Memory of Traumatic Experiences: From Amnesia to Post-traumatic Stress Disorder

Practical geriatrics: possible association of posttraumatic stress disorder with cognitive impairment among older adults.

The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.

Most youth in detention have 1 or more psychiatric disorders (1). Posttraumatic stress disorder (PTSD) is one of the more prevalent disorders in detention, affecting at least 1 in 10 youth (2–4). One of the more debilitating aspects of PTSD is its tendency to co-occur with other psychiatric disorders (5–7). In a community sample, Giaconia and colleagues (8) found that nearly four-fifths of those with lifetime PTSD also had one or more additional disorders. Studies of detained adolescent males in Russia (9) and detained adolescent females in Australia (10) found that all of the detainees with PTSD had at least 1 comorbid disorder. It is unclear if PTSD increases the vulnerability to other disorders or if there are common genetic or environmental factors underlying the disorders (5,11). Researchers agree, however, that comorbid disorders have an adverse impact on the prognosis and treatment of individuals with PTSD. Youth with PTSD and comorbid disorders have significantly more behavioral and health problems and more impaired interpersonal relationships than those without comorbid disorders (5). Effective treatment planning for detained youth with PTSD requires epidemiologic data on patterns of prevalence and comorbidity. Yet, to our knowledge, no epidemiologic study of detainees in the US has examined PTSD and comorbid psychiatric disorders. In this paper, we administered standardized diagnostic measures to a large, stratified random sample of detained youth to: (a) compare the prevalence of psychiatric disorders among juvenile detainees with and without PTSD and (b) examine the prevalence of PTSD among youth with and without other psychiatric disorders.

Update on Posttraumatic Stress Disorder and Implications for Acute and Critical Care APRNs.

Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions. To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set. The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016. Prevalence of PTSD assessed with the Composite International Diagnostic Interview. Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3). The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.

Toward the Predeployment Detection of Risk for PTSD

It is estimated that one in 10 children (approximately 230 million children) currently live in a war or conflict-affected society and will be exposed to daily violence in their communities (UNICEF, 2016). Some may be forced into violent combat, and many more will experience familial, social and cultural losses (Betancourt, McBain, Newnham & Brennan, 2013; Betancourt, Meyers-Ohki, Charrow & Tol, 2013; IASC, 2014; Santa Barbara, 2006). It is generally accepted that children and young people exposed to violence in areas of conflict are at an increased risk of harmful effects, including injury, sexual abuse, disability, illness and long-term mental health issues or psychological problems. The harmful psychological effects of living through war or conflict include depression and anxiety disorders and post-traumatic stress symptoms (PTSS) such as flashbacks, nightmares or intrusive thoughts about the trauma, avoidance of people, places or activities related to the trauma, disturbed sleep, disturbed play in young children and somatic symptoms (Attanayake et al., 2009; Dimitry, 2012; Fasfous, Peralta-Ramírez & Pérez-García, 2013; Jordans, Tol, Komproe & de Jong, 2009; Slone & Mann, 2016; Yule et al., 2000). While most people will experience some post-traumatic stress symptoms following trauma, those whose symptoms persist and interfere with daily life may be diagnosed with post-traumatic stress disorder (PTSD). A meta-analysis of child and adolescent mental health in conflict affected settings estimated that prevalence rates were elevated for PTSD (47%, 17 studies, 95% CI: 35–60%), depression (43%, four studies, 95% CI: 31–55%) and anxiety (27% three studies, 95% CI: 21–33%) (Attanayake et al., 2009). This is compared to much lower lifetime prevalence estimates in the general population of, for example, American adolescents of 5% PTSD, 12% depressive disorder, 2.2% generalized anxiety disorder (Merikangas et al., 2010). A systematic review of the effect of war or conflict related violence on young children (age 0–6) found that prevalence of either PTSD or PTSS ranged from 8% to 45% (Slone & Mann, 2016). PTSD is the most common mental-health condition associated with exposure to war, conflict or political violence (Attanayake et al., 2009; Betancourt, Borisova, et al., 2013; Dimitry, 2012; McDermott, Duffy, Percy, Fitzgerald & Cole, 2013; Slone & Mann, 2016). As with adults, children suffering PTSD present with broad categories of post-traumatic stress symptoms (re-experiencing, avoidance/numbing and increased arousal). Younger children may display more overt aggression and destructiveness and re-experiencing symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams. Subjective experience of the event and peri-trauma factors, such as perceived severity and proximity, have been identified as possible risk factors for developing PTSD after trauma (Trickey, Siddaway, Meiser-Stedman, Serpell & Field, 2012). Post-trauma risk factors include low social support, poor family functioning (Trickey et al., 2012) and higher negative posttraumatic cognitions (Punamäki, Palosaari, Diab, Peltonen & Qouta, 2014). Finally, pre-trauma factors, such as a non-related mental health disorder, age and gender have also been linked to development of PTSD following war and conflict related violence. The exact nature of the relationship between age, gender and PTSD is unclear. There is some evidence suggesting that girls are at greater risk than boys because they may have higher levels of rumination or pre-trauma anxiety (McDermott et al., 2013), girls may be more likely to experience greater subjective exposure than boys, but boys may exhibit more externalizing problems in response to trauma such as increased aggression (Dimitry, 2012). It may be that this different pattern of response in boys and girls reflects socially constructed gendered norms of appropriate behaviour and inequitable distribution of power and agency between boys and girls, but gender inequalities are understudied in the context of war and conflict and trauma more generally (Gilfus, 1999). Concerning age, older children are more likely to have direct exposure to conflict related violence (Dimitry, 2012) but younger children may be more vulnerable to developing PTSD as they lack the cognitive capability to process trauma that older children have developed. Others have argued that younger children may actually be protected by their less developed cognitive capacity as they cannot fully comprehend the meaning and implications of war and conflict (Barenbaum, Ruchkin & Schwab-Stone, 2004). In recent years there has been a noticeable shift in attention to the influence of mediating variables (e.g., cultural context, family/community support and personal capacity) and the importance of these influences in reducing the impact of war or conflict (Tol, Reis, Susanty & de Jong, 2010; Tol, Song & Jordans, 2013). This understanding has informed preventative psychosocial interventions, which aim to strengthen and improve protective factors for children living in war affected societies in order to inoculate children against the harmful effects of exposure to war, conflict or political violence. Having fundamental (although possibly relative) elements included in a intervention such as promoting community, self-efficacy, a sense of hope, and feeling connected to a place may help reduce the negative effects of war (Betancourt, Borisova, et al., 2013; IASC, 2007). While PTSD is common in children exposed to war and conflict related violence, it is important to note that not all children exposed to trauma will go on to develop PTSD. Severe distress and fear is a normal reaction to trauma and there is substantial natural recovery in the initial months and years after a traumatic event (Bisson et al., 2010). For example Punamäki et al. (2014) showed that 12% of children aged 10–12 exposed to war in Gaza suffered relatively low amount of post-traumatic stress symptoms in the following year. A further 76% of children had initial high levels of symptoms but recovered within 11 months. A sizeable minority of 12% experienced initial severe levels of post-traumatic stress symptoms which increased over a year. It is important to recognise that immediate intervention may not be necessary, and in the case of critical incident stress debriefing (CISD) may in fact be harmful (NICE, 2013; Rose, Bisson, Churchill & Wessely, 2002). Providing an intervention too early may interfere with the natural recovery process. A Cochrane Review of 11 trials involving adults indicated that CISD should not be routinely implemented with victims of trauma (Rose et al., 2002). The current evidence base for the use of debriefing with children is low quality (Pfefferbaum, Jacobs, Nitiéma & Everly, 2015; Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015) and while there is no current evidence of harm there is little empirical support for its use (Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015). This raises important questions; when, if at all, should intervention be offered after a potentially traumatising event? How can we decide who does and does not need intervention to reduce the risk that PTSD will develop? Can at-risk children be identified, screened and offered appropriate interventions? This review focuses on psychosocial interventions that can be implemented with children following exposure to war and conflict-related violence and will only include early interventions that aim to prevent childhood PTSD. We define psychosocial intervention as any intervention that offers psychological or social support (or both) with a goal of helping to prevent mental disorders developing (in particular PTSD) and improve long-term mental health. Universal interventions are offered to everyone in a population, regardless of the level of their exposure to war or conflict related violence. Selective interventions are targeted at subpopulations who may be at a higher risk of developing mental disorders, for example, only those directly exposed to war and conflict related violence. Indicated interventions are aimed at those already displaying some symptoms of disorder and who may benefit from intervention to prevent PTSD developing. We intend to include all three levels of intervention in this review. The range of approaches that may be included in this review is broad. To illustrate the kinds of interventions that may be included we describe examples of potentially relevant interventions at each level. Psychological First Aid (PFA), currently recommended by humanitarian guidelines (Sphere Project, 2004) to reduce distress after a humanitarian disaster through providing practical help, linking to services to meet basic needs for food, shelter and safety, along with listening and providing care and comfort. A school based intervention that used mind-body techniques to reduce PTSS among children in Gaza (Staples, Gordon & Abdel Atti, 2011). A classroom-based intervention in Indonesia that focused on trauma processing and co-operative play to reduce post-traumatic stress symptoms and anxiety for children aged 8–12 affected by political violence (Tol, Komproe, Susanty, Jordans & De Jong, 2008). The interventions described above are not an exhaustive list and we will include any interventions that provide psychological and/or social support to children affected by war and conflict that aims to prevent PTSD developing. Interventions may be delivered as a one-off session, or over a number of weeks and they may be delivered by a trained professional or by a school-teacher. Interventions to prevent the development of PTSD may work on a number of levels, from directly addressing and processing trauma through to improving individual, family or community resiliency and reducing distress for example, Jordans et al. (2010) and Khamis, Macy, and Coignez (2004). We do not yet claim to know the full universe of interventions that have been tested in this area and so, what follows, is a summary of the known mechanisms through which these interventions typically aim to bring about positive change. One goal of this review will be to examine intervention components to try to identify which components relate to greater effects. By providing safe spaces for children to reduce the risk of further traumatisation and facilitate access to psychosocial support can reduce the risk of post-traumatic symptoms developing into PTSD. For example.'Child Friendly Spaces' (CFS), primary goal is to protect children from further harm and traumatisation by reducing their exposure to potentially traumatic events, including the victimisation and abuse that children are at high risk of in emergency humanitarian settings. Child Friendly Spaces gives children spaces where they can play safely, whilst also creating opportunities to access psychosocial support and screening (Ager, Metzler, Vojta & Savage, 2013). This focus on building community capacity through improved child protection to reduce risk of further trauma, and community level psycho-educational/awareness raising activities and events to help communities support traumatised children through greater understanding of normal reactions to trauma. Community level psychosocial interventions can encourage groups of participants to reflect on difficult times and aim to develop coping skills to allow them to face trauma-related experiences in a supportive social environment for example, Kumakech, Cantor-Graae, Maling, and Bajunirwe (2009). Peltonen and Palosaari (2013) connect the benefits of resiliency interventions on short-term impacts (e.g., reducing the likelihood of trauma-related symptoms) and long-term impacts (i.e., the child has a resource to draw upon for life), with improved relationships with their family and connectedness to their community. Community level interventions can also help to reduce stigma (Betancourt, Agnew-Blais, Gilman, Williams & Ellis, 2010). Many psychosocial support programmes include a community component in which children's engagement in their local community is thought to increase hope, social connectedness and prosocial behaviour, and to reduce externalising symptoms such as aggression by increasing awareness of, and attachment to, the wider social environment. Activities may include community events, volunteer work or public theatre (Constandinides, Kamens, Marshoud & Flefel, 2011). The literature suggests that, in order to be able to withstand the harmful effects of living in a conflict-affected society, it is vital for children to have loving, secure and consistent relationships with their caregivers (Betancourt, Borisova, et al., 2013; Qouta, Punamäki & El Sarraj, 2008; Thabet, Ibraheem, Shivram, Winter & Vostanis, 2009). Caregiver-focused support interventions aim to protect dependents from the adverse consequences of experiencing conflict-related harm by improving family structures, for example, improving the relationship between parent and child, increasing parental involvement and reducing the risk of parental stress (see Dybdahl, 2001). This may include improved parenting skills, improved attachment behaviours or parental psycho-education, all of which aim to assist parents in meeting the needs of their children and promoting their well-being. Psycho-education for example may work by helping parents to understand the symptoms of PTSD, how this may manifest in a child and how parents can best support their child after exposure to a traumatic event. Therapies based in groups, often within a psycho-educational or skills based therapeutic model, draw on an added mechanism of change by drawing on peer influence and support. Group settings are used to normalise experiences, to alleviate shame, to build cooperative behaviours and provide a forum to practice skills (Bolton et al., 2007). Classroom based interventions use much the same rationale, but with the addition of a real world setting to further normalise and integrate learning (Constandinides et al., 2011). These formats are also used given the larger number of beneficiaries that can be reached with few resources (O'Callaghan, McMullen, Shannon, Rafferty & Black, 2013). Interventions that use psycho-educational techniques endeavour to use education, information and insight to protect and promote well-being and to challenge misperceptions and taboos. Providing evidence-based information on traumatic reactions and living through the daily stressors of war is thought to help normalise experiences, to screen for more serious reactive disorders and encourage healthy and adaptive coping responses (Betancourt, Meyers-Ohki, et al., 2013). For example, Individual Psychological First Aid aims to strengthen mental health outcomes immediately after conflict by providing psycho-education on posttraumatic reactions and encouraging positive coping strategies in the immediate aftermath of the potentially traumatic events(s) (Betancourt, Meyers-Ohki, et al., 2013). Many psychosocial preventative interventions include teaching the ability to self-regulate emotions during or after a traumatic event occurring using, for example, breathing exercises, help seeking, social connectedness or positive self-talk. For example, Punamäki et al. (2014) evaluated the effectiveness of the psychosocial intervention 'Teaching Recovery Techniques' which is based on cognitive behavioural therapy (CBT) principles and provides several ways of increasing emotion regulation, expression and recognition. This in turn can help children to develop effective coping skills, to feel empowered and be able to regulate their emotions using narrative, imagery and psychoeducational techniques. Psychosocial preventative interventions that incorporate trauma processing techniques aim to facilitate the integration of traumatic memories into autobiographical memory in order to reduce PTSS and the risk of PTSD. Trauma processing is most commonly used to treat PTSD through narrative storytelling, such as in KidNET (Neuner et al., 2008) or imaginal and in vivo exposure to specific distressing, and often intrusive, memories, such as in Trauma-Focused CBT (TF-CBT; Brown et al., 2017). Some interventions have incorporated these techniques for children with PTSS as part of a wider aim of healing, through play and guided imagery (Peltonen & Punamäki, 2010), to help to integrate and assign meaning to traumatic experiences (Apfel & Simon, 1996) and for indicated secondary prevention interventions for children already displaying symptoms of PTSD (Tol et al., 2008). Some trauma focused interventions, usually derived from CBT, include the identification and evaluation of unhelpful thoughts and appraisals of traumatic experiences (such as self-blame) in order to help integrate fragmented and intrusive thoughts about traumatic experiences (Peltonen & Punamäki, 2010). Children living in areas of conflict are at elevated risk of negative mental, emotional and behavioural outcomes, including high rates of PTSS, PTSD and depression and anxiety problems (Attanayake et al., 2009; Dimitry, 2012). There are multiple studies on the immediate impact or war and conflict-related violence on children but few studies on the long-term impacts (Attanayake et al., 2009; Shaw, 2003), or on the impact psychosocial preventative interventions can have. Few reviews explicitly address the mechanisms of change (Betancourt, Borisova, et al., 2013; Brown et al., 2017; Peltonen & Punamäki, 2010). There is professional debate around which approach is most effective and least harmful to children living in war or conflict-affected societies, and whether only children with a diagnosed condition should be treated (Apfel & Simon, 1996; Betancourt, Borisova, et al., 2013). The inevitable fact of limited resources in these contexts may mean resources are directed to those who are perceived to be in most immediate need, at the expense of 'inoculating' all children from potential future problems. What is vital, as we have learned from the debriefing trials in adults, is that interventions should not be harmful or inadvertently disable adaptive responses to trauma. It is currently recommended that children exposed to war or conflict-related violence should not be given pharmacological intervention (IASC, 2007, 2014), so psychosocial interventions provide an important alternative response to try to prevent mental health problems developing. Not all children exposed to trauma will go on to develop PTSD but it is assumed what works for adults will work for children as well. However, there is no evidence to support this assumption and less still is known in what is effective to prevent PTSD for children aged under 11. Adults and adolescents can have broadly the same techniques applied in interventions but this does not apply so readily to children where there is a much larger gap and less clear guidance around what works. There is the potential for vast clinical relevance if we can understand more in this area, especially in the context of childhood PTSD and exposure to war and conflict-related violence. We don't yet know which children are most at risk of developing PTSD following trauma and which children are likely to recover without intervention. Nor do we know how best to screen for potential problems and who to offer intervention too as a result. One aim of this review will be to examine which children are most likely to benefit from intervention. There are a number of relevant existing reviews detailed below. Our review and existing/ongoing reviews differ in three ways. First we will not be limiting our inclusion criteria to studies conducted in low income countries. Second, we will not be limiting our review to randomised controlled trials. Finally, our review will focus on prevention of PTSD rather than treatment. Reviews which focus only on LMIC's (e.g., Purgato et al., 2014, 2015, 2016; Morina, Malek, Nickerson & Bryant, 2017; Brown et al, 2017) overlook interventions for trauma-exposed youth in high income countries (HIC), such as Northern Ireland, Cyprus and Israel. Reviews that only include RCTs (e.g., Purgato et al., 2014, 2015, 2016; Morina et al., 2017; O'Sullivan, Bosqui & Shannon, 2016; Brown et al., 2017) risk missing interventions developed and evaluated within the LMIC context. The well conducted trials tend to be based on interventions developed in the west and so by including only RCTs 'home grown' interventions may be excluded. This means they may not capture the interventions being delivered in the challenging context of ongoing conflict and violence with limited resources which precludes the use of RCT designs, for example studies like (Ager et al. (2011), Jordans, Tol, Ndayisaba, and Komproe (2013), Loughry et al. (2006); Thabet, Vostanis, and As our review is focused on prevention of PTSD rather than have been evaluated by existing reviews et al., 2015; Morina et al., 2017). reviews have narrative of existing interventions but have been limited in their & 2013; Betancourt, Borisova, et al., 2013; et al., 2013; Jordans et al., 2009; Jordans, & Tol, 2016; Peltonen & Punamäki, 2010), not focus on children in or conflict-affected settings et al., 2013; & 2010; & & or were not systematic reviews & 2010; & 2006). affected by war and may not have the resources or be in the to offer the and secure environment to the level of in an For these we intend to include controlled studies and studies to allow for the of including more and context specific interventions developed within whilst not from our review. the number and of ongoing and the of children affected by war and conflict related violence, this review is likely to be to and around the world and in conflict affected countries. To the effectiveness of psychosocial interventions for PTSD in young children aged years living in war and conflict-affected controlled trials and participants are to groups using a such as of or controlled studies with that studies in which have participants (or to intervention or we be We will not include studies with case studies, studies or case Children aged from to 11 years who have been exposed to war and conflict-related violence. including children older than 11 years can be included providing that the mean age of participants is under In the case of studies where the mean age of participants is older than will be to summary to effect for children under We are in that population which does not have a of PTSD. As PTSD is the most commonly diagnosed mental health condition we are in interventions which aim to protect and support young people from developing this disorder, rather than those which are as to those with a of PTSD. we will studies children who have a of PTSD. In studies with a population with and without or where PTSD not as we will include studies where the of participants have not been identified as meeting the criteria for PTSD and where it is clear that the intervention is aimed at PTSD developing into a We will also children who are or they are or to that affected by war and conflict-related violence. This is because we feel children and will have issues to stressors and we to focus on interventions for children who are still living in conflict settings or living with the aftermath of psychosocial intervention that has an of PTSD or reducing PTSS and is delivered in any conflict-affected setting (e.g., or to children or their compared with no as or any We define psychosocial interventions in this as any intervention that offers psychological or social support (or both) with a goal of helping to prevent mental disorders developing (in particular PTSD) and improve long-term mental health. Interventions aimed at children affected by one-off of (e.g., or a natural disaster will be as this population in not living under of violence, war or We will studies that include children with a of PTSD. We will also interventions whose focus is to treat PTSD rather than prevent Interventions which were to treat (e.g., may be included so as the intervention is being used to prevent PTSD and/or reduce We will only their specific or stress reactions and post-traumatic stress of include the Child & the Child Trauma and the for Children 2006). for example to future of for example or of include the et al., the or the for Children & 2012). relationships for example family peer relationships and attachment of include the & Cole, 1996) which children's attachment to symptoms as a potential traumatic reaction for example depression and specific example is the for Child et al., 1999). symptoms as a potential traumatic reaction for example behaviour and specific include the Child and the and and the Psychological Betancourt, and 2014). will use those outcomes with an to the of are we will provide a narrative of the We will include all in included For will be into categories of immediate and than months We will include any psychosocial intervention that has an of reducing PTSS or PTSD and is delivered in any setting (e.g., or to children or their The developed by the from relevant reviews and the from a of relevant trials. The were into those to the setting and intervention. for in the in and a list of potentially relevant Review each list and added any missing and The tested to that studies already identified were The for participants setting political and intervention We will use the in A to and for the below. possible specific will be applied (e.g., the use of age to the number of We will the following and we will not apply any or Cochrane of part of The Cochrane which the of the Cochrane Psychosocial and on all to to to including and to to of

Distressing and intrusive reexperiencing of the trauma is a hallmark symptom of posttraumatic stress disorder (PTSD; American Psychiatric Association, 1994). However, unwanted memories of trauma are not a sign of pathology per se. In the initial weeks after a traumatic experience, intrusive memories are common. For most trauma survivors, intrusions become less frequent and distressing over time. A central question for understanding and treating patients with PTSD is therefore what maintains distressing intrusive reexperiencing in these people. Three factors appear to be important: (1) memory processes responsible for the easy triggering of intrusive memories, (2) the individuals’ interpretations of their trauma memories, and (3) their cognitive and behavioral responses to trauma memories.

Supporting Evidence from the DSM and ICD Classifications to Better Understand Traumatic Experiences, PTSD in Law

Background: The perinatal period is an exceptionally vulnerable time to experience posttraumatic stress disorder (PTSD). PTSD is a psychiatric disorder that occurs after experiencing at least one traumatic event and is characterized by intrusive thoughts, avoidance of trauma-related stimuli, negative changes in mood and cognition, and heightened physiological arousal. Pregnancy, labor and delivery, and entry into the postpartum period can be extremely stressful or retraumatizing for individuals with past trauma histories. This is especially true for individuals with a prior reproductive or interpersonal trauma history. Additionally, the perinatal period is ripe for experiencing new traumatic experiences, such as intimate partner violence, life-threatening pregnancy complications, or traumatic birth experiences. Thus, identifying individuals who experience perinatal PTSD and helping them to engage in treatment if desired is essential. Objective: Our team introduced screening for trauma exposure and accompanying PTSD symptoms at three clinics across the state of Indiana to better understand perinatal PTSD and increase implementation of treatment efforts. Method: A brief PTSD screen was implemented in both urban and rural settings utilizing the PC-PTSD-5 (a 5-item screen) or the PCL-6 (a 6-item screen). The clinics included Eskenazi Health, IU School of Medicine (IUSM) Coleman Center, and the Logansport Memorial Hospital Women’s Health Center. Eskenazi Health is a safety net healthcare system in Indianapolis, serving primarily racial and ethnic minority patients who have public insurance. Eskenazi Health recruitment took place at the weekly high-risk obstetrics clinic. The IUSM Coleman Center is a high-volume clinic that primarily serves low-risk patients. The Logansport Memorial Hospital Women’s Health Center is our rural community partner who is located in one of the most disadvantaged census tracts in the state (9th decile) and nation (92nd percentile). At all locations, a team member distributed a screening packet to all English-speaking pregnant adults to assess trauma exposure and PTSD symptoms, often alongside other mental health screening measures. Patients provided contact information if they were interested in hearing more about clinical research interventions aimed at reducing PTSD symptoms. Interested participants were then contacted by IUSM team members to complete the eligibility screening for intervention studies. Results: At Eskenazi Health, 91 patients were screened. There were 19 patients (20.8%) that scored above clinical threshold for probable PTSD (≥14 on the PCL-6). There were 27 patients (26.9%) that provided their contact information to hear more about our programs aimed at the reduction of PTSD symptoms. At Logansport, 334 patients were screened. Over half endorsed trauma exposure (53.3%, n=178). About 1 in 4 trauma-exposed patients (25.9%, n = 46) scored above clinical threshold for probable PTSD (≥3 on the PC-PTSD-5). There were 94 patients (28.1%) that provided their contact information to hear more about our programs. At the IUSM Coleman Center, there were 24 patients screened. There were 7 patients (29.2%) that endorsed trauma exposure with 2 trauma-exposed patients (26.9%) that scored above clinical threshold (≥3 on the PC-PTSD-5). Only 1 patient left their contact information to hear more about our programs. For rural patients, the most endorsed PTSD symptom type among trauma-exposed women was internal and external avoidance of trauma-related stimuli (n=52, 29.2%). For urban patients, the most commonly endorsed PTSD symptom type was intrusive symptoms (e.g., nightmares, intrusive memories; n=47, 29.1%). Conclusions: Results from screening at three obstetric clinics suggest that trauma exposure and accompanying PTSD symptoms are common in low- and high-risk prenatal women in urban and rural settings. There is a strong association between perinatal PTSD symptoms and the worst perinatal health outcomes, including pre-eclampsia, gestational diabetes, preterm birth, and increased likelihood of maternal and infant mortality. However, rates of engagement from screening alone were very low, suggesting selective screening for perinatal PTSD may not be sufficient. Future research needs to investigate how to implement: 1) universal screening of prenatal patients for trauma exposure and PTSD symptoms to normalize and incorporate discussion into prenatal care; 2) trauma-informed, stepped care models with a range of disciplines and provider types to help manage PTSD symptoms that arise during pregnancy; and 3) increased patient engagement in brief promising treatment interventions that address perinatal PTSD (Narrative Exposure Therapy (NET), Written Exposure Therapy (WET)).

Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care

OBJECTIVE: In this present study, we aimed to examine the relationship between particular traumatic past experiences and clinical features of post-traumatic stress disorder (PTSD) in an outpatient sample from Turkey. Overt or unknown childhood traumas were also examined as a robust risk factor that might affect the development of PTSD in this population. METHODS: The sample of this study was composed of 100 female patients with a history of traumatic experiences and with a documented psychiatric diagnosis except PTSD who were admitted to Health Sciences University’s Bagcilar Training and Research Hospital Outpatient Clinic. Semi-structured sociodemographic data form, Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician-Administered Posttraumatic Disorder Scale (CAPS) and Childhood Trauma Questionnaire (CTQ-28) were administered. Semi-structured sociodemographic form, were applied to the participants. Following clinical interviews and CAPS application, the patients were divided into two subgroups as patients with or without the diagnosis of current PTSD. Following screening of all variables for the accuracy of data entry, missing values, and homoscedasticity, statistical analyses were performed by using SPSS version 23 for Windows. RESULTS: The CTQ total scores (U = 233.000, z = −6.856, p = 0.000) and also Emotional Abuse (U = 235.000, z = −6.941, p = 0.000), Physical Abuse (U = 185.000, z = −7.424, p = 0.000), Emotional Neglect (U = 244.000, z = −6.851, p = 0.000), Physical Neglect (U = 208.000, z = −7.276, p = 0.000) and Sexual Abuse (U = 266.000, z = −7.554 p = 0.000) subscale scores were significantly higher in the PTSD present group. A statistically significant association was found between CAPS Total scores and Emotional Abuse (r = 0.870, p < 0.01), Physical Abuse (r = 0.879, p < 0.01), Emotional Neglect (r = 0.862, p < 0.01), Physical Neglect (r = 0.884, p < 0.01) and Sexual Abuse (r = 0.886, p < 0.01) subscale scores, and CTQ Total (r = 0.906, p < 0.01) scores. The regression analysis has indicated that CTQ Sexual Abuse scores were significant predictors of CAPS Total scores (p = 0.00) in patients with traumatic experiences when age was controlled. CONCLUSIONS: In addition to the sociodemographic risk factors, traumatic experiences of childhood are important risk factors for PTSD. Man-made traumas such as rape, assault have a higher risk and symptom severity than natural disasters and traffic accidents for PTSD. Our results suggested a strong association between childhood sexual trauma and post-traumatic stress disorder. © 2018, © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Co-morbid post-traumatic stress disorder in a substance misusing clinical population

Posttraumatic stress disorder (PTSD) is prevalent among adolescents following natural disasters, and the trauma experiences represent a critical risk factor for PTSD. Nevertheless, the underlying mechanism of adolescents’ PTSD following trauma experiences remains unclear. Rumination appears to be a mediating factor between trauma experiences and PTSD, and social support may moderate this mediating relationship between trauma experiences, rumination, and PTSD, but few studies have examined these assumptions. Thus, this study aimed to assess the mediating role of rumination and the moderating role of social support in the relationship between rainstorm-related experiences and PTSD among adolescents, following a rainstorm in China. Nine hundred and fifty-one middle school students completed self-report questionnaires, and structural equation modeling was conducted to examine the potential moderated mediation effect. Rainstorm-related experiences had a direct and positive effect on PTSD, and also indirectly influenced PTSD via rumination. Moreover, social support work to buffer the direct effect of rainstorm-related experiences on PTSD, but not the effect of rumination on PTSD. Implications for clinical practice and research are discussed along with study limitations.

It is known that the brains of animals and humans is active at resting state. In this paper we investigate how past experience affects characteristics of such resting state networks in animals. To do this we subjected mice to single traumatic experience that induced posttraumatic stress disorder (PTSD) and then analyzed activity of their brain (including cortex; hippocampus; amygdala; basal ganglia; thalamus; hypothalamus and midbrain) by c‐Fos cellular mapping during traumatic memory retrieval and at rest in comparison with non‐stressed animals.PTSD development led to global changes in brain activity: number of c‐Fos‐active neurons was significantly increased in different areas during traumatic memory retrieval. Similarly, at rest PTSD animals showed increased activity in 11 brain regions participating in fear memory.We identified resting state functional connections in PTSD and controls and compared them with model networks: random, scale‐free and small‐world. In both groups of mice clusterization exceeded random level. At the same time, these clusters did not interact well with each other: global efficiency of experimental networks was at the level of random network. Resting state networks of PTSD and control mice differed (Fig. 1): PTSD network was less clustered and longer paths linked the clusters. Induction of PTSD led to global changes in the structure of resting state networks. In naive animals, cortical regions had the most connections, whereas in PTSD thalamus, striatum and amygdala had. PTSD destroyed virtually all functional connections present in naive mice; only fully connected cluster of auditory and visual cortices remained. In addition, if in naive animals the main hubs were cingulate and retrosplenial cortices in PTSD animals paraventricular thalamic nucleus became the hub. In contrast, amygdala functional connectivity was virtually zero in naive animals, whereas in PTSD significant number of connections between amygdala, associative cortices, and striatum were observed.In addition, we have shown that PTSD induction changes spontaneous behavior, causing elevated anxiety and decreased research activity in safe conditions of home cages. Behavior in conditioned fear, EPM and sensitization tests also changed, and these changes could be disrupted by protein synthesis inhibition during traumatic experience, which also returned brain activity and structure of resting networks to normal in PTSD animals.Our findings show that stressful experiences can alter spontaneous behavior, induced and spontaneous brain activity and patterns of functional connections in resting state neuronal networks long after traumatic episode. We assume that these changes reflect replay of neuronal ensembles of the animal’s past subjective experience. This assumption was tested by disrupting the development of PTSD.Support or Funding InformationSupported by RSF 16‐15‐00300, 20‐15‐00187 and RFBR 19‐015‐00534, 20‐015‐00427.Resting state networks of naive mice (A, D) and PTSD animals (B, E), and their interception (C, F). A, B and C are for complete resting state networks, and D, E and À represents only connections of 11 brain areas that significantly change their activity in PTSD compared to naïve mice. Lines are Pearson’s correlations with R>0.5, p<0.05; green lines – naive resting state network; red lines – PTSD resting state network; blue lines – correlations that are present in naive and PTSD mice.Figure 1