效果评估提供科学客观的指标和方法。     

Autobiographical memory for shame or guilt provoking events: Association with psychological symptoms

The diagnostic criteria for posttraumatic stress disorder (PTSD) specify that a qualifying traumatic stressor must incite extreme peritraumatic fear, horror, or helplessness. However, research suggests that events inciting guilt or shame may be associated with PTSD. We devised a web-based survey in which non-clinical participants identified an event associated with shame or guilt and completed questionnaire measures of shame, guilt, PTSD, and depression. In addition, we assessed characteristics of memory for the event, including visual perspective and the centrality of the memory to the participant’s autobiographical narrative (CES). Shame predicted depression and PTSD symptoms. There was no association between guilt and psychological symptoms after controlling statistically for the effects of shame. CES predicted the severity of depression and PTSD symptoms. In addition, CES mediated the moderating effect of visual perspective on the relationship between emotional intensity and PTSD symptoms. Our results suggest shame is capable of eliciting the intrusive and distressing memories characteristic of PTSD. Furthermore, our results suggest aversive emotional events are associated with psychological distress when memory for those events becomes central to one’s identity and autobiographical narrative.     

Psychological trauma and PTSD symptoms as predictors of substance dependence treatment outcomes

Psychological trauma and post-traumatic stress disorder (PTSD) may complicate and reduce the effectiveness of treatment for substance use disorders (SUDs). This study assessed trauma history and symptoms of simple and complex PTSD at baseline in a randomized trial of contingency management (CM) compared to standard treatment (ST) with 142 cocaine- or heroin-dependent outpatients. History of exposure to each of eight types of psychological trauma was unrelated to treatment outcome, except for witnessed assaults and emotional abuse. Complex PTSD symptoms were inversely associated with short-term treatment outcomes, and PTSD symptoms were positively related to long-term outcome, independent of the effects of demographics, psychological distress, baseline substance use status, and treatment modality. Complex PTSD symptoms warrant further study as a potential negative prognostic factor in SUD interventions.     

Emotion Dysregulation in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders: A Narrative Review

Co-occurrence of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) is extremely common and is associated with elevated dropout and relapse rates. Given that PTSD/SUD co-occurrence rates among veterans have been found to be as high as 55?75%, it is important to identify mechanisms that may affect the interplay of both disorders. Emotion dysregulation (ED) presents a candidate mechanism that may underlie poor treatment response in co-occurring PTSD/SUD. This article proposes a transdiagnostic emotion regulation framework that considers ED conceptualized as a combination of low ability to tolerate emotional distress (low distress tolerance) and difficulties in the goal-directed use of emotion regulation strategies as a key risk factor in co-occurring PTSD/SUD. The authors review empirical findings from self-report and laboratory-based studies of ED in PTSD. They describe psychological explanations of the emotion-substance relationship and review studies documenting ED in SUDs and in co-occurring PTSD/SUD. The literature on ED in PTSD/SUD suggests that (a) patients with PTSD may resort to substances to cope with trauma-related symptoms due to ED, and (b) ED may maintain SUD symptoms and interfere with psychological treatment. Longitudinal studies on bidirectional relationships between ED and substance use in PTSD are needed, particularly research examining the course of ED in PTSD patients who use substances versus those who do not.     

Measurement differences from rating posttraumatic stress disorder symptoms in response to differentially distressing traumatic events

The authors explored differences in posttraumatic stress disorder (PTSD) symptoms as a result of rating symptoms from two separate, differentially distressing traumatic events. In an initial sample of 400 nonclinical participants, the authors inquired through a web survey about previous psychological trauma, instructing participants to nominate their most distressing and second most distressing traumatic events experienced. Using the PTSD Checklist, participants rated their PTSD symptoms separately from these worst and second worst events. Using the four-factor emotional numbing PTSD model in confirmatory factor analysis, results demonstrated evidence supporting separation of PTSD symptom rating sets from two differentially distressing traumas-specifically, the worst and second worst events. Measurement invariance tests revealed that factor loadings did not vary between the worst and second worst event PTSD ratings; item thresholds (indexing symptom severity) differed. Results generally support the recommended PTSD assessment protocol instructing participants to rate PTSD symptoms from a single, worst index event.     

The Effectiveness of Emotionally Focused Couples Therapy With Veterans With PTSD: A Pilot Study

The current study is a pilot project conducted at Baltimore VA Medical Center investigating the use of emotionally focused couples therapy (EFT) for couples in which one partner is a veteran who has been diagnosed with posttraumatic stress disorder (PTSD). Fifteen couples enrolled in the study and seven of these couples completed treatment (26 to 36 weekly sessions of EFT). Both partners were assessed on measures of relationship satisfaction, psychological distress, depression, and quality of life, and veterans were assessed on measures of PTSD symptoms at baseline and 2 weeks after the intervention. Paired t-tests were used to compare scores before and after EFT. In terms of results, the veterans' partners reported significant improvements in relationship and life satisfaction and in decreased depression and a decrease in psychological distress. Veterans demonstrated a significant decrease in self-reported symptoms of PTSD. These results provide preliminary evidence for the usefulness of EFT to help foster improved relationship satisfaction, and psychological well-being for veterans with PTSD and their partners who completed treatment.     

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

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

Traumatic events and early maladaptive schemas (EMS): Prison guard psychological vulnerability

Introduction and objectiveGuards are employed to maintain prison security partly because of inmate violence. In this environment, traumatic events such as attacks are frequent. In the aftermath of such events, two major psychopathological consequences can affect guards: (a) post-traumatic stress symptoms (PTSS) or disorder (PTSD or ASD) and (b) early maladaptive schema (EMS) re-enactment. The current study addresses inmate-on-staff attacks in terms of post-traumatic stress symptoms (PTSS) and EMS re-enactment.Method and resultsTwo hundred and thirty-five prison guards were assessed for (1) PTSS with the Impact of Event Scale-Revised, and (2) EMS with SCP II, a French EMS inventory. Post-traumatic stress symptoms are high among prison guards and “mistrust” EMS are significantly more re-enacted than other EMS. Correctional guards with PTSD show significantly higher EMS re-enactment levels than those without post-traumatic stress symptoms.ConclusionsIt appeared that inmate-on-staff attacks cause re-enactment of “mistrust” EMS in particular. We hypothesize a particular relationship between EMS and PTSD: after a traumatic event, EMS may be re-enacted. Once EMS are re-enacted, they act as a risk factor for post-traumatic stress symptoms. In return, post-traumatic symptoms may maintain EMS enactment. Further studies are necessary; nevertheless, we now know the importance of psychological help for prison guards.     

STRUCTURAL MODELS OF THE RELATIONS OF ASSAULT SEVERITY, SOCIAL SUPPORT, AVOIDANCE COPING, SELF-BLAME, AND PTSD AMONG SEXUAL ASSAULT SURVIVORS

A number of studies have identified which survivors of sexual assault are more likely to develop symptoms of posttraumatic stress disorder (PTSD). Most correlates that have been identified have been at the individual level. Insufficient attention has been given to whether survivors' social interactions impact their individual responses to assault and subsequent levels of psychological symptomatology. In this study, a large, diverse sample of community-residing women ( N = 636) was surveyed. Structural equation modeling was used to examine the relationships between assault severity, global support, negative social reactions, avoidance coping, self-blame, traumatic life experiences, and PTSD symptoms. The results suggest that negative social reactions and avoidance coping are the strongest correlates of PTSD symptoms and that the association typically observed between victim self-blame and PTSD symptoms may be partially due to the effect of negative social reactions from others. These reactions may contribute to both self-blame and PTSD. Implications for future research and clinical practice are discussed.     

Treating PTSD in active duty service members using cognitive processing therapy or prolonged exposure therapy: Examining everyday practice at a military outpatient clinic

The Institute of Medicine has stressed the need for evaluations of evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) among active duty service members (AD) using a variety of evaluation approaches (Institute of Medicine, 2012). The current study examined the clinical files of 134 service members who completed treatment for PTSD using either prolonged exposure (PE) or cognitive processing therapy at an outpatient clinic. At the completion of each session, therapists made a clinical rating as to whether or not the session was protocol adherent. The total number of treatment sessions and the proportion of sessions rated as being protocol adherent were calculated. Multi-level models estimated the change in patient PTSD and other psychological symptoms over time as a function of clinician-rated protocol adherence and total number of sessions. Approximately 65% of clinic encounters were rated by therapists as being protocol adherent. Significant reductions in PTSD and psychological symptoms were associated with protocol adherence, and this was particularly true for patients who began treatment above clinical thresholds for both PTSD and other psychological symptoms. However, as the number of sessions increased, the impact of protocol adherence was attenuated. Patient characteristics, including gender, ethnicity, and co-morbidity for other psychiatric disorders were not related to symptom change trajectories over time. These findings suggest that protocol adherence and efficiency in delivery of EBTs for the treatment of PTSD with AD is critical.     

Conceptually driven pharmacologic approaches to acute trauma

Secondary prevention of posttraumatic stress disorder (PTSD) entails intervening in the aftermath of a traumatic event to forestall the development of PTSD. There has been little psychopharmacologic research in this area. This is surprising, given that PTSD is the mental disorder with the most clearly identified cause and onset. In a translational model of PTSD's pathogenesis presented herein: A traumatic event (unconditioned stimulus) overstimulates endogenous stress hormones (unconditioned response); these mediate an overconsolidation of the event's memory trace; recall of the event in response to reminders (conditioned stimulus); releases further stress hormones (conditioned response); these cause further overconsolidation; and the overconsolidated memory generates PTSD symptoms. Noradrenergic hyperactivity in the basolateral amygdala is hypothesized to mediate this cycle. Preventing pre-synaptic norepinephrine release with alpha2-adrenergic agonists or opioids, or blocking post-synaptic norepinephrine receptors with beta-adrenergic antagonists such as propranolol, reduces hormonally enhanced memories and fear conditioning. Two controlled studies of trauma victims presenting to emergency rooms suggest that posttrauma propranolol reduces subsequent PTSD, as does one naturalistic clinical study of morphine treatment of burned children. Cortisol both enhances memory consolidation and reduces memory retrieval, leading to mixed predictions. Two controlled studies of intensive care unit patients found that cortisol reduced PTSD. One study did not find benzodiazepines effective in preventing PTSD. Selective serotonin reuptake inhibitors, antiepileptics, and alpha2-adrenergic agonists have yet to be tried.     

Connections among symptoms of obsessive-compulsive disorder and posttraumatic stress disorder: a case series

Theoretical, clinical, and empirical implications of the functional connections between symptoms of obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are abundant. As such, four cases are presented here of men and women who met criteria for comorbid OCD and PTSD. All had been diagnosed with treatment-resistant OCD and were seeking treatment from an OCD specialty clinic or institute, all reported a history of traumatic experiences prior to the onset of OCD, and all appeared to demonstrate negative treatment outcomes. Upon examination, it appeared that symptoms of OCD and PTSD were connected such that decreases in OCD-specific symptoms related to increases in PTSD-specific symptoms, and increases in OCD-specific symptoms related to decreases in PTSD-specific symptoms. Speculations about the function of OCD symptoms in relation to post-traumatic psychopathology are put forth; and theoretical, research, and treatment implications are discussed.     

Posttraumatic stress and physical health among adults: The role of coping mechanisms

The purpose of the present study was to examine whether coping mechanisms predict physical health, after controlling for posttraumatic stress disorder (PTSD) symptom clusters in a non-clinical sample of adults. Data were collected from 483 adults through an online survey. Most of the participants (66.7%) reported lifetime exposure to at least one traumatic event. The final sample of this study included 319 trauma-exposed individuals. Results indicated that PTSD symptoms on the avoidance and hyperarousal clusters had significant positive relationships with self-reported physical health symptoms. After controlling for gender and PTSD, denial, behavioral disengagement, and self-blame significantly and positively predicted physical health symptoms.