Psychotic symptoms in posttraumatic stress disorder

Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.     

Trauma-Related Negative Cognitions Mediate the Relationship Between Avoidant Personality Beliefs and Impeded Response to Psychotherapy for PTSD

There is strong research evidence for the association of personality pathology and posttraumatic stress disorder (PTSD), as well as trauma-related negative cognitions (TRNC) and PTSD symptoms. However, the relationship between personality pathology and TRNC in the context of PTSD is mostly unknown. In the present study, we aimed to examine whether avoidant and borderline personality beliefs (PB, indicator of personality pathology) could predict therapy outcome in PTSD, and whether the relationship between PB and therapy outcome could be mediated by TRNC. Sixty patients with PTSD were assessed for PB, TRNC and PTSD symptoms at baseline, and for PTSD symptoms at the termination of Prolonged Exposure Therapy. Baseline avoidant PB predicted significant variance in PTSD symptoms at termination over and above baseline PTSD symptoms (16% reduction in treatment effect per SD on avoidant PB). Moreover, TRNC at baseline fully mediated the relationships between baseline avoidant PB and PTSD symptoms at termination. This is the first study to show that avoidant PB predicts treatment response in PTSD, and that patients with avoidant beliefs are more vulnerable to have TRNC, which are associated with impeded therapy response. Our results highlight the importance of targeting both dysfunctional PB and TRNC in PTSD interventions.     

Post-Traumatic Stress Disorder as a Consequence of a Toxic Spill in Northern California

This study examined the development of post-traumatic stress disorder (PTSD) and associated features in residents of Dunsmuir, California, following a toxic spill. Classification of PTSD was based on a cutoff score from the Impact of Event Scale. It was predicted that greater exposure to the spill would increase the risk of PTSD and associated symptoms among spill residents; that those classified with PTSD would report more symptoms than would those without PTSD and controls; and that litigants would be classified with PTSD more than would nonlitigants. Results suggest that spill residents classified with PTSD had greater levels of tension, depression, anxiety, anger, fatigue, and confusion than did spill residents without PTSD and control residents with and without PTSD. Spill residents with PTSD reported more memory problems and sleep disorders than did those without PTSD and control residents with and without PTSD. Measures of physiological arousal showed that spill residents had higher systolic blood pressure several hours after a stressful interview than did control residents without PTSD. Pulse rates several hours after a stressful interview were higher for spill residents with and without PTSD than for control residents with PTSD. Results suggest that exposed residents are at risk for developing PTSD and associated symptoms.     

A Pilot Study of the Effects of Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder on Parenting

Parental posttraumatic stress disorder (PTSD) is associated with parenting difficulties. Cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD) improves PTSD symptoms, relationship adjustment, and partners’ mental health functioning. However, the impact of CBCT for PTSD on parenting competency is unknown. In this pilot study, the effects of CBCT for PTSD on parenting competency were investigated in 14 individuals (6 patients with PTSD and 8 partners) who had children under age 18. Results suggested that most participants perceived themselves as competent in their parenting prior to treatment, and some enhancements in competency occurred following CBCT for PTSD. Moreover, changes in parenting competency were associated with improvements in patient-rated PTSD. Adjunctive interventions targeting parenting and goals for future research are discussed.     

Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: results from confirmatory factor analyses.

Factor analytic studies of trauma victims' posttraumatic stress disorder (PTSD) have offered conflicting hypotheses about how to conceptualize PTSD into symptom categories. The present study used confirmatory factor analyses of self-reported PTSD symptomatology from 5,664 child and adolescent victims of Hurricane Hugo to compare 10 models of PTSD dimensionality. PTSD was best represented by a 2nd-order PTSD factor that manifests in 3 symptom clusters (Intrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal). This model was cross-validated on 3 age groups (late childhood, early adolescence, and late adolescence), and results indicated factorial invariance across groups. PTSD symptoms varied in relative centrality to the underlying dimensions of PTSD, which differed in their relations with anxiety and degree of traumatic exposure. Implications for classification criteria and an empirically supported theory of PTSD are discussed.     

Post-traumatic stress disorder,Vietnam veterans and the law: A challenge to effective representation

The legal system's increasing awareness of and understanding regarding post-traumatic stress disorders is presented. PTSD is discussed primarily in the context of litigation involving both violent criminal and nonviolent offenses. Other potential applications of PTSD at trial are reviewed. Post-conviction strategies involving PTSD are also discussed. A comprehensive review of case law involving PTSD is summarized.     

False memories in women with self-reported childhood sexual abuse: an empirical study

Although controversy exists about the validity of memories of childhood abuse, little is known about memory function in individuals reporting childhood abuse. This study assessed memories for previously presented words, including the capacity for false memory of critical lures not actually present in the word list, in 63 subjects, including abused women with posttraumatic stress disorder (PTSD), abused women without PTSD, and men and women without abuse or PTSD. Abused women with PTSD had a higher frequency of false recognition memory of critical lures (95%) than abused women without PTSD (78%), nonabused women without PTSD (79%), or nonabused men without PTSD (86%). PTSD women also showed poorer memory for studied words and increased insertions of non-studied words other than critical lures. These findings are consistent with a broad range of memory alterations in abused women with PTSD.     

Assessment and treatment of PTSD after a motor vehicle collision: Empirical findings and clinical observations

Individuals who experience a serious motor vehicle accident (MVA) are at increased risk for psychological problems, particularly Posttraumatic Stress Disorder (PTSD). In this article, we review the literature on PTSD among MVA survivors, with particular attention to available instruments to screen for and assess symptomatology of the disorder. Approaches to the treatment of PTSD in this population are reviewed, separated into interventions designed to prevent PTSD in unselected samples, treatment targeting individuals with Acute Stress Disorder that are designed to prevent subsequent development of PTSD, and therapy for individuals with chronic PTSD. Treatment process issues are discussed, in an effort to integrate empirical findings with clinical observations. The empirical literature suggests several approaches to treatment that have good potential outcomes, although continued work is needed to identify factors that predict treatment response, as well as augment individual-based treatment formats.     

The Current State of Intervention Research for Posttraumatic Stress Disorder Within the Primary Care Setting

Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.     

Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study

OBJECTIVE: Sleep disturbances are a core feature of post-traumatic stress disorder (PTSD), and are often resistant to first-line pharmacological and psychological PTSD interventions. The goal of this pilot study was to explore the effects of a very brief intervention for PTSD-related nightmares and insomnia in victims of violent crimes with PTSD. METHODS: Seven adult victims of violent crimes with a current diagnosis of PTSD received a single, 90-min intervention session that used cognitive-behavioral techniques aimed at reducing post-traumatic nightmares and insomnia. Sleep diary measures, and measures of sleep quality, PTSD severity, anxiety, and depression were completed at baseline and 6 weeks post-intervention. RESULTS: Improvements in self-report and sleep diary measures of sleep quality and dream frequency were observed post-intervention. Clinically meaningful reductions in daytime PTSD symptom severity were also observed. CONCLUSIONS: A very brief behavioral intervention targeting post-traumatic nightmares and insomnia was associated with significant improvements in sleep and daytime PTSD symptom severity. Brief sleep-focused intervention may be helpful adjuncts to first-line PTSD treatments.     

The Relationship Between Childhood Trauma,Combat Exposure,and Posttraumatic Stress Disorder in Male Veterans

The current study investigated the effects of combat exposure, childhood trauma, and depression on posttraumatic stress disorder (PTSD) severity. Participants were 299 male veterans from the Korean War, World War II, Vietnam, and the first Gulf War who were being screened for admission to the PTSD unit. Participants were assessed with the Clinician-Administered PTSD Scale (CAPS), Combat Exposure Scale (CES), Hamilton Depression Rating Scale (HAMD), Childhood Trauma Questionnaire (CTQ), and Mississippi Scale for PTSD (MPTSD). Results of multiple regression analyses indicated that, as expected, combat exposure and depression were significant predictors of PTSD severity. When examined with combat exposure, childhood trauma has a complex relationship to PTSD severity. Examination of the interaction between the CES and CTQ suggests that when levels of combat are low and childhood trauma levels are high, the CTQ is related to higher levels of PTSD severity on the CAPS, regardless of depression. Treatment implications are discussed.     

The Relationship Between Postdeployment Factors and PTSD Severity in Recent Combat Veterans

Combat traumas precipitate posttraumatic stress disorder (PTSD); however, nontraumatic deployment and postdeployment factors may also contribute to PTSD severity. The Deployment Risk and Resilience Inventory (DRRI) was used to investigate pre-, peri-, and postdeployment factors associated with current PTSD severity in 150 recent combat veterans with PTSD and hazardous alcohol use. Hierarchal linear regression analyzed what factors independently predicted PTSD severity when controlling for sociodemographic characteristics and combat specific variables. Four postdeployment factors independently predicted PTSD severity: unemployment, alcohol use, social support, and stressful (nontraumatic) life events. The centrality of trauma in the maintenance of PTSD and clinical implications for treatment providers are discussed.     

Posttraumatic stress disorder and psychosocial functioning within two samples of MVA survivors

To examine criterion F variables of PTSD, the psychosocial functioning of two samples of motor vehicle accident (MVA) survivors was investigated. Within each sample, comparisons between MVA survivors with and without PTSD were conducted on four psychosocial functioning indices at three time points. In addition, the relationships between specific PTSD symptom clusters and psychosocial functioning indices were examined. The study revealed that, in general, MVA survivors with PTSD evidenced poorer psychosocial functioning than did survivors without PTSD. The emotional numbing symptoms of PTSD emerged as the most consistent predictors of the psychosocial functioning indices. The implications of these findings to the comprehensive treatment of PTSD are discussed.     

Neuropsychological Functioning in Children with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) has been associated with deficits in the areas of verbal memory and learning, executive functioning, working memory, and attention in adults. Findings have been less consistent in the few studies examining neuropsychological functioning in childhood PTSD, which are often limited by comparing children with PTSD to children without trauma histories, making it unclear whether observed neuropsychological deficits are related to trauma exposure or to PTSD symptomatology. In an ethnically diverse sample of 62 children who witnessed intimate partner violence (n = 27 PTSD+ and 35 PTSD?), children with PTSD exhibited slower and less effective learning, heightened sensitivity to interference, and impaired effect of rehearsal on memory acquisition on the California Verbal Learning Test – Children's Version, a word list learning task. Both groups performed in the below average range on measures of executive functioning, attention, and intellectual ability.     

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up.Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.     

Attentional biases in PTSD: More evidence for interference

Attentional biases to trauma-related stimuli have been widely demonstrated in individuals with posttraumatic stress disorder (PTSD). However, the majority of these studies used methods not suited to differentiating difficulty disengaging attention from threatening stimuli (interference) from facilitated detection of threat. In the current study, a visual search task (VST) with a lexical decision component was used to differentiate between attentional interference and facilitation. Forty-six sexual assault survivors with High PTSD or Low PTSD symptoms completed the VST with three types of stimuli (trauma-related, general threat-related, and semantically-related neutral words), to examine the specificity of attentional biases associated with PTSD symptoms. High PTSD participants showed increased interference to trauma-related words relative to Low PTSD participants. Furthermore, the increased attentional interference in High PTSD participants was specific to trauma-related stimuli. No evidence was found for facilitated detection of threatening stimuli in PTSD. These results provide additional support for attentional biases in PTSD relating to attentional interference with trauma-related cues rather than facilitated detection of threat. The implications for this pattern of results are discussed in relation to anxiety disorders that are characterized by rumination and/or intrusions (e.g., PTSD, GAD) rather than those more circumscribed to fight or flight response (e.g., phobias).     

A Novel,Integrated Cognitive-Behavioral Therapy for Co-Occurring Posttraumatic Stress and Substance Use Disorders: A Case Study

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No preferred, evidence-based treatments for PTSD/SUD comorbidity are presently available. Promising integrated treatments have combined prolonged exposure therapy with cognitive-behavioral relapse prevention therapy for SUD. We describe a case study that showcases a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS). The TIPSS program integrates cognitive processing therapy with cognitive-behavioral therapy for SUD for the treatment of co-occurring PTSD/SUD. The present case report, based upon a woman with PTSD comorbid with both cocaine and alcohol dependence, demonstrates that TIPSS has the potential to effectively reduce PTSD symptoms as well as substance use.     

‘Comparisons of traumatic and positive memories in people with and without PTSD profile’

According to most post‐traumatic stress disorder (PTSD) theories, memory mechanisms are involved in its development and maintenance. However, the specific memory characteristics responsible for this disorder are still not well known. In the present study, 210 participants having reported at least one traumatic experience were assigned to a PTSD or to a non‐PTSD symptom profile group. Both groups rated their memories for their most traumatic and intense positive life events. We observed that the traumatic memories of PTSD profile participants were more clear, detailed and judged as significant compared with those of the non‐PTSD profile group. However, participants in the first group acknowledged having more difficulties putting their traumatic memories into words and controlling these remembrances. These differences were absent in their positive memories. Additionally, clear relationships emerged between memory ratings and PTSD symptoms measures. Results are discussed according to fragmentation and superiority views of traumatic memories in PTSD. Copyright © 2006 John Wiley & Sons, Ltd.     

Long term course of chronic posttraumatic stress disorder in traffic accident victims: a three-year prospective follow-up study

The purpose of the present study was to gather prospective longitudinal data on the long-term course and outcome of chronic posttraumatic stress disorder (PTSD). The target population for this study was 74 injured traffic accident victims who had been previously followed-up for one year after the trauma. Nineteen of the original 24 PTSD subjects (79%) and 39 of the original 50 Non-PTSD subjects (78%) were available for this study, which took place during the fourth year after the accident. Our results show that 10 (53%) of the 19 patients with PTSD at one-year still suffered from PTSD after another two-year follow-up interval, while 9 recovered from PTSD during this follow-up period. Only 2 of the 39 without PTSD at one year developed delayed onset PTSD. The best predictor of recovery from chronic PTSD was the initial level of posttraumatic reaction immediately after the accident. These results demonstrate that spontaneous recovery from PTSD can occur even among patients who are currently considered chronic. Severity of initial reaction to the trauma appears to be a major risk factor for non-remitting chronic PTSD.