Remission from post-traumatic stress disorder in the general population

ArticleinPsychological Medicine 42(8):1695-703 · December 2011with 644 Reads
Abstract
Few studies have focused on post-traumatic stress disorder (PTSD) remission in the population, none have modelled remission beyond age 54 years and none have explored in detail the correlates of remission from PTSD. This study examined trauma experience, symptom severity, co-morbidity, service use and time to PTSD remission in a large population sample. Data came from respondents (n=8841) of the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB). A modified version of the World Health Organization's World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to determine the presence and age of onset of DSM-IV PTSD and other mental and substance use disorders, type, age, and number of lifetime traumas, severity of re-experiencing, avoidance and hypervigilance symptoms and presence and timing of service use. Projected lifetime remission rate was 92% and median time to remission was 14 years. Those who experienced childhood trauma, interpersonal violence, severe symptoms or a secondary anxiety or affective disorder were less likely to remit from PTSD and reported longer median times to remission compared to those with other trauma experiences, less severe symptoms or no co-morbidity. Although most people in the population with PTSD eventually remit, a significant minority report symptoms decades after onset. Those who experience childhood trauma or interpersonal violence should be a high priority for intervention.

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  • ... Little research has been done on the predictors of the long-term course of post-traumatic stress disorder (PTSD) (reviewed by Steinert et al. 2015). Existing evi- dence suggests that even though a substantial propor- tion of cases recover within a few months, at least one-third of cases persist for many years ( Kessler et al. 1995;Breslau et al. 1998;Pietrzak et al. 2011;Chapman et al. 2012), and that chronic PTSD can lead to secondary disorders ( Perkonigg et al. 2005) and suicidality (Tarrier & Gregg, 2004). The predictors of PTSD recovery considered most often in retrospect- ive research have been trauma type-characteristics, PTSD symptom severity, and history of comorbid mental disorders ( Breslau et al. 1998;Pietrzak et al. 2011;Chapman et al. 2012), although systematic reviews of prospective naturalistic studies suggest that socio-demographic factors and childhood adversi- ties might also be important predictors ( Steinert et al. 2015). ...
    ... Existing evi- dence suggests that even though a substantial propor- tion of cases recover within a few months, at least one-third of cases persist for many years ( Kessler et al. 1995;Breslau et al. 1998;Pietrzak et al. 2011;Chapman et al. 2012), and that chronic PTSD can lead to secondary disorders ( Perkonigg et al. 2005) and suicidality (Tarrier & Gregg, 2004). The predictors of PTSD recovery considered most often in retrospect- ive research have been trauma type-characteristics, PTSD symptom severity, and history of comorbid mental disorders ( Breslau et al. 1998;Pietrzak et al. 2011;Chapman et al. 2012), although systematic reviews of prospective naturalistic studies suggest that socio-demographic factors and childhood adversi- ties might also be important predictors ( Steinert et al. 2015). ...
    ... Despite substantial variation in the definitions of PTSD 'recovery' in prior studies of PTSD course (Morina et al. 2014;Steinert et al. 2015), our findings that 50% of WMH respondents with PTSD recovered within 2 years and roughly 25% had not recovered within 10 years are broadly consistent with previous epidemio- logical estimates of PTSD recovery after random trau- mas ( Breslau et al. 1998). Somewhat lower and slower rates of recovery have been reported in epidemio- logical studies of PTSD associated with 'worst' trau- mas ( Kessler et al. 1995;Chapman et al. 2012). ...
    Article
    Background Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors. Methods The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD. Results 20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2–0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66–55% v. 43%) and later-recovery (75–68% v. 39%). Conclusions We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.
  • ... Posttraumatic stress disorder (PTSD) is a chronic condition ( Steinert et al., 2015); less than 40% of subjects remit from their symptoms without specific treatment within one to five years while the majority of subjects report symptoms for a much longer period ( Chapman et al., 2012;Perez Benitez et al., 2012). Results from the National Comorbidity Survey ( Kessler et al., 1995) suggest that PTSD is very unlikely to remit if it persists beyond 6 years. ...
    ... A recent meta-analysis indicated variable PTSD trajectories, whereof the nature of the traumatic event was identified as a major predictor of remission ( Morina et al., 2014). Evidence from either clinical or epidemiological studies, using prospective or retrospective study designs, suggests that more severe trauma experiences, such as sexual abuse and childhood trauma, can cause more long-term adverse effects and are strong predictors of a chronic course of PTSD ( Bremner, 2003;Chapman et al., 2012). In particular, exposure to sexual adversity in the early developmental stages substantially decreased the likelihood of long-term remission from PTSD ( Zanarini et al., 2011;Zlotnick et al., 1999). ...
    ... Thus, a recent meta-analysis has shown that sexual abuse experience more than other trauma types has clear ties to a higher incidence of mood, anxiety or substance use disorders, even independently from PTSD ( Dworkin et al., 2017). Interestingly, these conditions were also found to be more likely among individuals with chronic PTSD than among those with faster symptom improvement ( Chapman et al., 2012;McFarlane, 2000;Zlotnick et al., 2004Zlotnick et al., , 1999). This raises the question of whether those independent findings might represent specific pathways. ...
    Article
    Full-text available
    Epidemiological data on the chronicity of posttraumatic stress disorder (PTSD) symptoms in relation to trauma type and underlying pathways are rare. The current study explored how PTSD symptoms change over time across different trauma types and examined mediators of their persistence. A trauma-exposed community sample, whereof approximately one quarter met diagnostic criteria for PTSD, provided retrospective data on the duration of PTSD symptoms. Those who remitted and those who had not at the time of assessment were compared regarding worst trauma, symptom severity, comorbidity, demographic and treatment-seeking variables. Time to remission was estimated using Cox proportional hazard models including candidate predictors of remission. A mediated survival analysis was used to explore indirect pathways that explain trauma-specific differences in remission times. Both the full sample and PTSD subgroup were analyzed separately. Overall, lower socio-economic status, lifetime and childhood sexual trauma, symptom severity, comorbid depression and past treatment were associated with non- and longer remissions. PTSD avoidance symptoms and comorbid depression were found to mediate longer remission times after lifetime or childhood sexual trauma. Our findings provide insight into the mechanisms and complicating factors of remission from PTSD symptoms after trauma, which might have important implications for therapeutic interventions.
  • ... The lifetime prevalence of PTSD is approximately 7 % in the general population234. It has a chronic course when untreated – up to one third of those with PTSD remain symptomatic for 30 years [5]. The impact of the disorder on the individual is significant. ...
    ... Finally, history of child sexual and/or physical abuse is not an exclusion criterion in the current study. This approach was undertaken to maximise the generalisability of the study findings, given the prevalence of early life abuse histories in those suffering from PTSD e.g. [5]. It is noted that emerging evidence suggests emotion regulation skills training may be required prior to trauma-focused treatment for survivors of child trauma in order to optimise their potential benefit from trauma-focused treatment e.g. ...
    Article
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    Background: This randomised controlled trial (RCT) with two parallel arms will evaluate the efficacy of an internet-delivered six-lesson 10-week cognitive behavioural therapy (iCBT) intervention for posttraumatic stress disorder (PTSD). It will also investigate the association between changes in PTSD symptoms, intolerance of uncertainty (IU) and emotion regulation. Methods/design: Patients with PTSD will be recruited via the research arm of a not-for-profit clinical and research unit in Australia and randomised to a treatment group or waitlist control group. The minimum sample size for each group (alpha 0.05, power 0.80 for a g of 0.47) was identified as 72, but 10 % more will be recruited to hedge against expected attrition. PTSD diagnosis will be determined using the PTSD module from the Mini International Neuropsychiatric Interview version 5.0.0. The PTSD Checklist - Civilian version (PCL-C) will be used to measure PTSD symptoms (the primary outcome measure), with the Intolerance of Uncertainty Scale 12-item version (IUS-12) and the Emotion Regulation Questionnaire (ERQ) used to measure intolerance of uncertainty and emotion regulation, respectively. The PCL-C will be administered to the treatment group before each lesson of the PTSD program and at 3-month follow-up. The IUS-12 and ERQ will be administered before lessons 1 and 4, at post-treatment and at 3-month follow-up. The waitlist control group will complete these measures at week 1, week 5 and week 11 of the waitlist period. PTSD program efficacy will be determined using intent-to-treat mixed models. Maintenance of gains will be assessed at 3-month follow-up. Mediation analyses using PROCESS will be used to examine the association between change in PTSD symptoms over treatment and change in each of IU and emotion regulation ability in separate analyses. Discussion: The current RCT seeks to replicate previous efficacy findings of iCBT for PTSD in a formally assessed PTSD sample from the general population. Findings may point to future lines of enquiry for the role of IU and emotion regulation in the mechanism of PTSD symptom change during CBT. Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12614001213639 , registered 18 November 2014. This trial protocol is written in compliance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.
  • ... Posttraumatic stress disorder (PTSD) is a common and disabling mental disorder that incurs substantial social and economic costs to societies worldwide [1][2][3][4][5]. Criterion A of the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) defines PTSD as a reaction to an event that is threatening to the life or physical integrity of the self or close others, and to which the survivor exhibits an acute psychological response (horror, fear, helplessness) [6]. ...
    ... Although the criteria for PTSD have been expanded in the most recent edition of the DSM (DSM-5), the symptom domains of DSM-IV applied in the present study continue to be regarded as core to the disorder [7, 8]. A consistent finding in the research literature on PTSD is that women exhibit twice the rate of the disorder as men, in spite of men experiencing greater lifetime exposure to traumatic events (TEs) overall [3,[9][10][11][12]. Clarifying the reasons for this gender disparity in PTSD rates may assist in furthering understanding of the pathogenesis of the disorder as well as in guiding the tailoring of interventions to suit the specific needs of men and women [13, 14]. ...
    Article
    Full-text available
    Background Posttraumatic stress disorder (PTSD) occurs twice as commonly amongst women as men. Two common domains of trauma, network trauma and gender based violence (GBV), may contribute to this gender difference in PTSD rates. We examined data from a nationally representative sample of the Australian population to clarify the characteristics of these two trauma domains in their contributions to PTSD rates in men and women. Methods We drew on data from the 2007 Australian National Survey of Mental Health and Well-being to assess gender differences across a comprehensive range of trauma domains, including (1) prevalence of lifetime exposure; (2) identification of an index trauma or DSM-IV Criterion A event; and (3) the likelihood of developing full DSM-IV PTSD symptoms once an index trauma was identified. Results Men reported more traumatic events (TEs) overall but women reported twice the prevalence of lifetime PTSD (women, 13.4%; men, 6.3%). Women reported a threefold higher level of exposure to GBV and were seven times more likely to nominate GBV as the index trauma as compared to men. Women were twice more likely than men to identify a network trauma as the index trauma and more likely to meet full PTSD symptoms in relation to that event (women, 20.6%; men, 14.6%). Conclusion Women are more likely to identify GBV and network trauma as an index trauma. Women’s far greater exposure to GBV contributes to their higher prevalence of PTSD. Women are markedly more likely to develop PTSD when network trauma is identified as the index trauma. Preventing exposure to GBV and providing timely interventions for acute psychological reactions following network trauma may assist in reducing PTSD rates amongst women.
  • ... A majority of adults will experience at least one potentially traumatic event (PTE) at some point in their life ( Benjet et al., 2015). Some individuals will experience several debilitating and distressing symptoms as a direct result of PTEs and a significant minority will continue to experience a prolonged emotional response for some time ( Chapman et al., 2012;Lukaschek et al., 2013). Indeed, the prevalence of post-traumatic stress disorder (PTSD) ranges from 1.3% to 8.3% in the general population ( Breslau, 2012). ...
    Article
    Full-text available
    The experience of traumatic events has been linked to the development of psychopathology. Changing perspectives on psychopathology have resulted in the hypothesis that broad dimensional constructs account for the majority of variance across putatively distinct disorders. As such, traumatic events may be associated with several disorders due to their relationship with these broad dimensions rather than any direct disorder-specific relationship. The current study used data from 8,871 Australians to test this hypothesis. Two broad dimensions accounted for the majority of relationships between traumatic events and mental and substance use disorders. Direct relationships remained between post-traumatic stress disorder and six categories of traumatic events in the total population and between drug dependence and accidents/disasters for males only. These results have strong implications for how psychopathology is conceptualized and offer some evidence that traumatic events are associated with an increased likelihood of experiencing psychopathology in general.
  • ... Although sparse and heterogeneous data produced non-significant time trends of prevalence, there may be value in creating hypotheses around these findings given what we know about the time course of MDD and PTSD from other research. Across the lifespan, remission rates of PTSD are relatively high; however, even in conflict-free settings in developed nations the median time to remission can be lengthy (Chapman et al. 2012). The lack of an observed time trend in our analyses of a 10-year post-conflict period could therefore be reasonable expected. ...
    Article
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    Despite significant research examining mental health in conflict-affected populations we do not yet have a comprehensive epidemiological model of how mental disorders are distributed, or which factors influence the epidemiology in these populations. We aim to derive prevalence estimates specific for region, age and sex of major depression, and PTSD in the general populations of areas exposed to conflict, whilst controlling for an extensive range of covariates. Methods A systematic review was conducted to identify epidemiological estimates of depression and PTSD in conflict-affected populations and potential predictors. We analyse data using Bayesian meta-regression techniques. Results We identified 83 studies and a list of 34 potential predictors. The age-standardised pooled prevalence of PTSD was 12.9% (95% UI 6.9–22.9), and major depression 7.6% (95% UI 5.1–10.9) – markedly lower than estimated in previous research but over two-times higher than the mean prevalence estimated by the Global Burden of Disease Study [3.7% (95% UI 3.0–4.5) and 3.5% (95% UI 2.9–4.2) for anxiety disorders and MDD, respectively]. The age-patterns reveal sharp prevalence inclines in the childhood years. A number of ecological variables demonstrated associations with prevalence of both disorders. Symptom scales were shown to significantly overestimate prevalence of both disorders. Finding suggests higher prevalence of both disorders in females. Conclusion This study provides, for the first time, age-specific estimates of PTSD and depression prevalence adjusted for an extensive range of covariates and is a significant advancement on our current understanding of the epidemiology in conflict-affected populations.
  • ... Prevalence estimates are drawn from a previously published meta-regression (Charlson et al. 2015) and age-standardised for the Syrian population distribution. The proportion of PTSD cases comorbid with depression derived from general population and post conflict settings was set at 50% based on documented rates including a sample of Bosnian refugees living in Croatia (Mollica et al. 1999; Chapman et al. 2012). ...
    Article
    Full-text available
    Epidemiological models are frequently utilised to ascertain disease prevalence in a population; however, these estimates can have wider practical applications for informing targeted scale-up and optimisation of mental health services. We explore potential applications for a conflict-affected population, Syria. Methods We use prevalence estimates of major depression and post-traumatic stress disorder (PTSD) in conflict-affected populations as inputs for subsequent estimations. We use Global Burden of Disease (GBD) methodology to estimate years lived with a disability (YLDs) for depression and PTSD in Syrian populations. Human resource (HR) requirements to scale-up recommended packages of care for PTSD and depression in Syria over a 15-year period were modelled using the World Health Organisation mhGAP costing tool. Associated avertable burden was estimated using health benefit analyses. Results The total number of cases of PTSD in Syria was estimated at approximately 2.2 million, and approximately 1.1 million for depression. An age-standardised major depression rate of 13.4 (95% UI 9.8–17.5) YLDs per 1000 Syrian population is estimated compared with the GBD 2010 global age-standardised YLD rate of 9.2 (95% UI 7.0–11.8). HR requirements to support a linear scale-up of services in Syria using the mhGAP costing tool demonstrates a steady increase from 0.3 FTE in at baseline to 7.6 FTE per 100 000 population after scale-up. Linear scale-up over 15 years could see 7–9% of disease burden being averted. Conclusion Epidemiological estimates of mental disorders are key inputs into determining disease burden and guiding optimal mental health service delivery and can be used in target populations such as conflict-affected populations.
  • ... PTSD symptom presentation appears to vary reliably by type of traumatic experience (Elhai, Frueh, Gold, Gold, & Hamner, 2000; Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 2009; Rasmussen, Smith, & Keller, 2007). For instance, existing research has found that interpersonal trauma is associated with more symptomatic PTSD presentation and longer duration of symptoms when compared to non-interpersonal trauma such as exposure to natural disaster or motor vehicle accident (Chapman et al., 2012; Chung & Breslau, 2008; Cougle, Resnick, & Kilpatrick, 2013; Ehring and Quack, 2010; Ford, Steinberg, & Zhang, 2011; Green et al., 2000; Lancaster, Melka, & Rodriguez, 2009; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993 ). In terms of differential severity across diagnostic symptom clusters, Amir, Kaplan, and Kotler (1996) examined symptom presentation differentially across trauma type in a sample of Israeli civilians and military personnel. ...
  • ... Strengths of our study included a large sample size drawn from all service branches and ranks and that was not derived from treatment seekers. Additionally, our design was prospective, whereas many such studies have been retrospective, relying solely on recall of symptom onset and remission (Chapman et al., 2012;Kessler et al., 2005;Schnurr et al., 2003). ...
    Article
    Full-text available
    We estimated the temporal course of posttraumatic stress disorder (PTSD) in Vietnam-era veterans using a national sample of male twins with a 20-year follow-up. The complete sample included those twins with a PTSD diagnostic assessment in 1992 and who completed a DSM-IV PTSD diagnostic assessment and a self-report PTSD checklist in 2012 (n = 4,138). Using PTSD diagnostic data, we classified veterans into 5 mutually exclusive groups, including those who never had PTSD, and 4 PTSD trajectory groups: (a) early recovery, (b) late recovery, (c) late onset, and (d) chronic. The majority of veterans remained unaffected by PTSD throughout their lives (79.05% of those with theater service, 90.85% of those with nontheater service); however, an important minority (10.50% of theater veterans, 4.45% of nontheater veterans) in 2012 had current PTSD that was either late onset (6.55% theater, 3.29% nontheater) or chronic (3.95% theater, 1.16% nontheater). The distribution of trajectories was significantly different by theater service (p < .001). PTSD remains a prominent issue for many Vietnam-era veterans, especially for those who served in Vietnam.
  • ... For studies with a longer time gap between the HID and screening, there is the possibility that some cases of PTSD may have spon- taneously remitted. 34 It is possible that all these differences in method may have contributed to the heterogeneity we observed in the meta-analysis. Although we attempted to take het- erogeneity into account using a random-effects model, our results should be treated with caution. ...
    Article
    Full-text available
    Background Older people are increasingly “in harm's way” following human-induced disasters (HID). There is debate in the literature as to the relative impact of disasters on their psychological health compared with other age groups. Natural Disasters and HID are thought to affect survivors differentially, and this may extend to older adults as a group. In the absence of existing systematic reviews, we aimed to synthesis the available evidence and conduct meta-analyses of the effects of HID on the psychological health of older versus younger adults. Methods A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, adjustment disorder, and psychological distress. Results We identified eleven papers from 10 studies on HID (n= 26, 753 ), of which eight had sufficient data for a random-effects meta-analysis. Older adults were 2.85 times less likely to experience PTSD symptoms following HID (95% CI= 1.42-5.70) when compared to younger adults. There was no statistically significant difference in terms of anxiety and depressive symptoms. Conclusion Health and emergency services need to be increasingly prepared to meet the psychological needs of older people, given the global rise in the numbers of older adults affected by disasters of all kinds. Preliminary evidence suggests that, that old age may be a protective factor for the development of post-traumatic stress disorder in the wake of HID. Keywords: Mental Health, Post Traumatic Stress Disorder, Older Persons, Human-induced Disaster, Meta-analysis
  • ... There are two likely explanations for this result. First, several reports have shown that in general, patients with PTSD often experience remission of symptoms without any treatment[21]. Second, the assessment of symptoms in this study did not sufficiently differentiate between PTSD and acute stress disorder (ASD), where symptoms only last for a maximum of four weeks. ...
    Article
    Full-text available
    Objective: Home care of advanced cancer patients often has adverse effects on physical and mental health of family caregivers. Little is known about the long-term effects of continuous caregiving on mental health as compared to the effects of bereavement. The objectives of this study were to describe the course of psychiatric morbidity in family caregivers over time, to identify the impact of the patients' death on caregivers, and to explore possible predictor variables for psychiatric morbidity. Methods: This multi-institutional, prospective study included 80 family caregivers of 80 advanced cancer patients for baseline and nine months follow-up assessment. Possible psychiatric disorders (i.e. depression, anxiety, posttraumatic stress disorder (PTSD), and alcohol abuse/dependence) as well as potentially predictive factors (i.e. socio-demographic factors, burden, hope, and coping mechanisms) were assessed. Results: Follow-up assessment was conducted on average 9.2 months (±2.9) after baseline assessment. Prevalence rates of anxiety and PTSD decreased significantly over time, whereas depression and alcoholism remained stable. Bereavement was experienced by 53% of caregivers in the follow-up period. The patients' death had no influence on psychiatric morbidity at follow-up. Predictors for the development of a psychiatric disorder varied according to condition, with hope and emotion-oriented coping identified as important influences, especially for anxiety and depression. Conclusion: Family caregivers with certain psychiatric disorders might need targeted psychosocial support to ensure their mental wellbeing and prevent long-term disability. Supporting hope and functional coping strategies early after the patient's diagnosis might limit development and extent of psychiatric morbidity.
  • ... It is an inhibition of an otherwise normal adaptive and effective reaction to diminishing extreme threat and is triggered by stimuli characteristic of that threat [34]. Although most individuals diagnosed with PTSD eventually remit, there remains a significant minority that continues to experience the symptoms for decades after the stressor event occurred [35]. Negativity bias might be construed as the normal response to a negative experience, such as Hurricane Katrina, and thus a mechanism for survival adaptation. ...
  • ... PTSD is frequently a chronic condition, with meta-analytic evi- dence suggesting that, on average, over half of indivi- duals with PTSD (56%) do not remit from the disorder naturally after a mean of more than 3 years ( Morina et al. 2014). Epidemiological research indicates that more than a third of individuals continue to have symptoms of PTSD 30 years after onset of the disorder (Chapman et al. 2012). Although this topic has not been explored extensively, there is some evidence that greater chronicity is associated with worse cardiovas- cular outcomes. ...
    Article
    Post-traumatic stress disorder (PTSD) has been declared ‘a life sentence’ based on evidence that the disorder leads to a host of physical health problems. Some of the strongest empirical research – in terms of methodology and findings – has shown that PTSD predicts higher risk of cardiometabolic diseases, specifically cardiovascular disease (CVD) and type 2 diabetes (T2D). Despite mounting evidence, PTSD is not currently acknowledged as a risk factor by cardiovascular or endocrinological medicine. This view is unlikely to change absent compelling evidence that PTSD causally contributes to cardiometabolic disease. This review suggests that with developments in methods for epidemiological research and the rapidly expanding knowledge of the behavioral and biological effects of PTSD the field is poised to provide more definitive answers to questions of causality. First, we discuss methods to improve causal inference using the observational data most often used in studies of PTSD and health, with particular reference to issues of temporality and confounding. Second, we consider recent work linking PTSD with specific behaviors and biological processes, and evaluate whether these may plausibly serve as mechanisms by which PTSD leads to cardiometabolic disease. Third, we evaluate how looking more comprehensively into the PTSD phenotype provides insight into whether specific aspects of PTSD phenomenology are particularly relevant to cardiometabolic disease. Finally, we discuss new areas of research that are feasible and could enhance understanding of the PTSD–cardiometabolic relationship, such as testing whether treatment of PTSD can halt or even reverse the cardiometabolic risk factors causally related to CVD and T2D.
  • ... [17] PTSD is a serious psychological abnormality that can affect military and civilian personnel. [18][19][20] Depending on an individual's personality and resilience, PTSD can occur after exceedingly stressful incidents or seemingly minor ones. ...
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    Summary: Data support that neuroendocrine abnormalities attributed to PTSD include HPA hyper-reactivity and sensitized glucocorticoid feedback [26]. Resulting inconsistent hormonal pattern represents a key pathological maladaptation to stress. These abnormal hormonal, metabolic responses, and mitochondrial, biochemical, and neurohormonal abnormalities lead to structural brain vicissitudes occurring in the amygdala and hippocampus, locus coeruleus, and autonomic norepinephrine centers in the brainstem, which further alters behavioral responses. The development of the symptoms of PTSD can be explained in part by disturbances of parallel distributing processing of neural pathways. Moreover, the disturbances of noradrenergic neurons in PTSD are likely to be manifest as a dysfunctional modulation of working memory and involuntary traumatic recollection. Meanwhile, comorbidities in major depressive disorders and PTSD reflects not only overlapping symptoms in the two disorders, but also the co-occurrence of biological correlates and trauma-related phenotypes. While a there are some similarities of presentation and biochemical abnormalities of depression and PTSD, the neuroendocrine abnormalities observed are much different, and thus, different modes and targeted treatments are necessary. In those with unmanaged stresses, it is essential to (A) make an accurate diagnosis as early as possible, (B) establish a network of support, and (C) provide focused multimodal, individualized treatments to maximize the recovery process and prevent relapses. However, because of the underlying hormonal abnormalities, psychotherapy and psychiatric medications alone may not be adequate to cure PTSD. Thus, adjunct therapy, with treatments based on understanding the pathobiology and alterations of the neurohormonal system, can be designed as cost-effective hormonal replacement therapies for better outcomes of PTSD, with fewer adverse effects and greater chance of cure. Current evidence indicates PTSD should be a psychological disorder and also a chronic medical illness resulting from endocrine pathology.
  • ... Even with this potential bias, the persistence of PTSD is striking, with approximately 50% of affected responders having active PTSD. Interestingly, the percentage with remitted PTSD 12–14 years post-9/11 was comparable with the median time to remission (14 years) for participants with PTSD in the 2007 Australian National Survey of Mental Health and Wellbeing (Chapman et al. 2012). Second, although the diagnosis of PTSD connotes 'flashbacks' and 'nightmares' in popular culture, these symptoms were far less frequently reported than avoidance and hyperarousal symptoms. ...
    Article
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    Background: Post-traumatic symptomatology is one of the signature effects of the pernicious exposures endured by responders to the World Trade Center (WTC) disaster of 11 September 2001 (9/11), but the long-term extent of diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) post-traumatic stress disorder (PTSD) and its impact on quality of life are unknown. This study examines the extent of DSM-IV PTSD 11-13 years after the disaster in WTC responders, its symptom profiles and trajectories, and associations of active, remitted and partial PTSD with exposures, physical health and psychosocial well-being. Method: Master's-level psychologists administered sections of the Structured Clinical Interview for DSM-IV and the Range of Impaired Functioning Tool to 3231 responders monitored at the Stony Brook University World Trade Center Health Program. The PTSD Checklist (PCL) and current medical symptoms were obtained at each visit. Results: In all, 9.7% had current, 7.9% remitted, and 5.9% partial WTC-PTSD. Among those with active PTSD, avoidance and hyperarousal symptoms were most commonly, and flashbacks least commonly, reported. Trajectories of symptom severity across monitoring visits showed a modestly increasing slope for active and decelerating slope for remitted PTSD. WTC exposures, especially death and human remains, were strongly associated with PTSD. After adjusting for exposure and critical risk factors, including hazardous drinking and co-morbid depression, PTSD was strongly associated with health and well-being, especially dissatisfaction with life. Conclusions: This is the first study to demonstrate the extent and correlates of long-term DSM-IV PTSD among responders. Although most proved resilient, there remains a sizable subgroup in need of continued treatment in the second decade after 9/11.
  • ... Research across different countries, trauma-exposed populations, and assessment instruments has robustly demonstrated that, although men tend to experience higher rates of exposure to traumatic events, women have a two-fold higher risk of being diagnosed with PTSD ( Tolin and Foa, 2006). For instance, the lifetime PTSD prevalence rate is 7% for males and 9.7% for females in Australia ( Chapman et al., 2012) and 4.1% for men and 8.6% for women in the U.S. ( Pietrzak et al., 2011). This marked gender difference in prevalence raises questions about potential gender differences in PTSD symptom structure and symptom expression, which have implications for treatment and prevention approaches. ...
  • ... Les donné es e ´ pidé miologiques permettent donc de supposer un processus de ré mission important au cours de la vie. Ainsi, dans une ré cente e ´ tude australienne[7], ré alisant une ré trospective sur 54 anné es d'existence, il est apparu un taux de ré mission de 92 %, avec un dé lai de ré mission mé dian de 14 ans. La pré valence de l'ESPT reste malgré tout associé e aux risques d'exposition, ayant par exemple montré qu'elle est plus importante chez les personnes a ˆgé es ayant vé cu la Seconde Guerre mondiale que chez des individus plus jeunes, qui n'ont pas e ´ té impliqué s dans un conflit armé , variant de 5 a ` 20 %[20]. ...
    Article
    Le grand âge donne lieu à des tableaux sémiologiques complexes, où se mêlent des pathologies variées, dont l’expression est liée à influence de l’histoire de vie. Les interrelations entre pathologies psychiatriques et neuro-dégénératives sont de ce fait particulièrement mal connues. Il est pourtant possible de préciser les relations entre état de stress post-traumatique et maladie d’Alzheimer, à travers la caractérisation des symptômes psychiatriques et cognitifs, ainsi que de l’autobiographie du patient. Cette approche est illustrée par le cas d’un homme, ancien combattant de 93 ans. Le recueil de l’histoire de vie, dont les attitudes liées au partage des informations sur les événements traumatogènes, ainsi que des caractéristiques psychopathologiques concernant les deux pathologies selon une perspective vie entière a permis de montrer qu’après plusieurs dizaines d’années d’adaptation aux souvenirs traumatiques, la perte d’autonomie cognitive était associée à l’émergence d’un état de stress post-traumatique retardé.
  • ... One of the recurrent findings in the psycho-traumatology literature is the gender differences in posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS) (Tolin & Foa, 2006). There is extensive evidence, across different nations, range of traumatic events and assessment instruments, for higher rates of PTSD and stronger intensity of PTSS among women than men (e.g.Chapman et al., 2012). Moreover, even though men experience higher rates of potentially traumatic events (PTEs), women have about a twofold higher risk of being diagnosed with PTSD (Pietrzak, Goldstein, Southwick, & Grant, 2011). ...
    Article
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    Objectives: The lifetime risk for posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS) among primary and secondary female victims is known to be higher than for male. This study assessed gender differences in PTSS among former prisoners of war’s (ex-POWs) adult offspring and the associations with their fathers’ and mothers’ PTSS and the parental bonding with them. Design: A correlative study. Methods: A sample of 79 Israeli father–mother-offspring ex-POW triads from the 1973 Yom Kippur War completed self-report measures. Fathers were assessed in 2008, mothers were assessed in 2011 and their adult offspring took part in 2014. Results: Sons of ex-POWs reported higher levels of PTSS as compared to daughters of ex-POWs. However, fathers’ PTSS was positively related to daughters’ PTSS, but not significantly related to sons’ PTSS. Daughters’ PTSS were also associated with both parents’ lower care and higher overprotection, while sons’ PTSS were associated only with fathers’ lower care and higher overprotection. Conclusions: Among adult offspring of ex-POWs, sons are at greater risk for psychological distress in the form of PTSS. Nevertheless, the intergenerational transmission of captivity-related PTSS from both fathers and spouses to their offspring is more prominent among daughters of ex-POWs.
  • ... Primary exposure to trauma and diagnoses of trauma and stressor related disorders (see American Psychiatric Association[APA], 2013) may increase the risk for students to experience adverse reactions to course materials in classrooms that introduce traumatic materials (Cunningham, 2004). Traumatic experiences have been shown to be prevalent in both the general population (Chapman et al., 2012;Finkelhor, Turner, Ormrod, & Hamby, 2009;Kilpatrick et al., 2013;Lukaschek et al., 2013) as well as populations of undergraduate students (Bernat, Ronfeldt, Calhoun, & Arias, 1998;Frazier et al., 2009). A recent study found approximately 85% of students reported having experienced at least one traumatic event in their lifetime and 21% of students reported having experienced a trauma while in college (Frazier et al., 2009). ...
    Article
    Full-text available
    p>niversity courses in disciplines such as social work, family studies, humanities, and other areas often use classroom materials that contain traumatic material (Barlow & Becker-Blease, 2012). While many recommendations based on trauma theory exist for instructors at the university level, these are often made in the context of clinical training programs, rather than at the undergraduate level across disciplines. Furthermore, no organized model exists to aid instructors in developing a trauma-informed pedagogy for teaching courses on traumatic stress, violence, and other topics that may pose a risk for secondary traumatic stress in the classroom (Kostouros, 2008). This paper seeks to bridge the gap between trauma theory and implementation of sensitive content in classrooms of higher education, and presents a model of trauma-informed teaching that was developed in the context of an undergraduate trauma studies program. Implications and future directions for research in the area of trauma-informed university classrooms are discussed. </p
  • ... Research across different countries, trauma-exposed populations , and assessment instruments has robustly demonstrated that, although men tend to experience higher rates of exposure to traumatic events, women have a two-fold higher risk of being diagnosed with PTSD (Tolin and Foa, 2006). For instance, the lifetime PTSD prevalence rate is 7% for males and 9.7% for females in Australia (Chapman et al., 2012) and 4.1% for men and 8.6% for women in the U.S. (Pietrzak et al., 2011). This marked gender difference in prevalence raises questions about potential gender differences in PTSD symptom structure and symptom expression, which have implications for treatment and prevention approaches. ...
  • ... Research across different countries, trauma-exposed populations, and assessment instruments has robustly demonstrated that, although men tend to experience higher rates of exposure to traumatic DSM-5 POST-TRAUMATIC STRESS DISORDER events, women have a two-fold higher risk of being diagnosed with PTSD (Tolin & Foa, 2006). For instance, the lifetime PTSD prevalence rate is 7% for males and 9.7% for females in Australia (Chapman et al., 2012) and 4.1% for men and 8.6% for women in the U.S. (Pietrzak et al., 2011). This marked gender difference in prevalence raises questions about potential gender differences in PTSD symptom structure and symptom expression, which have implications for treatment and prevention approaches. ...
    Article
    Background: The posttraumatic stress disorder (PTSD) literature is replete with investigations of factor structure, however, few empirical studies have examined discriminant validity and the moderating role of gender on factor structure and symptom expression. This study aimed to address these gaps. Methods: An online, population-based study of 3175 Australian adults was conducted. This study analyzed data from 642 participants who reported a traumatic event. Overall, 10.2% (13.4% females, 7.6% males) met diagnostic criteria for current PTSD. Results: Confirmatory factor analyses indicated that eight factor models provided excellent fit to the data. The DSM-5 model, anhedonia and hybrid models provided strong fit to the data, based on statistical fit indices and parsimony. The models' factors were significantly associated with a number of external correlates. Factor structure was gender invariant for the three models, albeit significant latent mean-level differences were apparent in relation to the intrusion/re-experiencing and alterations in arousal and reactivity factors. Bonferroni-adjusted Wald chi-square tests indicated significant gender differences in four DSM-5 PTSD symptoms: females reported significantly higher rates of negative beliefs, diminished interest, restricted affect and sleep disturbance symptoms compared to men. Limitations: Response rate to the survey was low. However, the number of respondents who completed the survey was high and population weights were employed to account for self-selection biases and aid generalizability. Conclusions: The findings provide support for the DSM-5, anhedonia and hybrid models compared to alternative models based on DSM-5 symptoms. Discriminant validity analyses indicated similar patterns of significant associations with the transdiagnostic factors, potentially suggesting that all the PTSD factors are related to non-specific distress. Further research investigating how gender influences PTSD symptom expression is warranted, including possible gender differences in symptom item interpretation.
  • ... Among mental health disorders, posttraumatic stress disorder (PTSD) has been identified as a particularly salient predictor of smoking ( Feldner et al., 2007;Fu et al., 2007;Lawrence et al., 2010). Recent analysis of the 2007 National Survey of Mental Health and Wellbeing (NSMHWB) revealed that 7% of the Australian general population met DSM-IV criteria for a lifetime diagnosis of PTSD and 4% met criteria for current (12-month) PTSD ( Chapman et al., 2012). Approximately half of individuals with PTSD have been found to report daily smoking ( Feldner et al., 2007), making smoking twice as prevalent among individuals with PTSD compared to the general population ( Acierno et al., 2000;Hapke et al., 2005;Lasser et al., 2000). ...
  • ... Based on these diagnostic criteria, it is possible that at least two studies were reporting acute stress reaction rather than PTSD. For studies with a longer time gap between traumatic event and screening, there is the possibility that some cases of PTSD may have spontaneously remitted ( Chapman et al., 2012). However, one study ( Musa et al., 2014) reported on rates of depression, anxiety, and stress, but not PTSD, in two geographically distinct regions that were exposed to separate natural disasters five years apart from each other. ...
    Article
    Background: Natural disasters affect the health and well-being of adults throughout the world. There is some debate in the literature as to whether older persons have increased risk of mental health outcomes after exposure to natural disasters when compared with younger adults. To date, no systematic review has evaluated this. We aimed to synthesize the available evidence on the impact of natural disasters on the mental health and psychological distress experienced by older adults. Design: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, adjustment disorder, and psychological distress. Results: We identified six papers with sufficient data for a random effects meta-analysis. Older adults were 2.11 times more likely to experience PTSD symptoms and 1.73 more likely to develop adjustment disorder when exposed to natural disasters when compared with younger adults. Conclusions: Given the global rise in the number of older adults affected by natural disasters, mental health services need to be prepared to meet their needs following natural disasters, particularly around the early detection and management of PTSD.
  • Article
    Violence is a public health challenge that affects public health and Public Mental Health. Violence can take many forms at the individual level (e.g. self-inflicted violence, child abuse), the family level (e.g. domestic violence, partner violence), the community level (e.g. community violence) and at groups level (e.g. wars, genocide). Child abuse, self-inflicted violence, domestic violence, partner violence, community violence, wars and genocide not only influence somatic health and incidence and burden of psychopathology. However, the impact of violence on psychopathology remains a contented issue. In this chapter, we aim to review studies on violence and psychopathology within a longitudinal framework. We focus on the impact of violence on depression and anxiety. Resulting from this review we describe that the impact of violence on depression and anxiety are pervasive, independent of potential well known risk factors such as gender and socioeconomic status. The thorough understanding of the impact of violence on the incidence and burden of depression and anxiety requires a life course perspective. Studies suggest that the impact of violence on psychopathology may be immediate or become apparent many years after the exposure, which has only become possible to ascertain because of the demographic ageing in many countries. Violence exposure is a main modifiable factor for psychopathology in children, adolescents, adults and older persons. Violence informed Public Health Research and Services are needed to develop and implement tailored interventions.
  • Chapter
    Reports in the mainstream media suggest that traumatic events, such as natural disasters, sexual assault, and child abuse, are frequent occurrences throughout the world and take a tremendous psychological toll on individuals and communities. In this chapter, we aim to present the global public health burden posed by trauma exposure. To accomplish this goal, we review the prevalence and distribution of traumatic events and trauma-related disorders from epidemiologic studies. Epidemiology is the cornerstone of public health and focuses on the distribution and causes of disease in human populations and on developing and testing ways to prevent and control disease. Epidemiological studies have provided empirical evidence on the high prevalence of trauma and the devastating effects of trauma-related disorders and have shown that trauma is not equally distributed across populations. When presenting the results, we note methodological considerations that make cross-study comparisons difficult. Finally, we use the epidemiologic data presented to discuss public health approaches to addressing trauma and trauma-related disorders. We conclude that trauma exposure is a major public health problem whose health burden has only begun to be appreciated.
  • Article
    Increasing evidence indicates that posttraumatic stress disorder (PTSD) may develop following traumatic brain injury (TBI), despite most patients having no conscious memory of their accident. This prospective study examined the frequency, timing of onset, symptom profile, and trajectory of PTSD and its psychiatric comorbidities during the first four years following moderate to severe TBI. Participants were 85 individuals (78.8% male) with moderate or severe TBI recruited following admission to acute rehabilitation between 2005 and 2010. Using the Structured Clinical Interview for DSM-IV Disorders (SCID-I), participants were evaluated for pre- and postinjury PTSD soon after injury and reassessed at 6 and 12 months, 2, 3, and 4 years postinjury. Over the first four years postinjury 17.6% developed injury-related PTSD, none of whom had PTSD prior to injury. PTSD onset peaked between 6- and 12-months postinjury. The majority of PTSD cases (66.7%) had a delayed-onset, which for a third was preceded by subsyndromal symptoms in the first six months postinjury. PTSD frequency increased over the first year postinjury, remained stable during the second year and gradually declined thereafter. The majority with PTSD experienced a chronic symptom course and all developed one or more comorbid psychiatric disorder, with mood, other anxiety and substance-use disorders being the most common. Despite event-related amnesia, posttraumatic stress symptoms, including vivid re-experiencing phenomena, may develop following moderate to severe TBI. Onset is typically delayed and symptoms may persist for several years postinjury.
  • Article
    Objectives: To examine the effects of the cumulative victimization experienced by lesbian, gay, bisexual, and transgender youths on mental disorders. Methods: We recruited 248 participants from the Chicago, Illinois, area in 7 waves of data collected over 4 years, beginning in 2007 (83.1% retention rate). Mean age at enrollment was 18.7 years, and 54.7% were Black. We measured depression and posttraumatic stress disorder using structured psychiatric interviews. Results: Latent class analyses of victimization over time identified a 4-class solution. Class 1 (65.4%) had low, decreasing victimization. Class 2 (10.3%) had moderate, increasing victimization. Class 3 (5.1%) had high, steady victimization. Class 4 (19.2%) had high, decreasing victimization. Controlling for baseline diagnoses and birth sex, lesbian, gay, bisexual, and transgender youths in classes 2 and 3 were at higher risk for depression than were those in class 1; youths in classes 2, 3, and 4 were at elevated risk for posttraumatic stress disorder. Conclusions: Lesbian, gay, bisexual, and transgender youths with steadily high or increasing levels of victimization from adolescence to early adulthood are at higher risk for depression and posttraumatic stress disorder. (Am J Public Health. Published online ahead of print January 21, 2016: e1-e7. doi:10.2105/AJPH.2015.302976).
  • Article
    Using clinical data at a specialized trauma clinic, this study investigated pre-treatment clinical factors predicting response to eye movement desensitization and reprocessing (EMDR) among adult patients diagnosed with posttraumatic stress disorder (PTSD). Participants were evaluated on the Clinician-administered PTSD Scale (CAPS), the Symptom Checklist-90-Revised, the Beck Depression Inventory, and the Dissociative Experiences Scale before treatment, and were reassessed on the CAPS after treatment and at 6-month follow-up. A total of 69 patients underwent an average of four sessions of EMDR and 60 (87%) completed the post-treatment evaluation, including eight participants who terminated treatment prematurely. Intent-to-treat analysis revealed that 39 (65%) of the 60 patients were classified as responders and 21 (35%) as non-responders when response was defined as a more than 30% decrease in total CAPS score. The non-responders had higher levels of dissociation (depersonalization and derealization) and numbing symptoms, but other PTSD symptoms such as avoidance, hyperarousal and intrusion were not significantly different. The number of psychiatric comorbidities was also associated with treatment non-response. The final logistic regression model yielded two significant variables: dissociation (p < .001) and more than two comorbidities compared to none (p<.05). These results indicate that complex symptom patterns in PTSD may predict treatment response, and support the inclusion of the dissociative subtype of PTSD in the DSM-5.
  • Chapter
    Anxiety disorders are highly prevalent and debilitating psychiatric conditions, which often remain unrecognised and untreated. However, left untreated, anxiety disorders often persist and can contribute to the development of other psychiatric disorders. Therefore, early detection and subsequent intervention are important. Information on the age of onset (AOO) of anxiety disorders could be informative for the timing of prevention strategies.
  • Article
    This randomized pilot study aimed to determine whether a single session of psychoeducation improved mental health outcomes, attitudes toward treatment, and service engagement among urban, impoverished, culturally diverse, trauma-exposed adults. Sixty-seven individuals were randomly assigned to a single-session psychoeducation treatment or a delayed treatment comparison control group. The control group was found to be superior to the treatment group at posttest with respect to symptoms of posttraumatic stress disorder, anxiety, and occupational and family disability. At follow-up, all participants had completed the psychoeducation treatment, and a mixed-effects model indicated significant improvements over time in symptoms of posttraumatic stress disorder, anxiety, depression, somatization, and attitudes toward treatment. Ninety-eight percent of the participants reported the psychoeducation was helpful at follow-up. Participants also reported a 19.1% increase in mental health service utilization at follow-up compared with baseline. Implications for treatment and future research are discussed.
  • Article
    Full-text available
    Although posttraumatic stress disorder (PTSD) is used as a distinct diagnosis in clinical practice, its symptoms were characterized as a dimensional structure in several taxometric analyses. However, a categorical latent structure of PTSD could be superimposed by using indistinct PTSD symptoms that can appear within the framework of other trauma-induced syndromes (e.g., depression, anxiety disorders). For that reason, in revising the International Classification of Diseases (ICD-11), a core set of cardinal symptoms that determine the presence of PTSD as selectively as possible will be used. To determine whether the latent status of a recommended core set of PTSD symptoms is dimensional, the authors analyzed the latent status of PTSD symptoms reported by participants who had experienced at least 1 traumatic event during their lifetime in 2 nationwide surveys of the German population (N = 1,212). Using the Posttraumatic Diagnostic Scale (PDS), they applied 3 popular taxometric methods: maximum eigenvalue, mean above minus below a cut, and latent mode factor analysis, using the core set and PTSD symptom clusters of previous taxometric studies. Although the analysis replicated findings of previous taxometric analyses using symptom clusters, the item core-set approach indicated a categorical solution of PTSD cardinal symptoms. These results seem to support the procedure used by the ICD-11 expert group. (PsycINFO Database Record
  • Article
    Objective: In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems. Methods: The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM). Results: No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems. Conclusions: This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.
  • Chapter
    Cambridge Core - Epidemiology Public Health and Medical Statistics - Trauma and Posttraumatic Stress Disorder - edited by Evelyn Bromet
  • Chapter
    Trauma and Posttraumatic Stress Disorder - edited by Evelyn Bromet August 2018
  • Article
    Full-text available
    Posttraumatic stress disorder (PTSD) is a prevalent, chronic disorder with high psychiatric morbidity; however, a substantial portion of affected individuals experience remission after onset. Alterations in brain network derived from cortical thickness correlations are associated with PTSD, but the effects of remitted symptoms on network topology remain essentially unexplored. In this cross-sectional study, US military veterans (N=317) were partitioned into three diagnostic groups, current PTSD (CURR-PTSD, N=101), remitted PTSD with lifetime but no current PTSD (REMIT-PTSD, N=35), and trauma-exposed controls (CONTROL, n=181). Cortical thickness was assessed for 148 cortical regions (nodes) and suprathreshold interregional partial correlations across subjects constituted connections (edges) in each group. Four centrality measures were compared to characterize between-group differences. The REMIT-PTSD and CONTROL groups showed greater centrality in left frontal pole than the CURR-PTSD group. The REMIT-PTSD group showed greater centrality in right subcallosal gyrus than the other two groups. Both REMIT-PTSD and CURR-PTSD groups showed greater centrality in right superior frontal sulcus than CONTROL group. The centrality in right subcallosal gyrus, left frontal pole and right superior frontal sulcus may play a role in remission, current symptoms and PTSD history, respectively. The network centrality changes in critical brain regions and structural networks are associated with remitted PTSD, which typically coincides with enhanced functional behaviors, better emotion regulation, and improved cognitive processing. These brain regions and associated networks may be candidates for developing novel therapies for PTSD. Longitudinal work is needed to characterize vulnerability to chronic PTSD, and resilience to unremitting PTSD.
  • Article
    The extent and severity of the psychological effects following chemical release disasters have not been widely reported. The aim of this study was to examine the prevalence of hydrogen fluoride (HF)–related posttraumatic stress disorder (PTSD) and to identify associated psychological risk factors. On September 2012, an estimated 8 to 12 tons of HF gas, which dissolves in air moisture to form droplets of corrosive hydrofluoric acid, escaped from an industrial complex in Gumi, South Korea. Ten months later, structured questionnaires that included items from the Impacts of Event Scale (revised Korean version) as well as questions about demographic and psychological risk factors related to PTSD were distributed to workers in the affected area. The prevalence rate of PTSD was 5.7%. The odds of PTSD in non-alcohol-dependent workers (odds ratio [OR] = 3.10, 95% confidence interval [CI] = [1.27, 7.60]) was significantly higher than in alcohol-independent workers. The OR for PTSD in workers with anxiety (OR = 7.63, 95% CI = [2.10, 27.71) was significantly higher than the OR workers without anxiety. The odds of PTSD in workers with high perceived stress scale (PSS) scores (OR = 8.72, 95 % CI = [2.29, 33.16]) was significantly higher than for workers with low PSS. Alcohol dependence, psychiatric symptoms at the time of the event, anxiety, and high PSS were associated with HF-related PTSD. Long-term employee assistance programs are needed to assist occupational health nurses and clinicians to reduce PTSD after industrial disasters.
  • Technical Report
    Full-text available
    Psychological disorders are prevalent among young people who come into contact with the juvenile justice system, and are substantially more common in for those entering custody than for young people in the general population.
  • Technical Report
    Full-text available
    Information reported in this section relates to the offending behaviour of young people, including previous and current orders, most serious offences, amount of time spent in custody, and criminal history.
  • Article
    Recent research suggests that greater country vulnerability is associated with a decreased, rather than increased, risk of mental health problems. Because societal parameters may have gender-specific implications, our objective was to explore whether the "vulnerability paradox" equally applies to women and men. Lifetime posttraumatic stress disorder (PTSD) prevalence data for women and men were retrieved from 11 population studies (N = 57,031): conducted in Australia, Brazil, Canada, France, Lebanon, Mexico, Netherlands, Portugal, Sweden, Switzerland, and the United States. We tested statistical models with vulnerability, gender, and their interaction as predictors. The average lifetime PTSD prevalence in women was at least twice as high as it was in men and the vulnerability paradox existed in the prevalence data for women and men (R(2) = .70). We could not confirm the possibility that gender effects are modified by socioeconomic and cultural country characteristics. Issues of methodology, language, and cultural validity complicate international comparisons. Nevertheless, this international sample points at a parallel paradox: The vulnerability paradox was confirmed for both women and men. The absence of a significant interaction between gender and country vulnerability implies that possible explanations for the paradox at the country-level do not necessarily require gender-driven distinction.
  • Chapter
    Posttraumatic stress disorder (PTSD) is a mental health condition that develops in a minority of individuals following exposure to a life-threatening or other extremely distressing event. The disorder is characterized by four groups of symptoms: (a) reexperiencing the trauma; (b) avoidance and emotional numbing; (c) negative alterations in cognition and mood; and (d) persistent hyperarousal. Prevalence varies considerably depending on trauma type, with interpersonal violence (especially rape) consistently resulting in the highest rates. Risk factors for development and maintenance of PTSD include a combination of pretrauma, peritrauma, and posttrauma variables. A variety of evidence-based treatments are available, with trauma-focused psychological approaches being the treatment of choice. Pharmacological interventions provide an important second-line approach.
  • Article
    Posttraumatic stress disorder (PTSD) has symptoms that exist along a spectrum that includes depression and the 2 disorders may coexist. Collaborative care management (CCM) has been successfully used in outpatient mental health management (especially depression and anxiety) with favorable outcomes. Despite this, there exist limited data on clinical impact of a diagnosis of PTSD on depression outcomes in CCM. The present study used a retrospective cohort design to examine the association of PTSD with depression outcomes among 2121 adult patients involved in CCM in a primary care setting. Using standardized self-report measures, baseline depression scores and 6-month outcome scores were evaluated. Seventy-six patients had a diagnosis of PTSD documented in their electronic medical record. Patients with PTSD reported more severe depressive symptoms at baseline (Patient Health Questionnaire-9 score of 17.9 vs 15.4, P < .001) than those without PTSD. Controlling for sociodemographic and clinical characteristics, a clinical diagnosis of PTSD was associated with lower odds (AOR = 0.457, CI = 0.274-0.760, P = .003) of remission at 6 months and was also associated with higher odds (AOR = 3.112, CI = 1.921-5.041, P < .001) of persistent depressive symptoms at 6 months after CCM. When coexisting with depression, a diagnosis of PTSD was associated with worse depression outcomes, when managed with CCM in primary care. Opportunities still exist for more aggressive management of depression in these patients to help improve remission as well as reduce persistent depressive symptoms.
  • Chapter
    The literature on the prevalence of traumatic exposure among older adults is vast; but only during the last years have data emerged about the actual lifetime prevalence of post-traumatic stress disorder (PTSD) in late life, and the chronic course of the disorder. One of the main risk factors for the development of PTSD is exposure to multiple traumatic events. Therefore older adults with a past history of trauma are at increased risk of mental health sequelae when exposed to a disaster. Past history of trauma is also associated with comorbid medical and mental illnesses, further complicating the delivery of care immediately following a disaster, among this group of vulnerable older adults. This chapter reviews the topic with special focus on Holocaust Survivors for which a very long-term follow up since the initial traumatic event is available.
  • Article
    Full-text available
    Extinction-based exposure therapy is used to treat anxiety- and trauma-related disorders; however, there is the need to improve its limited efficacy in individuals with impaired fear extinction learning and to promote greater protection against return-of-fear phenomena. Here, using 129S1/SvImJ mice, which display impaired fear extinction acquisition and extinction consolidation, we revealed that persistent and context-independent rescue of deficient fear extinction in these mice was associated with enhanced expression of dopamine-related genes, such as dopamine D1 (Drd1a) and -D2 (Drd2) receptor genes in the medial prefrontal cortex (mPFC) and amygdala, but not hippocampus. Moreover, enhanced histone acetylation was observed in the promoter of the extinction-regulated Drd2 gene in the mPFC, revealing a potential gene-regulatory mechanism. Although enhancing histone acetylation, via administering the histone deacetylase (HDAC) inhibitor MS-275, does not induce fear reduction during extinction training, it promoted enduring and context-independent rescue of deficient fear extinction consolidation/retrieval once extinction learning was initiated as shown following a mild conditioning protocol. This was associated with enhanced histone acetylation in neurons of the mPFC and amygdala. Finally, as a proof-of-principle, mimicking enhanced dopaminergic signaling by L-dopa treatment rescued deficient fear extinction and co-administration of MS-275 rendered this effect enduring and context-independent. In summary, current data reveal that combining dopaminergic and epigenetic mechanisms is a promising strategy to improve exposure-based behavior therapy in extinction-impaired individuals by initiating the formation of an enduring and context-independent fear-inhibitory memory.
  • Article
    Background: Survivors of traumatic events may develop a range of psychopathology, across the internalizing and externalizing dimensions of disorder and associated personality traits. However, research into personality-based internalizing and externalizing trauma responses has been limited to cross-sectional investigations of PTSD comorbidity. Personality typologies may present an opportunity to identify and selectively intervene with survivors at risk of posttraumatic disorder. Therefore this study examined whether personality prospectively influences the trajectory of disorder in a broader trauma-exposed sample. Methods: During hospitalization for a physical injury, 323 Australian adults completed the Multidimensional Personality Questionnaire-Brief Form and Structured Clinical Interview for DSM-IV, with the latter readministered 3 and 12 months later. Latent profile analysis conducted on baseline personality scores identified subgroups of participants, while latent change modelling examined differences in disorder trajectories. Results: Three classes (internalizing, externalizing, and normal personality) were identified. The internalizing class showed a high risk of developing all disorders. Unexpectedly, however, the normal personality class was not always at lowest risk of disorder. Rather, the externalizing class, while more likely than the normal personality class to develop substance use disorders, were less likely to develop PTSD and depression. Conclusions: Results suggest that personality is an important mechanism in influencing the development and form of psychopathology after trauma, with internalizing and externalizing subtypes identifiable in the early aftermath of injury. These findings suggest that early intervention using a personality-based transdiagnostic approach may be an effective method of predicting and ultimately preventing much of the burden of posttraumatic disorder.
  • Article
    Workshop Age of onset of mental disorders: etiopathogenetic and treatment implications. Background Age of onset (AOO) of anxiety disorders could serve as a vital statistic in the formulation of mental health policy. Previous reviews have reported on the AOO of anxiety disorders in the general population. However, these review studies did not systematically estimate the AOO of different anxiety disorder subtypes, and did not examine factors that might have influenced reported AOO. Objective The aims of the present study were (1) to estimate the AOO for all anxiety disorders and for specific subtypes, (2) to examine gender differences in AOO of anxiety disorders, and (3) to examine the influence of study characteristics on reported AOO. Method Seven electronic databases were searched with keywords representing anxiety disorder subtypes, AOO and study design. The inclusion criteria were studies using a general population sample that provided data on AOO for all anxiety disorders, or specific anxiety disorders, according to DSM-III-R, DSM-IV or ICD-10 criteria. Meta-analysis was used to estimate AOO and gender differences, while meta-regression was used to examine the influence of study characteristics. Results A total of 1028 titles were examined, which yielded 24 studies meeting the inclusion criteria. Meta-analysis found an average AOO of all anxiety disorders of 21.3 years (95% CI: 17.46 to 25.07). Separation anxiety disorder, specific phobia and social phobia had their mean onset before the age of 15 years, whereas AOO of agoraphobia, obsessive compulsive disorder, post-traumatic stress disorder, panic disorder and generalized anxiety disorder began on average between 21.1 and 34.9 years. Anxiety disorder is more common in women, but meta-analysis revealed no difference in AOO between genders. Prospective study design and higher developmental level of the study country were associated with earlier AOO. Conclusion Results from this meta-analysis indicate that anxiety disorder subtypes differ in mean AOO, with onsets ranging from early adolescence to young adulthood. These findings suggest that prevention strategies of anxiety disorders should be directed towards the factors associated with the development of subtypes of anxiety disorder in the age groups with the greatest vulnerability for developing those disorders.
  • Chapter
    PTSD is a major health problem for military and civilian populations and treatment has proven to be less than effective. There are many people exposed to trauma who suffer flashbacks, bad dreams, emotional numbing, fear, anxiety, sleeplessness, hypervigilance, hyperarousal, and an inability to cope. Current behavioral and drug treatment strategies for PTSD are based on animal models of fear conditioning which typically do not focus on treating all PTSD symptoms. For example, the extinction of fear to trauma-associated trigger cues using techniques such as cognitive behavioral therapy does not deal with the general hyperarousal experienced by people with PTSD. A new animal model based on classical conditioning of the rabbit has been developed in which conditioning and hyperarousal can both be extinguished using modified unpaired stimulus presentations. This potential form of treatment might be implemented in clinical practice using a virtual reality environment.
  • Chapter
    Trauma and Posttraumatic Stress Disorder - edited by Evelyn Bromet August 2018
  • Article
    Objective: The objective was to estimate the age of onset (AOO) for all anxiety disorders and for specific subtypes. Gender differences in the AOO of anxiety disorders were examined, as were the influence of study characteristics on reported AOOs. Methods: Seven electronic databases were searched up to October 2014, with keywords representing anxiety disorder subtypes, AOO, and study design. The inclusion criteria were studies using a general population sample that provided data on the AOO for all anxiety disorders, or specific anxiety disorders, according to DSM-III-R, DSM-IV, or ICD-10 criteria. Results: There were 1028 titles examined, which yielded 24 studies meeting the inclusion criteria. Eight studies reported the AOO and gender. Meta-analysis found a mean AOO of all anxiety disorders of 21.3 years (95% CI 17.46 to 25.07). Separation anxiety disorder, specific phobia, and social phobia had their mean onset before the age of 15 years, whereas the AOO of agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety disorder began, on average, between 21.1 and 34.9 years. Meta-analysis revealed no difference in the AOO between genders. A prospective study design and higher developmental level of the study country were associated with an earlier AOO. Conclusions: Results from this meta-analysis indicate that anxiety disorder subtypes differ in the mean AOO, with onsets ranging from early adolescence to young adulthood. These findings suggest that prevention strategies of anxiety disorders should be directed towards factors associated with the development of anxiety disorder subtypes in the age groups with the greatest vulnerability for developing those disorders.
  • Article
    Full-text available
    Background: Trauma experienced by adolescents has considerable importance because significant physical and emotional growth occurs at this age. With the events of the Arab Spring and the Egyptian revolution in 2011, many adolescents faced highly challenging and dramatic life events. Post-traumatic stress disorder (PTSD) was clinically noticed in this group of patients. Aim: Because of the scarcity of research during this critical period, we aimed to determine the occurrence of PTSD in a sample of adolescent students in Tanta in order to assess their level of anxiety and study comorbid disorders. Methodology: A total of 423 adolescents were randomly selected from both public and private schools with random selection of the participating classes. The enrolled students were subjected to the Taylor Manifest Anxiety Scale to determine the level of anxiety, to the PTSD Checklist – Civilian Version, and the Mini International Neuropsychiatric Interview as a diagnostic interview for PTSD and associated comorbidities. Results: PTSD was seen in 16.31% of students, which was highly significantly more among female students compared with male students (P=0.006). The highest comorbidity was major depressive disorder in 33.33% of the sample, followed by social phobia in 28.99%. The level of anxiety on Taylor Manifest Anxiety Scale was highly significantly associated with female sex, public school education, and presence of PTSD (P<0.001). Conclusion: Despite its limitations, this study played an exploratory role in revealing the incidence, comorbidity, and risks for PTSD among adolescent students in Tanta and we recommend a replication of the study in adolescents belonging to other geographic locations in Egypt to draw effective educational programs on adolescent mental health for parents and teachers.
  • Article
    Prevalence estimates of delayed posttraumatic stress disorder (PTSD) have varied widely in the literature. This study is the first to establish the prevalence of delayed PTSD in prospective studies and to evaluate associated factors through meta-analytic techniques. Studies were located by an electronic search using the databases EMBASE, MEDLINE, and PsycINFO. Search terms were posttraumatic stress disorder [include all subheadings] AND (delayed OR prospective OR longitudinal OR follow-up). Results were limited to journal articles published between 1980 and April 4, 2008. We included longitudinal, prospective studies of humans exposed to a potentially traumatic event that assessed participants at 1 to 6 months after the event, that included a follow-up of at least 12 months after the event, and that specified rates of new onset and remission between assessments in study completers. Data were extracted concerning the study design, demographic features, and event-related characteristics and the number of PTSD cases at first assessment, the number of PTSD cases among study dropouts, and the number of new event-related PTSD cases at each subsequent assessment among study completers. Data from 24 studies were included. Four of these provided additional data on initial subthreshold PTSD and subsequent risk of delayed PTSD. The proportion of PTSD cases with delayed PTSD was 24.8% (95% CI = 22.6% to 27.2%) after adjusting for differences in study methodology, demographic features, and event-related characteristics. Military combat exposure, Western cultural background, and lower cumulative PTSD incidence were associated with delayed PTSD. Participants with initial subthreshold PTSD were at increased risk of developing delayed PTSD. Delayed PTSD was found among about a quarter of PTSD cases and represents exacerbations of prior symptoms.
  • Article
    Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:617-627), an author’s name was inadvertently omitted from the byline on page 617. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” Also on that page, the affiliations paragraph should have appeared as follows: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Drs Kessler, Chiu, Demler, and Walters); Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Md (Dr Merikangas). On page 626, the acknowledgment paragraph should have appeared as follows: We thank Jerry Garcia, BA, Sara Belopavlovich, BA, Eric Bourke, BA, and Todd Strauss, MAT, for assistance with manuscript preparation and the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on the data analysis. We appreciate the helpful comments of William Eaton, PhD, Michael Von Korff, ScD, and Hans-Ulrich Wittchen, PhD, on earlier manuscripts. Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
  • Article
    SUMMARY Nonproportional hazards can often be expressed by extending the Cox model to include time varying coefficients; e.g., for a single covariate, the hazard function for subject i is modelled as exp {β(t)Zi(t)}. A common example is a treatment effect that decreases with time. We show that the function βi(t) can be directly visualized by smoothing an appropriate residual plot. Also, many tests of proportional hazards, including those of Cox (1972), Gill & Schumacher (1987), Harrell (1986), Lin (1991), Moreau, O'Quigley & Mesbah (1985), Nagelkerke, Oosting & Hart (1984), O'Quigley & Pessione (1989), Schoenfeld (1980) and Wei (1984) are related to time-weighted score tests of the proportional hazards hypothesis, and can be visualized as a weighted least-squares line fitted to the residual plot.
  • Article
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    Objective: Exposure to traumatic experiences, especially those occurring in childhood, has been linked to substance use disorders (SUDs), including abuse and dependence. SUDs are also highly comorbid with Posttraumatic Stress Disorder (PTSD) and other mood-related psychopathology. Most studies examining the relationship between PTSD and SUDs have examined veteran populations or patients in substance treatment programs. The present study further examines this relationship between childhood trauma, substance use, and PTSD in a sample of urban primary care patients. Method: There were 587 participants included in this study, all recruited from medical and OB/GYN clinic waiting rooms at Grady Memorial Hospital in Atlanta, GA. Data were collected through both screening interviews as well as follow-up interviews. Results: In this highly traumatized population, high rates of lifetime dependence on various substances were found (39% alcohol, 34.1% cocaine, 6.2% heroin/opiates, and 44.8% marijuana). The level of substance use, particularly cocaine, strongly correlated with levels of childhood physical, sexual, and emotional abuse as well as current PTSD symptoms. In particular, there was a significant additive effect of number of types of childhood trauma experienced with history of cocaine dependence in predicting current PTSD symptoms, and this effect was independent of exposure to adult trauma. Conclusions: These data show strong links between childhood traumatization and SUDs, and their joint associations with PTSD outcome. They suggest that enhanced awareness of PTSD and substance abuse comorbidity in high-risk, impoverished populations is critical to understanding the mechanisms of substance addiction as well as in improving prevention and treatment.
  • Article
    Previous studies have shown that children and adolescents exposed to traumatic experience in a disaster can suffer from high levels of post-traumatic stress. The present paper is the first a series reporting on the long-term follow-up of a group of young adults who as teenagers had survived a shipping disaster—the sinking of the “Jupiter” in Greek waters—between 5 and 8 years previously. The general methodology of the follow-up study as a whole is described, and the incidence and long-term course of Post-Traumatic Stress Disorder (PTSD). It is the first study of its kind on a relatively large, representative sample of survivors, using a standardised diagnostic interview, and comparing survivors with a community control group. Survivors of the Jupiter disaster (N= 217), and 87 young people as controls, were interviewed using the Clinician Administered PTSD Scale (CAPS). Of the 217 survivors, 111 (51.7%) had developed PTSD at some time during the follow-up period, compared with an incidence in the control group of 3.4% (N= 87). In the large majority of cases of PTSD in the survivors for whom time of onset was recorded, 90%(N= 110), onset was not delayed, being within 6 months of the disaster. About a third of those survivors who developed PTSD (30%,N= 111) recovered within a year of onset, through another third (34%,N= 111) were still suffering from the disorder at the time of follow-up, between 5 and 8 years after the disaster. Issues relating to the generalisability of these findings are discussed.
  • Article
    This is a review and meta-analysis of school-based intervention programs targeted at reducing symptoms of posttraumatic stress disorder (PTSD). Nineteen studies conducted in 9 different countries satisfied the inclusionary criteria. The studies dealt with various kinds of type I and type II trauma exposure. Sixteen studies used cognitive-behavioral therapy methods; the others used play/art, eye movement desensitization and reprocessing, and mind-body techniques. The overall effect size for the 19 studies was d = 0.68 (SD = 0.41), indicating a medium-large effect in relation to reducing symptoms of PTSD. The authors' findings suggest that intervention provided within the school setting can be effective in helping children and adolescents following traumatic events.
  • Article
    Full-text available
    As exposure to different types of traumatic stressors increases, the prevalence of PTSD increases. However, little is known about the effects of cumulative exposure to traumatic stress on the maintenance and remission from PTSD. In 2006/2007, we investigated 444 refugees from the 1994 Rwandan genocide, assessing exposure to traumatic events, current and lifetime PTSD, and PTSD symptom severity. Higher trauma exposure was associated with higher prevalence of current and lifetime PTSD, with lower probability of spontaneous remission from PTSD, and with higher current and lifetime PTSD symptom severity in clear dose-response effects. The results suggest traumatic load as a root cause of both PTSD chronicity and symptom severity and support the hypothesis of a neural fear network in the etiology of PTSD.
  • Article
    We examined patterns and correlates of speed of recovery of estimated posttraumatic stress disorder (PTSD) among people who developed PTSD in the wake of Hurricane Katrina. A probability sample of prehurricane residents of areas affected by Hurricane Katrina was administered a telephone survey 7-19 months following the hurricane and again 24-27 months posthurricane. The baseline survey assessed PTSD using a validated screening scale and assessed a number of hypothesized predictors of PTSD recovery that included sociodemographics, prehurricane history of psychopathology, hurricane-related stressors, social support, and social competence. Exposure to posthurricane stressors and course of estimated PTSD were assessed in a follow-up interview. An estimated 17.1% of respondents had a history of estimated hurricane-related PTSD at baseline and 29.2% by the follow-up survey. Of the respondents who developed estimated hurricane-related PTSD, 39.0% recovered by the time of the follow-up survey with a mean duration of 16.5 months. Predictors of slow recovery included exposure to a life-threatening situation, hurricane-related housing adversity, and high income. Other sociodemographics, history of psychopathology, social support, social competence, and posthurricane stressors were unrelated to recovery from estimated PTSD. The majority of adults who developed estimated PTSD after Hurricane Katrina did not recover within 18-27 months. Delayed onset was common. Findings document the importance of initial trauma exposure severity in predicting course of illness and suggest that pre- and posttrauma factors typically associated with course of estimated PTSD did not influence recovery following Hurricane Katrina.
  • Estimates of the prevalence of exposure to potentially traumatic events (PTEs) in population surveys have increased over time. There is limited empirical evidence on the impact of changes in measurement practices on these estimates. The present study examined the effect of increasing the number of events assessed on the prevalence of exposure longitudinally. Data were ultilized from the 1997 and 2007 Australian National Surveys of Mental Health and Wellbeing. The 1997 survey assessed exposure using 11 items from the Composite International Diagnostic Interview (CIDI), version 2.1. The 2007 survey utilized 29 items from the World Mental Health CIDI. Prevalence rates of exposure to matched events among age-matched samples from both surveys were compared to determine whether differences in the estimates obtained were due to respondents having been asked about an increased number of event types in the latter survey. The effect of increasing the number of event types in the CIDI from 11 to 29 was to increase the overall population prevalence of exposure to PTEs by 18%. The difference between estimates was more pronounced in women than in men. The cross-cohort analyses revealed that these differences were not indicative of an increase in trauma exposure over time; but rather the endorsement of new events that were not listed in the earlier survey. The findings underscore the importance of using comprehensive assessments in the measurement of exposure to PTEs. Previous epidemiological surveys may have underestimated the prevalence of traumatic and other stressful life events, particularly among women.
  • Article
    The present study used data from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,653) to examine lifetime Axis I psychiatric comorbidity of posttraumatic stress disorder (PTSD) in a nationally representative sample of U.S. adults. Lifetime prevalences ± standard errors of PTSD and partial PTSD were 6.4% ± 0.18 and 6.6% ± 0.18, respectively. Rates of PTSD and partial PTSD were higher among women (8.6% ± 0.26 and 8.6% ± 0.26) than men (4.1% ± 0.19 and 4.5% ± 0.21). Respondents with both PTSD and partial PTSD most commonly reported unexpected death of someone close, serious illness or injury to someone close, and sexual assault as their worst stressful experiences. PTSD and partial PTSD were associated with elevated lifetime rates of mood, anxiety, and substance use disorders, and suicide attempts. Respondents with partial PTSD generally had intermediate odds of comorbid Axis I disorders and psychosocial impairment relative to trauma controls and full PTSD.
  • Article
    Full-text available
    Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity.
  • Article
    Full-text available
    Evidence is accumulating that child sexual abuse (CSA) is associated with many psychiatric disorders in adulthood. This paper uses the detailed information available from the 2007 Adult Psychiatric Morbidity Survey of England (APMS 2007) to quantify links between CSA and a range of psychiatric conditions. The prevalence of psychiatric disorder was established in a random sample of the English household population (n=7403), which also provided sociodemographic and experiential information. We analyzed six types of common mental disorder, alcohol abuse and drug abuse, and people who screened positively for post-traumatic stress disorder (PTSD) and eating disorders. All were strongly and highly significantly associated with CSA, particularly if non-consensual sexual intercourse was involved, for which odds ratios (ORs) ranged from 3.7 to 12.1. These disorders were also related to adult sexual abuse (ASA), although the likelihood of reverse causality is then increased. Revictimization in adulthood was common, and increased the association of CSA with disorder. For several disorders, the relative odds were higher in females but formal tests for moderation by gender were significant only for common mental disorders and only in relation to non-consensual sexual intercourse. The population attributable fraction (PAF) was higher in females in all cases. The detailed and high-quality data in APMS 2007 provided important confirmation both of the strength of association of CSA with psychiatric disorder and of its relative non-specificity. Our results have major implications at the public health level and the individual level, in particular the need for better recognition and treatment of the sequelae of CSA.
  • Article
    Full-text available
    Little is known about prevalence rates of DSM-IV disorders across age strata of older adults, including common conditions such as individual and coexisting mood and anxiety disorders. To determine nationally representative estimates of 12-month prevalence rates of mood, anxiety, and comorbid mood-anxiety disorders across young-old, mid-old, old-old, and oldest-old community-dwelling adults. The National Comorbidity Survey Replication (NCS-R) is a population-based probability sample of 9282 participants 18 years and older, conducted between February 2001 and April 2003. The NCS-R survey used the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. Continental United States. We studied the 2575 participants 55 years and older who were part of NCS-R (43%, 55-64 years; 32%, 65-74 years; 20%, 75-84 years; 5%, >or=85 years). This included only noninstitutionalized adults, as all NCS-R participants resided in households within the community. Twelve-month prevalence of mood disorders (major depressive disorder, dysthymia, bipolar disorder), anxiety disorders (panic disorder, agoraphobia, specific phobia, social phobia, generalized anxiety disorder, posttraumatic stress disorder), and coexisting mood-anxiety disorder were assessed using DSM-IV criteria. Prevalence rates were weighted to adjust for the complex design to infer generalizability to the US population. The likelihood of having a mood, anxiety, or combined mood-anxiety disorder generally showed a pattern of decline with age (P < .05). Twelve-month disorders showed higher rates in women compared with men, a statistically significant trend with age. In addition, anxiety disorders were as high if not higher than mood disorders across age groups (overall 12-month rates: mood, 5% and anxiety, 12%). No differences were found between race/ethnicity groups. Prevalence rates of DSM-IV mood and anxiety disorders in late life tend to decline with age, but remain very common, especially in women. These results highlight the need for intervention and prevention strategies.
  • Article
    Full-text available
    Cross-lagged panel analysis of interview data collected from survivors of traumatic physical injury (N = 677) was used to examine the temporal relationship between anxiety sensitivity and posttraumatic stress disorder (PTSD) symptom severity. The 2 constructs were assessed at 3 time points: within days of physical injury, at 6-month follow-up, and at 12-month follow-up. Results indicated that anxiety sensitivity and PTSD symptom severity were reciprocally related such that anxiety sensitivity predicted subsequent PTSD symptom severity, and symptom severity predicted later anxiety sensitivity. Findings have both theoretical and clinical implications.
  • Article
    Traumatic injury affects millions of people each year. There is little understanding of the extent of psychiatric illness that develops after traumatic injury or of the impact of mild traumatic brain injury (TBI) on psychiatric illness. The authors sought to determine the range of new psychiatric disorders occurring after traumatic injury and the influence of mild TBI on psychiatric status. In this prospective cohort study, patients were drawn from recent admissions to four major trauma hospitals across Australia. A total of 1,084 traumatically injured patients were initially assessed during hospital admission and followed up 3 months (N=932, 86%) and 12 months (N=817, 75%) after injury. Lifetime psychiatric diagnoses were assessed in hospital. The prevalence of psychiatric disorders, levels of quality of life, and mental health service use were assessed at the follow-ups. The main outcome measures were 3- and 12-month prevalence of axis I psychiatric disorders, levels of quality of life, and mental health service use and lifetime axis I psychiatric disorders. Twelve months after injury, 31% of patients reported a psychiatric disorder, and 22% developed a psychiatric disorder that they had never experienced before. The most common new psychiatric disorders were depression (9%), generalized anxiety disorder (9%), posttraumatic stress disorder (6%), and agoraphobia (6%). Patients were more likely to develop posttraumatic stress disorder (odds ratio=1.92, 95% CI=1.08-3.40), panic disorder (odds ratio=2.01, 95% CI=1.03-4.14), social phobia (odds ratio=2.07, 95% CI=1.03-4.16), and agoraphobia (odds ratio=1.94, 95% CI=1.11-3.39) if they had sustained a mild TBI. Functional impairment, rather than mild TBI, was associated with psychiatric illness. A significant range of psychiatric disorders occur after traumatic injury. The identification and treatment of a range of psychiatric disorders are important for optimal adaptation after traumatic injury.
  • Article
    Full-text available
    Childhood adversity (CA) is associated with adult mental disorders, but the mechanisms underlying this association remain inadequately understood. Stress sensitization, whereby CA increases vulnerability to mental disorders following adult stressful life events, has been proposed as a potential mechanism. We provide a test of the stress sensitization hypothesis in a national sample. We investigated whether the association between past-year stressful life events and the 12-month prevalence of major depression, post-traumatic stress disorder (PTSD), other anxiety disorders, and perceived stress varies according to exposure to CA. We used data from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) (n=34 653). Past-year stressful life events were associated with an increased risk of major depression, PTSD, anxiety disorders, and perceived stress. However, the magnitude of the increased risk varied according to respondents' history of CA. For example, past-year major stressors were associated with a 27.3% increase in the 12-month risk of depression among individuals with 3 CAs and a 14.8% increased risk among individuals without CAs. Stress sensitization effects were present for depression, PTSD, and other anxiety disorders in women and men, although gender differences were found in the threshold of past-year stress needed to trigger such effects. Stress sensitization was most evident among individuals with 3 CAs. CA is associated with increased vulnerability to the deleterious mental health effects of adult stressors in both men and women. High levels of CA may represent a general diathesis for multiple types of psychopathology that persists throughout the life course.
  • Article
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    The purpose of the analysis was to examine the temporal course of improvement in symptoms of posttraumatic stress disorder (PTSD) and substance use disorder among women in outpatient substance abuse treatment. Participants were 353 women randomly assigned to 12 sessions of either trauma-focused or health education group treatment. PTSD and substance use assessments were conducted during treatment and posttreatment at 1 week and after 3, 6, and 12 months. A continuous Markov model was fit on four defined response categories (nonresponse, substance use response, PTSD response, or global response [improvement in both PTSD and substance use]) to investigate the temporal association between improvement in PTSD and substance use symptom severity during the study's treatment phase. A generalized linear model was applied to test this relationship over the follow-up period. Subjects exhibiting nonresponse, substance use response, or global response tended to maintain original classification; subjects exhibiting PTSD response were significantly more likely to transition to global response over time, indicating maintained PTSD improvement was associated with subsequent substance use improvement. Trauma-focused treatment was significantly more effective than health education in achieving substance use improvement, but only among those who were heavy substance users at baseline and had achieved significant PTSD reductions. PTSD severity reductions were more likely to be associated with substance use improvement, with minimal evidence of substance use symptom reduction improving PTSD symptoms. Results support the self-medication model of coping with PTSD symptoms and an empirical basis for integrated interventions for improved substance use outcomes in patients with severe symptoms.
  • Article
    Full-text available
    Gender differences in mental disorders, including more anxiety and mood disorders among women and more externalizing disorders among men, are found consistently in epidemiological surveys. The gender roles hypothesis suggests that these differences narrow as the roles of women and men become more equal. To study time-space (cohort-country) variation in gender differences in lifetime DSM-IV mental disorders across cohorts in 15 countries in the World Health Organization World Mental Health Survey Initiative and to determine if this variation is significantly related to time-space variation in female gender role traditionality as measured by aggregate patterns of female education, employment, marital timing, and use of birth control. Face-to-face household surveys. Africa, the Americas, Asia, Europe, the Middle East, and the Pacific. Community-dwelling adults (N = 72,933). The World Health Organization Composite International Diagnostic Interview assessed lifetime prevalence and age at onset of 18 DSM-IV anxiety, mood, externalizing, and substance disorders. Survival analyses estimated time-space variation in female to male odds ratios of these disorders across cohorts defined by the following age ranges: 18 to 34, 35 to 49, 50 to 64, and 65 years and older. Structural equation analysis examined predictive effects of variation in gender role traditionality on these odds ratios. In all cohorts and countries, women had more anxiety and mood disorders than men, and men had more externalizing and substance disorders than women. Although gender differences were generally consistent across cohorts, significant narrowing was found in recent cohorts for major depressive disorder and substance disorders. This narrowing was significantly related to temporal (major depressive disorder) and spatial (substance disorders) variation in gender role traditionality. While gender differences in most lifetime mental disorders were fairly stable over the time-space units studied, substantial intercohort narrowing of differences in major depression was found to be related to changes in the traditionality of female gender roles. Additional research is needed to understand why this temporal narrowing was confined to major depression.
  • Article
    Full-text available
    To provide a description of the methods and key findings of the 2007 Australian National Survey of Mental Health and Wellbeing. A national face-to-face household survey of 8841 (60% response rate) community residents aged between 16 and 85 years was carried out using the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Diagnoses were made according to ICD-10. Key findings include the prevalence of mental disorder, sex and age distributions of mental disorders, severity of mental disorders, comorbidity among mental disorders, and the extent of disability and health service use associated with mental disorders. The prevalence of any lifetime mental disorder was 45.5%. The prevalence of any 12 month mental disorder was 20.0%, with anxiety disorders (14.4%) the most common class of mental disorder followed by affective disorders (6.2%) and substance use disorders (5.1%). Mental disorders, particularly affective disorders, were disabling. One in four people (25.4%) with 12 month mental disorders had more than one class of mental disorder. One-third (34.9%) of people with a mental disorder used health services for mental health problems in the 12 months prior to the interview. Mental disorders are common in Australia. Many people have more than one class of mental disorder. Mental disorders are associated with substantial disability, yet many people with mental disorders do not seek help for their mental health problems.
  • Article
    Epidemiologic studies have reported that the majority of community residents in the United States have experienced posttraumatic stress disorder (PTSD)-level traumatic events, as defined in the DSM-IV. Only a small subset of trauma victims develops PTSD (<10%). Increased incidence of other disorders following trauma exposure occurs primarily among trauma victims with PTSD. Female victims of traumatic events are at higher risk for PTSD than male victims are. Direct evidence on the causes of the sex difference in the conditional risk of PTSD is unavailable. The available evidence suggests that the sex difference is not due to (a) the higher occurrence of sexual assault among females, (b) prior traumatic experiences, (c) preexisting depression or anxiety disorder, or (d) sex-related bias in reporting. Observed sex differences in anxiety, neuroticism, and depression, inducing effects of stressful experiences, might provide a theoretical context for further inquiry into the greater vulnerability of females to PTSD.
  • Article
    Full-text available
    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.
  • Article
    Full-text available
    The study estimates the relative importance of specific types of traumas experienced in the community in terms of their prevalence and risk of leading to posttraumatic stress disorder (PTSD). A representative sample of 2181 persons in the Detroit area aged 18 to 45 years were interviewed by telephone to assess the lifetime history of traumatic events and PTSD, according to DSM-IV. Posttraumatic stress disorder was assessed with respect to a randomly selected trauma from the list of traumas reported by each respondent, using a modified version of the Diagnostic Interview Schedule, Version IV, and the World Health Organization Composite International Diagnostic Interview. The conditional risk of PTSD following exposure to trauma was 9.2%. The highest risk of PTSD was associated with assaultive violence (20.9%). The trauma most often reported as the precipitating event among persons with PTSD (31% of all PTSD cases) was sudden unexpected death of a loved one, an event experienced by 60% of the sample, and with a moderate risk of PTSD (14.3%). Women were at higher risk of PTSD than men, controlling for type of trauma. The risk of PTSD associated with a representative sample of traumas is less than previously estimated. Previous studies have overestimated the conditional risk of PTSD by focusing on the worst events the respondents had ever experienced. Although recent research has focused on combat, rape, and other assaultive violence as causes of PTSD, sudden unexpected death of a loved one is a far more important cause of PTSD in the community, accounting for nearly one third of PTSD cases.
  • Article
    The purpose of this study was to examine the course of comorbid posttraumatic stress disorder (PTSD) in 54 patients with another anxiety disorder. Using a prospective longitudinal design, the present study found that during the first 5 years of follow-up the probability of full remission from a chronic episode of PTSD was .18. Findings from this and other research confirm clinical impressions that a substantial number of people never fully remit from their PTSD even after many years. Variables associated with a longer time to remit from an episode of chronic PTSD were a history of alcohol abuse and a history of childhood trauma.
  • Article
    Full-text available
    With the exception of a few reports of higher rates of childhood trauma in Vietnam veterans with posttraumatic stress disorder (PTSD), little is known about the influence of previous exposure to trauma on the PTSD effects of subsequent trauma. The authors examine interrelated questions about the effects of previous exposure to trauma. A representative sample of 2,181 individuals in southeast Michigan were interviewed by telephone to record lifetime history of traumatic events specified in DSM-IV as potentially leading to PTSD. PTSD was assessed with respect to a randomly selected index trauma from the list of events reported by each respondent. History of any previous exposure to traumatic events was associated with a greater risk of PTSD from the index trauma. Multiple previous events had a stronger effect than a single previous event. The effect of previous assaultive violence persisted over time with little change. When they examined several features of the previous exposure to trauma, the authors found that subjects who experienced multiple events involving assaultive violence in childhood were more likely to experience PTSD from trauma in adulthood. Furthermore, previous events involving assaultive violence--single or multiple, in childhood or later on--were associated with a higher risk of PTSD in adulthood. Previous exposure to trauma signals a greater risk of PTSD from subsequent trauma. Although these results are consistent with a sensitization hypothesis, like the results from previous research on PTSD, they do not address the mechanism of increased responsivity to trauma. Long-term observational studies can further elucidate these observations.
  • Article
    Posttraumatic stress disorder (PTSD) differs from other anxiety disorders in that experience of a traumatic event is necessary for the onset of the disorder. The condition runs a longitudinal course, involving a series of transitional states, with progressive modification occurring with time. Notably, only a small percentage of people that experience trauma will develop PTSD. Risk factors, such as prior trauma, prior psychiatric history, family psychiatric history, peritraumatic dissociation, acute stress symptoms, the nature of the biological response, and autonomic hyperarousal, need to be considered when setting up models to predict the course of the condition. These risk factors influence vulnerability to the onset of PTSD and its spontaneous remission. In the majority of cases, PTSD is accompanied by another condition, such as major depression, an anxiety disorder, or substance abuse. This comorbidity can also complicate the course of the disorder and raises questions about the role of PTSD in other psychiatric conditions. This article reviews what is known about the emergence of PTSD following exposure to a traumatic event using data from clinical studies.
  • Article
    Previous studies have shown that children and adolescents exposed to traumatic experience in a disaster can suffer from high levels of post-traumatic stress. The present paper is the first a series reporting on the long-term follow-up of a group of young adults who as teenagers had survived a shipping disaster-the sinking of the "Jupiter" in Greek waters-between 5 and 8 years previously. The general methodology of the follow-up study as a whole is described, and the incidence and long-term course of Post-Traumatic Stress Disorder (PTSD). It is the first study of its kind on a relatively large, representative sample of survivors, using a standardised diagnostic interview, and comparing survivors with a community control group. Survivors of the Jupiter disaster (N = 217), and 87 young people as controls, were interviewed using the Clinician Administered PTSD Scale (CAPS). Of the 217 survivors, 111 (51.7%) had developed PTSD at some time during the follow-up period, compared with an incidence in the control group of 3.4 % (N = 87). In the large majority of cases of PTSD in the survivors for whom time of onset was recorded, 90 % (N = 110), onset was not delayed, being within 6 months of the disaster. About a third of those survivors who developed PTSD (30%, N = 111) recovered within a year of onset, through another third (34 %, N = 111) were still suffering from the disorder at the time of follow-up, between 5 and 8 years after the disaster. Issues relating to the generalisability of these findings are discussed.
  • Article
    Issues that are salient in understanding posttraumatic stress disorder (PTSD) in older adults are examined in this review. Although this issue has received scattered attention in the literature since introduction of the diagnosis of PTSD to the Diagnostic and Statistical Manual (DSM) in 1980, it is clear that numerous conceptual and defining questions exist in our understanding of the aftermath of trauma exposure in older adults. In approaching this issue, studies pertaining to diagnostic status as well as broader dimensions of psychosocial functioning are examined. Concerns that are unique to older adults are highlighted throughout, with particular attention to areas where additional research is warranted.
  • Article
    We examine whether traumatic events increase the risk for major depression independent of their effects on posttraumatic stress disorder (PTSD). Data come from the Epidemiologic Study of Young Adults in southeast Michigan (N = 1007). Retrospective and prospective data were used to estimate the risk of major depression in persons with PTSD and persons exposed to trauma with no PTSD, compared with persons who did not experience a trauma. National Comorbidity Survey data were used to evaluate the influence of trauma type. In the retrospective lifetime data, hazard ratios were, for first-onset major depression in exposed persons with PTSD, 2.8 and, in exposed persons with no PTSD, 1.3 (not significant), as compared with persons who were not exposed. Corresponding estimates from the prospective data were 11.7 and 1.4 (not significant). The difference in the risk for depression associated with PTSD versus exposure without PTSD is unlikely to be due to differences in trauma type. The findings of a markedly increased risk for major depression in persons with PTSD, but not in exposed persons without PTSD, do not support the hypothesis that PTSD and major depression in trauma victims are influenced by separate vulnerabilities.
  • Article
    Full-text available
    We report on the epidemiology of post-traumatic stress disorder (PTSD) in the Australian community, including information on lifetime exposure to trauma, 12-month prevalence of PTSD, sociodemographic correlates and co-morbidity. Data were obtained from a stratified sample of 10,641 participants as part of the Australian National Survey of Mental Health and Well-being. A modified version of the Composite International Diagnostic Interview was used to determine the presence of PTSD, as well as other DSM-IV anxiety, affective and substance use disorders. The estimated 12-month prevalence of PTSD was 1-33%, which is considerably lower than that found in comparable North American studies. Although females were at greater risk than males within the subsample of those who had experienced trauma, the large gender differences noted in some recent epidemiological research were not replicated. Prevalence was elevated among the never married and previously married respondents, and was lower among those aged over 55. For both men and women, rape and sexual molestation were the traumatic events most likely to be associated with PTSD. A high level of Axis 1 co-morbidity was found among those persons with PTSD. PTSD is a highly prevalent disorder in the Australian community and is routinely associated with high rates of anxiety, depression and substance disorders. Future research is needed to investigate rates among other populations outside the North American continent.
  • Article
    The benefits of providing early intervention for people recently exposed to trauma have highlighted the need to develop means to identify people who will develop chronic posttraumatic stress disorder (PTSD). This review provides an overview of prospective studies that have indexed the acute reactions to trauma that are predictive of chronic posttraumatic stress disorder. Ten studies of the predictive power of the acute stress disorder diagnosis indicate that this diagnosis does not have adequate predictive power. There is no convergence across studies on any constellation of acute symptoms that predict posttraumatic stress disorder. A review of biological and cognitive mechanisms occurring in the acute posttraumatic phase suggests that these factors may provide more accurate means of predicting chronic posttraumatic stress disorder. Recommendations for future research to facilitate identification of key markers of acutely traumatized people who will develop posttraumatic stress disorder are discussed.
  • Article
    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.
  • Article
    With an aging population increasing presentations of cases of Post Traumatic Stress Disorder (PTSD) can be expected to old age services. While progress has been made in recent years in relation to the understanding and development of aetiological theories, classification, assessment and management strategies and protocols in the adult population, similar advances have lagged behind for the elderly. To review the adult literature regarding PTSD and discuss how this might apply to an elderly population. An attempt is made to highlight a better awareness of the field of psychological trauma in the elderly in the hope of stimulating debate and research. A review of the adult literature is conducted relating to classification, aetiology, demographic features, vulnerability, assessment, clinical management including psychotherapy and medications and how these may apply to the elderly. Little has been published in this field that directly relates to the elderly. The adult literature allows insight into understanding how PTSD may present in the elderly, and how they may be managed. Further specific research is needed in the elderly in order to facilitate a better understanding of PTSD that present in this unique population. This will lead to better clinical assessment, management and treatment provision.
  • Article
    This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.
  • Article
    Full-text available
    Dramatic changes have occurred in mental health treatments during the past decade. Data on recent treatment patterns are needed to estimate the unmet need for services. To provide data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. Nationally representative face-to-face household survey using a fully structured diagnostic interview, the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview, carried out between February 5, 2001, and April 7, 2003. A total of 9282 English-speaking respondents 18 years and older. Proportions of respondents with 12-month DSM-IV anxiety, mood, impulse control, and substance disorders who received treatment in the 12 months before the interview in any of 4 service sectors (specialty mental health, general medical, human services, and complementary and alternative medicine). Number of visits and proportion of patients who received minimally adequate treatment were also assessed. Of 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a non-psychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by >1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality.
  • Article
    Full-text available
    Little is known about the general population prevalence or severity of DSM-IV mental disorders. To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Twelve-month DSM-IV disorders. Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
  • Article
    Full-text available
    Few studies have focused on the natural course of posttraumatic stress disorder (PTSD) and its determinants in samples of the general population. The authors examined determinants of remission and chronicity of PTSD and associations with other disorders in a prospective community sample. The data were drawn from a prospective, longitudinal epidemiological study of adolescents and young adults (age 14-24 years) in Munich, Germany (N=2,548). The course of PTSD from baseline to follow-up 34-50 months later was studied in 125 respondents with DSM-IV PTSD or subthreshold PTSD at baseline. Although 52% of the PTSD cases remitted during the follow-up period, 48% showed no significant remission of PTSD symptoms. Respondents with a chronic course were more likely to experience new traumatic event(s) during follow-up (odds ratio=5.21, 95% confidence interval [CI]=1.95-13.92), to have higher rates of avoidant symptoms at baseline (odds ratio=10.16, 95% CI=1.73-59.51), and to report more help seeking (odds ratio=5.50, 95% CI=1.04-29.05), compared to respondents with remission. Rates of incident somatoform disorder (odds ratio=4.24, 95% CI=1.60-11.19) and other anxiety disorders (odds ratio=4.07, 95% CI=1.15-14.37) were also significantly associated with a chronic course. PTSD is often a persistent and chronic disorder. Specific symptom clusters--especially avoidant symptoms--might be associated with the course of PTSD. In addition, the occurrence of new traumatic events differentiates PTSD cases with a chronic course from those with remission.
  • Article
    This study investigated the predictors of posttraumatic stress disorder (PTSD) following a diagnosis of cancer. Individuals who were recently diagnosed with 1st onset head and neck or lung malignancy (N = 82) were assessed within 1 month of diagnosis for acute stress disorder (ASD) and other psychological responses including depression; individuals were reassessed (N = 63) for PTSD 6 months following their cancer diagnosis. At the initial assessment ASD was diagnosed in 28% of participants, and 22% met criteria for PTSD at 6-months follow-up. Peritraumatic dissociative symptoms at the time of receiving one's cancer diagnosis was the sole predictor of PTSD severity at 6-months follow-up. Elevated dissociative symptoms and greater distress at the initial assessment were the best predictors of PTSD caseness at 6-months follow-up. This study provides evidence for identifying recently diagnosed cancer patients who may benefit from psychological assistance in order to prevent chronic psychopathology.
  • Article
    Full-text available
    Data are presented on the lifetime prevalence, projected lifetime risk, and age-of-onset distributions of mental disorders in the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Face-to-face community surveys were conducted in seventeen countries in Africa, Asia, the Americas, Europe, and the Middle East. The combined numbers of respondents were 85,052. Lifetime prevalence, projected lifetime risk, and age of onset of DSM-IV disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI), a fully-structured lay administered diagnostic interview. Survival analysis was used to estimate lifetime risk. Median and inter-quartile range (IQR) of age of onset is very early for some anxiety disorders (7-14, IQR: 8-11) and impulse control disorders (7-15, IQR: 11-12). The age-of-onset distribution is later for mood disorders (29-43, IQR: 35-40), other anxiety disorders (24-50, IQR: 31-41), and substance use disorders (18-29, IQR: 21-26). Median and IQR lifetime prevalence estimates are: anxiety disorders 4.8-31.0% (IQR: 9.9-16.7%), mood disorders 3.3-21.4% (IQR: 9.8-15.8%), impulse control disorders 0.3-25.0% (IQR: 3.1-5.7%), substance use disorders 1.3-15.0% (IQR: 4.8-9.6%), and any disorder 12.0-47.4% (IQR: 18.1-36.1%). Projected lifetime risk is proportionally between 17% and 69% higher than estimated lifetime prevalence (IQR: 28-44%), with the highest ratios in countries exposed to sectarian violence (Israel, Nigeria, and South Africa), and a general tendency for projected risk to be highest in recent cohorts in all countries. These results document clearly that mental disorders are commonly occurring. As many mental disorders begin in childhood or adolescents, interventions aimed at early detection and treatment might help reduce the persistence or severity of primary disorders and prevent the subsequent onset of secondary disorders.
  • Article
    Previous studies showed increased probability of a posttraumatic stress disorder (PTSD) effect of trauma in persons who had experienced prior trauma. The evidence comes chiefly from retrospective data on earlier events, obtained from trauma-exposed persons with and without PTSD. A generally overlooked major limitation is the failure to assess the PTSD response to the prior trauma. To estimate the risk of PTSD after traumas experienced during follow-up periods in relation to respondents' prior traumatic events and PTSD. A cohort study of young adults interviewed initially in 1989, with repeated assessments during a 10-year follow-up. The sample was randomly selected from a large health maintenance organization in Southeast Michigan, representing the geographic area. The relative risk of PTSD precipitated by traumatic events occurring during follow-up periods in relation to prior exposure and PTSD that had occurred during preceding periods, estimated by general estimating equations (n = 990). The conditional risk of PTSD during the follow-up periods was significantly higher among trauma-exposed persons who had experienced prior PTSD, relative to those with no prior trauma (odds ratio, 3.01; 95% confidence interval, 1.52-5.97). After adjustment for sex, race, education, and preexisting major depression and anxiety disorders, the estimates were only marginally revised. In contrast, the conditional risk of PTSD during follow-up among trauma-exposed persons who had experienced prior traumatic events but not PTSD was not significantly elevated, relative to trauma-exposed persons with no prior trauma. The difference between the 2 estimates was significant (P = .005). Prior trauma increases the risk of PTSD after a subsequent trauma only among persons who developed PTSD in response to the prior trauma. The findings suggest that preexisting susceptibility to a pathological response to stressors may account for the PTSD response to the prior trauma and the subsequent trauma.
  • Article
    Full-text available
    The article reviews psychosocial treatments for phobic and anxiety disorders in youth. Using criteria from Nathan and Gorman (2002), 32 studies are evaluated along a continuum of methodological rigor. In addition, the treatments evaluated in each of the 32 studies are classified according to Chambless et al.'s (1996) and Chambless and Hollon's (1998) criteria. Findings from a series of meta-analyses of the studies that used waitlists also are reported. In accordance with Nathan and Gorman, the majority of the studies were either methodologically robust or fairly rigorous. In accordance with Chambless and colleagues, although no treatment was well-established, Individual Cognitive Behavior Therapy, Group Cognitive Behavior Therapy (GCBT), GCBT with Parents, GCBT for social phobia (SOP), and Social Effectiveness Training for children with SOP each met criteria for probably efficacious. The other treatments were either possibly efficacious or experimental. Meta-analytic results revealed no significant differences between individual and group treatments on diagnostic recovery rates and anxiety symptom reductions, as well as other youth symptoms (i.e., fear, depression, internalizing and externalizing problems). Parental involvement was similarly efficacious as parental noninvolvement in individual and group treatment formats. The article also provides a summary of the studies that have investigated mediators, moderators, and predictors of treatment outcome. The article concludes with a discussion of the clinical representativeness and generalizability of treatments, practice guidelines, and future research directions.
  • High occurrence of mood and anxiety disorders among older adults : the National Comorbidity Survey Replication
    • Al Byers
    • K Yaffe
    • Ke Covinsky
    • Mb Friedman
    • Ml Bruce
    Byers AL, Yaffe K, Covinsky KE, Friedman MB, Bruce ML (2010). High occurrence of mood and anxiety disorders among older adults : the National Comorbidity Survey Replication. Archives of General Psychiatry 67, 489–496.
  • Posttraumatic stress disorder in older adults : a conceptual review
    • Pm Averill
    • Jg Beck
    Averill PM, Beck JG (2000). Posttraumatic stress disorder in older adults : a conceptual review. Journal of Anxiety Disorders 14, 133–156.