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Follow-Up of Child War-Related Post-Traumatic Stress Disorder and Other Psychiatric Disorders in Two Exposed Towns in Cundinamarca, Colombia
Abstract
A B S T R A C T OBJECTIVE To determine the evolution of war-related posttraumatic stress disorder (PTSD), other psychiatric disorders, and associated factors, in school-aged children. METHODS Of 493 school-aged children evaluated initially in two war-exposed towns of Cundinamarca, Colombia, 148 children who were diagnosed with war-related PTSD, anxiety, or depression were invited to participate in a second follow-up assessment. Fifty-five children attended and were evaluated with a semi-structured psychiatric interview and the clinician-administered posttraumatic stress scale. RESULTS PTSD persisted in 50% of the children. Statistical associations were found between persistent PTSD and global child abuse (OR 017.8, 95% CI 02.73Á116.8), psychological child abuse (OR 016.0, 95% CI01.7Á154.6), psychosomatic disorder (OR 06.0, 95% CI01.2Á30.7), simple phobia (OR 06.0, 95% CI01.2Á30.7), learning disorder (P0.008), major depressive disorder (P0.021, Fisher exact test), and habitual alcohol consumption (P 0.050, Fisher exact test). Compared with the initial evaluation, this assessment found higher frequencies of anxiety disorder (73.3% vs 6.7%, McNemar test, PB.001) and child abuse (66.7% vs 20.0%, McNemar test, P0.008). Multivariate analysis found child abuse as predictor of persistent PSTD. CONCLUSIONS There was a high level of persistent war-related PSTD and child psychopathology. A civil population exposed to war events is at a high mental health risk. These children require urgent specialized mental health intervention in order to improve and to reduce long-term persistence of negative effects on their mental health. Child abuse prevention is essential for recovery from childhood PTSD.
... Diversos estudios relacionan el TEPT con eventos tales como secuestros, violaciones, atentados terroristas, guerras y eventos catastróficos en población tanto adulta como pediátrica [19][20][21][22][23] . Sobre los estresores atípicos en la población adulta, están los reportes de caso de una neurosis asociada con ver la película El exorcista en 1975 24 y el del caso de un varón de 47 años al que se diagnosticó este trastorno tomando como estresor haber ingerido una barra de chocolate infestada de gusanos 4 . ...
Resumen
Introducción
El trastorno de estrés postraumático (TEPT) se caracteriza por síntomas intrusivos, ansiosos y evitativos que se desencadenan luego de una experiencia estresante y afectan a la esfera del ánimo. La definición de un estresor que genera un TEPT ha estado en controversia en los últimos años, ya que se puede presentar un cuadro clínico compatible con el trastorno tras la exposición a estresores que no cumplen el criterio A1 del DSM-V. Estos estresores se han definido en la literatura como «de baja magnitud, poco comunes, inusuales o atípicos».
Caso clínico
Se presenta el caso clínico de un paciente en edad pediátrica en el que se desarrolló un TEPT luego de exponerse a un estresor atípico.
Conclusiones
Se evidencia en la literatura que estos estresores se han documentado más a menudo en la población pediátrica, por lo cual se propone analizar los casos como un complejo entrecruzamiento de variables, de las que una de las más importantes es la interpretación que cada paciente hace del evento según su historia de vida y su contexto social, y no por una característica inherente al estresor en sí.
La violencia política en Colombia tiene un impacto en la vida social diferenciado por género. Una de las más dramáticas consecuencias sociales del conflicto armado entre la guerrilla, los grupos paramilitares y el ejército, durante las dos últimas décadas, ha sido la migración interna forzada de más de un millón y medio de personas, quienes, individualmente o en pequeños grupos, escapan hacia las ciudades provinciales o hacia la capital del país. Los hombres y las mujeres viven de manera diferente el desarraigo, el desplazamiento y la reconstrucción de la vida. El propósito de este artículo es contribuir al entendimiento de los procesos por los cuales los hombres y las mujeres reconstruyen sus vidas, y renegocian sus identidades y roles de género. También presenta los aspectos que deben tenerse en cuenta para el diseño de políticas sensitivas al género, para las personas que hayan sido desplazadas internamente.
“Sectarianism lives in all of us – it is in the choices we make, it is in the words we say, it is even in the friends we make. It lives in our churches and it taints our community life. It makes possible the violent actions which we abhor” (McKittrick et al, 1999).
As Northern Ireland celebrates the first year in 30 years when a soldier or police officer has not been killed and as it currently struggles to implement yet another political initiative to gain peace, now seems an appropriate time to reflect upon the effect of political violence on the psychiatric services in the province. For almost two generations the campaign of political violence has touched every doctor professionally. Indeed, one of us was a houseman in the front line Royal Victoria Hospital and the other was just born when the sectarian street pogroms and internecine violence first erupted. Neither of us knew that what was to follow would determine our professional futures. In the fresh air of the new millennium, and particularly following the horror of the Omagh massacre of August 1998 and the hope of the Good Friday agreement of April 1998, we can reflect upon and review the psychiatric aspects of politically inspired violence.
Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences.
To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries.
Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585).
Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire.
The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively).
Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.
Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.
The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.
Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
This study determined the severity of posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch and the relationship of these reactions to objective and subjective features of hurricane exposure, death of a family member, forced relocation, and thoughts of revenge.
Six months after the hurricane, 158 adolescents from three differentially exposed cities were evaluated by using a hurricane exposure questionnaire, the Child Posttraumatic Stress Disorder Reaction Index, and the Depression Self-Rating SCALE:
Severe levels of posttraumatic stress and depressive reactions were found among adolescents in the two most heavily affected cities. Severity of posttraumatic stress and depressive reactions and features of objective hurricane-related experiences followed a "dose-of-exposure" pattern that was congruent with the rates of death and destruction across cities. Level of impact (city), objective and subjective features, and thoughts of revenge accounted for 68% of the variance in severity of posttraumatic stress reaction. Severity of posttraumatic stress reaction, death of a family member, and sex accounted for 59% of the variance in severity of depression.
After a category 5 hurricane, adolescents in heavily affected areas with extreme objective and subjective hurricane-related traumatic features of exposure experience severe and chronic posttraumatic stress and comorbid depressive reactions. The recovery of the severely affected Nicaraguan adolescents is vital to the social and economic recovery of a country ravaged by years of political violence and poverty. These findings strongly indicate the need to incorporate public mental health approaches, including systematic screening and trauma/grief-focused interventions, within a comprehensive disaster recovery program.
This study examined the influence of bomb-related television viewing in the context of physical and emotional exposure on posttraumatic stress symptoms--intrusion, avoidance, and arousal--in middle school students following the 1995 Oklahoma City bombing. Over 2,000 middle school students in Oklahoma City were surveyed 7 weeks after the incident. The primary outcome measures were the total posttraumatic stress symptom score and symptom cluster scores at the time of assessment. Bomb-related television viewing in the aftermath of the disaster was extensive. Both emotional and television exposure were associated with posttraumatic stress at 7 weeks. Among children with no physical or emotional exposure, the degree of television exposure was directly related to posttraumatic stress symptomatology. These findings suggest that television viewing in the aftermath of a disaster may make a small contribution to subsequent posttraumatic stress symptomatology in children or that increased television viewing may be a sign of current distress and that it should be monitored. Future research should examine further whether early symptoms predict increased television viewing and/or whether television viewing predicts subsequent symptoms.
The prevalence and determinants of PTSD were assessed among 121 Palestinian children (6-16 years; 45% girls and 55% boys) living in the area of bombardment. The mothers (21-55 years) and the children themselves reported their exposure to military violence (being personally the target of violence or witnessing it towards others) and symptoms of posttraumatic stress disorders (PTSD: intrusion, avoidance and hypervigilance). The results showed that 54% of the children suffered from severe, 33.5 % from moderate and 11 % from mild and doubtful levels of PTSD. Girls were more vulnerable; 58% of them suffered from severe PTSD, and none scored on the mild or doubtful levels of PTSD. The child's gender and age, mother's education and PTSD symptoms were significant, and the exposure to traumatic experiences marginally significant determinants of children's PTSD symptoms. The most vulnerable to intrusion symptoms were younger girls whose mothers showed a high level of PTSD symptoms, whereas those most vulnerable to avoidance symptoms were children who had personally been targets of military violence and whose mothers were better educated and showed a high level of PTSD symptoms. The results are discussed in the context of military violence interfering with the protective function of family and home.
Following exposure to trauma, a large number of survivors will develop acute symptoms of posttraumatic stress disorder (PTSD), which mostly dissipate within a short time. In a minority, however, these symptoms will evolve into chronic and persistent PTSD. A number of factors increase the likelihood of this occurring, including characteristic autonomic and hypothalamic-pituitary-adrenal axis responses. PTSD often presents with comorbid depression, or in the form of somatization, both of which significantly reduce the possibilities of a correct diagnosis and appropriate treatment. Mainstay treatments include exposure-based psychosocial therapy and selective serotonin reuptake inhibitors, such as paroxetine and sertraline, both of which have been found to be effective in PTSD. This paper looks at the course of PTSD, its disabling effect, its recognition and treatment, and considers possible new research directions.
Determining the prevalence of post-traumatic stress disorder (PTSD) related to the type of war exposure and associated factors in school-aged children from three Colombian towns.
Cross-sectional epidemiological study. Representative randomised sample of 493 children aged 5-14. The children were evaluated during 2002 using semi-structured psychiatric interviews and the clinician administered PTSD scale. 167 children were evaluated in La Palma who had been chronically exposed to war, 164 in Arbeláez who had had recent war-exposure and 162 in Sopó who had not been exposed to war. War-related PTSD prevalence was calculated in each municipality. Odds ratio (OR) and chi-square were used for evaluating the association between exposure to war and PTSD and the related risk. Multivariate analysis used the logistic regression model. The affected children required specialised mental health counselling.
The prevalence of PTSD resulting from war was 16,8 % in La Palma, 23,2 % in Arbeláez and 1.2% in Sopó. A 19.9 OR (CI 4.7, 119.2), 30,5 Chi-square and p = 0.000 revealed war-related PTSD association and risk for children when comparing the exposed towns to Sopó. The logistic regression showed that geographical closeness to war zone and intense emotional reaction to war increased the probability of war-related PTSD. Vulnerability factors were predominant in war-exposed towns. Poverty, parents' low educational level and child abuse predominated in La Palma. Attention-deficit and psychosomatic disorders were more prevalent in Arbeláez.
War affects children's mental health; the children from the exposed towns had 19 times greater probability of war-related PTSD than those from a non-exposed town. Early therapeutic intervention is a public health priority. The results are useful for countries suffering from war, internal conflict and/or terrorism.
Objective: To summarize the literature about the clinical presentation and treatment interventions of childhood reactions to terrorism-induced trauma. Method: The literature on children's responses to terrorist activities was reviewed. Results: Over the past 10 years, more research has emerged on the subject of terrorism in children. Many of the effects of terrorism-induced trauma are similar to the effects of natural and man-made trauma. Children's responses include acute stress disorder, posttraumatic stress disorder, anxiety, depression, regressive behaviors, separation problems, sleep difficulties, and behavioral problems. However, several aspects of terrorist attacks result in unique stressors and reactions and pose specific challenges for treatment. The unpredictable, indefinite threat of terrorist events, the profound effect on adults and communities, and the effect of extensive terrorist-related media coverage exacerbates underlying anxieties and contributes to a continuous state of stress and anxiety. Intervention strategies include early community-based interventions, screening of children at risk, triage and referral, and trauma-loss-focused treatment programs. Conclusions: Advances have been made in the research of childhood reactions to terrorism-induced trauma. Further research is needed to identify children at risk and to determine the long-term impact on children's development. Although the preliminary results of interventions developed to help children are promising, outcome data have not been examined, and further research is needed to evaluate their effectiveness.
Objective
Most studies of the long-term after-effects of war have focused on survivors seeking treatment or financial compensation. The present study examined the current psychological adjustment of a community sample of ageing World War II (WWII) survivors, including survivors of bombardments, persecution, resistance, combat and other violence.MethodA community sample of 4057 Dutch WW II survivors answered a 4-page postal questionnaire. Of these, 1461 survivors answered a second follow-up questionnaire.ResultsEven 50 years after World War II, a statistically significant but modest relationship was found to exist between exposure to shocking war events and current psychological adjustment in terms of symptoms of post-traumatic stress disorder (PTSD), anxiety and anger. A total of 66 respondents (4.6%) met the criteria for PTSD. The highest level of current PTSD (13%) was found among survivors of persecution. The lowest level of PTSD (4%) was found among civilian war victims and resistance participants, while military veterans had an intermediate score (7%). With regard to absolute numbers, civilian war victims represented the largest proportion of PTSD sufferers.Conclusion
In a study of a community sample of WW II survivors, we found that most of these survivors had no severe symptoms of PTSD. Nevertheless, probably tens of thousands of Dutch individuals are still suffering from long-term after-effects from World War II. For these vulnerable survivors, the ageing process will complicate the coping process.
This study examined the longitudinal course, over a 25-month period, of posttraumatic morbidity in a group of 469 firefighters exposed to a bushfire disaster. The patterns of posttraumatic morbidity were defined by the General Health Questionnaire. Contrary to expectation, an acute pattern of morbidity was less common than the delayed-onset or chronic forms. Predisaster variables were found to be as important in the onset and course of the disorder as were the firefighters' losses or extent of exposure to the disaster. These data suggest that exposure to an extreme trauma is necessary but not sufficient to explain the onset and pattern of posttraumatic morbidity.
There have been numerous studies of post-traumatic stress disorder in trauma victims, war veterans, and residents of communities exposed to disaster. Epidemiologic studies of this syndrome in the general population are rare but add an important perspective to our understanding of it. We report findings on the epidemiology of post-traumatic stress disorder in 2493 participants examined as part of a nationwide general-population survey of psychiatric disorders. The prevalence of a history of post-traumatic stress disorder was 1 percent in the total population, about 3.5 percent in civilians exposed to physical attack and in Vietnam veterans who were not wounded, and 20 percent in veterans wounded in Vietnam. Post-traumatic stress disorder was associated with a variety of other adult psychiatric disorders. Behavioral problems before the age of 15 predicted adult exposure to physical attack and (among Vietnam veterans) to combat, as well as the development of post-traumatic stress disorder among those so exposed. Although some symptoms of post-traumatic stress disorder, such as hyperalertness and sleep disturbances, occurred commonly in the general population, the full syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition, was common only among veterans wounded in Vietnam.
This study examines posttraumatic stress disorder (PTSD) symptoms, trauma exposure, gender, and diagnostic comorbidity in a sample of 59 Cambodian young adults (29 male and 30 female) who survived massive trauma as children.
Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-III-R-Non-Patient version, a structured diagnostic interview, and trauma exposure was measured with a Traumatic Life Events Questionnaire.
A significant number of those with PTSD (59%) had one or more additional DSM-III-R Axis I disorders. Major depression and generalized anxiety disorder were the most common comorbid disorders. Somatoform pain disorder was also found to coexist with PTSD but only among females. Women were also found to have higher levels of both current and lifetime PTSD symptoms.
Trauma symptoms were related to exposure and exposure was related to age, but age was not related to symptoms. The findings suggest that the significant levels of comorbid diagnoses previously found to exist with PTSD in people traumatized as adults can be found among survivors of massive childhood trauma. Also, the rate of PTSD diagnoses found in this sample 15 years after the trauma of Pol Pot is comparable to findings previously reported in studies of Cambodian youths and shows that the effects of trauma experienced in childhood persist into early adulthood.
To examine the expression of war-related trauma as manifested by DSM-III-R rates of posttraumatic stress disorder (PTSD) and major depressive disorder in two generations of Cambodian refugees living in the western United States.
A probability sample of 209 Khmer adolescents and one of their parents were interviewed using portions of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of the Diagnostic Interview for Children and Adolescents. Interviews were conducted in English by a master's-level clinician with a Khmer interpreter.
PTSD was found to be significantly related across parent-child generations. A nonsignificant generational trend was also found for depressive disorders. A number of environmental variables measured in the study (amount of reported war trauma, loss, living arrangements, treatment received, socioeconomic status) were not related to these findings. Parents were more likely to report an earlier onset of PTSD symptoms.
This study suggests that PTSD in refugees may cluster in families. Whether this phenomenon is caused by a genetic susceptibility to trauma awaits further research. PTSD and depressive disorders in refugee populations, while often comorbid, appear to follow different courses over time.
To determine the prevalence rates of posttraumatic stress disorder (PTSD) and depression in a sample of 99 Cambodian youths, aged 18 to 25 years, living in the Site II refugee camps along the Thai-Cambodian border; to compare these rates to data collected in a similarly aged sample of Cambodian refugees living in the United States; and to illustrate the findings with case vignettes and a brief description of the refugee camp at Site II.
The senior author describes the main features of life in the Site II camp while being employed in one of its medical clinics. A Khmer translated version of the depression section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of Diagnostic Interview Schedule for Children and Adolescents were used in interview format by trained bilingual research assistants. Khmer versions of the Beck Depression Inventory and the Impact of Events Scale were also administered.
The enduring nature of PTSD was evident in this sample of Khmer youths who had survived the Pol Pot regime as children. Similar rates of Pol Pot-related PTSD were found when compared to rates from the US sample. Subclinical forms of PTSD were found in those who reported their worst trauma during life in the camp, while the full PTSD syndrome was associated with those who reported trauma occurring during the earlier Pol Pot regime. Extremely high rates of depressive disorder were found which were interpreted as related to the repatriation back to Cambodia as this study was undertaken.
PTSD in this sample appears to be specifically related to earlier war trauma, while depressive symptoms appear more related to recent stressors. As with other findings from the Khmer adolescent project, this study reaffirms the strong connection between the diagnosis of current PTSD and earlier war trauma in an additional sample of youths at Site II, Thailand. Depressive symptoms, on the other hand, appear to be related to the vicissitudes of recent stressful events in this refugee population.
The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae.
A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms.
The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city.
The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.
There has been considerable controversy regarding the impact of the Holocaust on the second generation, but few empirical data are available that systematically document trauma exposure and psychiatric disorder in these individuals. To obtain such data, the authors examined the prevalence of stress and exposure to trauma, current and lifetime posttraumatic stress disorder (PTSD), and other psychiatric diagnoses in a group of adult offspring of Holocaust survivors (N=100) and a demographically similar comparison group (N=44).
Subjects were recruited from both community and clinical populations and were evaluated with the use of structured clinical instruments. Stress and trauma history were evaluated with the Antonovsky Life Crises Scale and the Trauma History Questionnaire, PTSD was diagnosed with the Clinician Administered PTSD Scale, and other psychiatric disorders were evaluated according to the Structured Clinical Interview for DSM-IV.
The data show that 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.
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.
Most studies of the long-term after-effects of war have focused on survivors seeking treatment or financial compensation. The present study examined the current psychological adjustment of a community sample of ageing World War II (WW II) survivors, including survivors of bombardments, persecution, resistance, combat and other violence.
A community sample of 4057 Dutch WW II survivors answered a 4-page postal questionnaire. Of these, 1461 survivors answered a second follow-up questionnaire.
Even 50 years after World War II, a statistically significant but modest relationship was found to exist between exposure to shocking war events and current psychological adjustment in terms of symptoms of post-traumatic stress disorder (PTSD), anxiety and anger. A total of 66 respondents (4.6%) met the criteria for PTSD. The highest level of current PTSD (13%) was found among survivors of persecution. The lowest level of PTSD (4%) was found among civilian war victims and resistance participants, while military veterans had an intermediate score (7%). With regard to absolute numbers, civilian war victims represented the largest proportion of PTSD sufferers.
In a study of a community sample of WW II survivors, we found that most of these survivors had no severe symptoms of PTSD. Nevertheless, probably tens of thousands of Dutch individuals are still suffering from long-term after-effects from World War II. For these vulnerable survivors, the ageing process will complicate the coping process.
The objective of our investigation was to study the course of direct and indirect posttraumatic disorders over 18 months in children after they were taken hostage in their school.
Twenty-six young hostages were evaluated by using standardized clinical interviews and self-administered questionnaires (State and Trait Anxiety Inventory for Children [STAIC]and Revised Impact of Event Scale [IES]) 2, 4, 7, and 18 months after the event. They were compared with 21 children from the same school who were not taken hostage (indirect exposure).
Symptoms of acute stress were observed in 25 (96%) of the children who were directly involved in the traumatic event. After 2 months, 18 children had developed disorders according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, including 7 cases of full posttraumatic stress disorder (PTSD), 11 cases of subclinical PTSD, 3 cases of separation anxiety, 1 case of specific phobia, and 2 cases of major depressive disorder. Anxiety scores (STAIC) decreased between 2 and 4 months and then stabilized, whereas symptoms of avoidance (IES-avoidance) decreased gradually throughout the follow-up period, and symptoms of repetition (IES-intrusion) decreased less markedly. Children who were indirectly exposed to the trauma also manifested protracted posttraumatic symptomatology (two full cases of PTSD and six cases of subclinical PTSD), but their IES-intrusion scores were significantly lower at 7 months than those of children who were directly exposed, and the severity of their symptoms diminished over time. Girls tended to show a higher level of anxiety and more features of intrusion than boys. Psychological debriefing did not prevent occurrence of the disorders, but children who were not debriefed had the worst outcomes.
Even after a short event and even if they are not directly exposed, children under the age of 9 years can develop high rates of posttraumatic disorders that follow a protracted course despite early intervention and careful monitoring.
Severe early stress and maltreatment produces a cascade of events that have the potential to alter brain development. The first stage of the cascade involves the stress-induced programming of the glucocorticoid, noradrenergic, and vasopressin-oxytocin stress response systems to augment stress responses. These neurohumors then produce effects on neurogenesis, synaptic overproduction and pruning, and myelination during specific sensitive periods. Major consequences include reduced size of the mid-portions of the corpus callosum; attenuated development of the left neocortex, hippocampus, and amygdala along with abnormal frontotemporal electrical activity; and reduced functional activity of the cerebellar vermis. These alterations, in turn, provide the neurobiological framework through which early abuse increases the risk of developing post-traumatic stress disorder (PTSD), depression, symptoms of attention-deficit/hyperactivity, borderline personality disorder, dissociative identity disorder, and substance abuse.
Neural networks and their behavior provide an information-processing model for initiation and maintenance of the biologic aspects of post-traumatic stress disorder (PTSD). The repeated replaying of the intrusive and distressing recollections that follow a trauma modifies the structure of the neural networks involved in the processing of traumatic memories. The hypothesis is proposed that this repetition instigates the mechanisms of iterative learning, top-down activation and pruning. The development of the symptoms of PTSD can be explained by current knowledge about modeling disturbances of parallel distributing processing. The noradrenergic neurons play a central role in coordinating the interaction of multiple cortical regions, which is an essential aspect of parallel distributed processing. Disturbances of this system in PTSD are likely to be manifest as a dysfunctional modulation of working memory and involuntary traumatic recollection. Modifications of neural networks have a secondary effect of kindling in the hippocampus that further moderates the individual's sensitivity to a range of stressors. Therefore, a neural network model of PTSD provides a method for conceptualizing the onset of PTSD symptoms and their subsequent modification with the passage of time.
Many recent immigrant children are at risk for violence exposure and related psychological distress resulting from experiences before, during, and after immigration. This study examines the rates of violence exposure and associated symptoms among recent immigrant children in Los Angeles.
1,004 recent immigrant schoolchildren (aged 8-15 years) were surveyed about their prior exposure to violence and symptoms of posttraumatic stress disorder (PTSD) and depression. Participants included children whose native language was Spanish, Korean, Russian, or Western Armenian.
Participants reported high levels of violence exposure, both personal victimization and witnessing violence, in the previous year and in their lifetimes. Thirty-two percent of children reported PTSD symptoms in the clinical range, and 16% reported depressive symptoms in the clinical range. Although boys and older children were more likely to have experienced violence, girls reported more PTSD and depressive symptoms. Linear multiple regressions revealed that PTSD symptoms were predicted by both recent and lifetime violence exposure (p values < .001 and p < .05, respectively), when depressive symptoms and gender were controlled. On the other hand, depressive symptoms were predicted by recent victimization only (p < .001) when PTSD and gender were controlled.
These findings document the need for interventions addressing the psychological sequelae of violence exposure in immigrant children.
The present study examined the course of posttraumatic stress disorder (PTSD) in a sample of 84 primary care patients. More specifically, this study investigated the role of Axis I comorbidity, psychosocial impairment, and treatment participation in the maintenance of an episode of chronic PTSD and whether patients at follow-up met criteria for PTSD (full remission) or continued to exhibit residual PTSD symptoms and impairment (partial PTSD). Diagnostic structured interviews established all clinical diagnoses and information on the course of anxiety disorder symptoms, psychosocial functioning, and treatment status. Using a prospective, longitudinal design, this study found that during the first 2 years of follow-up, the probability of no longer meeting full DSM-IV criteria for PTSD was .69, and .18 for full remission from PTSD. The number of comorbid anxiety disorders and degree of psychosocial impairment at intake were significantly related to remission status (i.e., full and partial PTSD). This study suggests that, in a primary care setting, PTSD is a persistent illness, and that many subjects who have recovered from PTSD continue to suffer from subthreshold symptoms of PTSD.
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