Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm

The authors' goal was to determine the levels of trauma and psychiatric symptoms in a randomly selected group of Cambodian refugees and to determine the relationship between the amount of trauma experienced and subsequent psychiatric symptoms. Data on traumatic experiences and symptoms of posttraumatic stress, dissociation, depression, and anxiety were collected on 50 randomly selected Cambodian refugees who had resettled in the United States. Subjects experienced multiple and severe traumas and showed high levels of all symptoms measured. Forty-three (86%) of the subjects met DSM-III-R criteria for posttraumatic stress disorder, 48 (96%) had high dissociation scores, and 40 (80%) could be classified as suffering from clinical depression. Correlations between trauma scores and symptom scores and among symptom scores were moderate to large. These results indicate that a high proportion of Cambodian refugees who are not psychiatric patients suffer from severe psychiatric symptoms and that there is a relationship between the amount of trauma they experienced and the severity of these symptoms.

The authors compared the hypnotizability of 65 Vietnam veteran patients with posttraumatic stress disorder (PTSD) to that of a normal control group and four patient samples using the Hypnotic Induction Profile. The patients with PTSD had significantly higher hypnotizability scores than patients with diagnoses of schizophrenia (N = 23); major depression, bipolar disorder--depressed, and dysthymic disorder (N = 56); and generalized anxiety disorder (N = 18) and the control sample (N = 83). This finding supports the hypothesis that dissociative phenomena are mobilized as defenses both during and after traumatic experiences. The literature suggests that spontaneous dissociation, imagery, and hypnotizability are important components of PTSD symptoms.

Recent research has differentiated several distinct classes of self-destructive behavior. This paper describes the clinical characteristics of one class, the deliberate self-harm syndrome. Analysis of 56 published case reports of self-harm revealed a typical pattern of onset in late adolescence, multiple recurrent episodes, low lethality, harm deliberately inflicted upon the body, and extension of the behavior over many years. Since the clinical characteristics of the deliberate self-harm syndrome differ substantially from those of other classes of self-destructive behavior, the authors propose that DSM-IV classify deliberate self-harm as a separate diagnostic syndrome.

The author develops a nosologic framework for understanding the psychopathology of low-grade chronic depressions: 1) late-onset primary depressions with residual chronicity, 2) chronic secondary dysphorias, having a variable onset age and considered part of the symptomatic picture of nonaffective "neurotic" disorders or reactions to longstanding incapacitating medical diseases, and 3) early-onset characterologic depressions, which include a) character-spectrum disorders developing in the setting of tempestuous early object relationships and b) subaffective dysthymic disorders, conceptualized as genetically attenuated forms of primary affective illnesses. Differences in family history, REM latency, and pharmacologic responsiveness are presented in support of these distinctions. The author also proposes operational criteria to identify a thymoleptic-responsive subaffective dysthymic group.

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The authors gave the CES-D, a self-report depression symptom scale, to 515 people drawn from a longitudinal community survey. The subjects were also interviewed using the Schedule for Affective Disorders and Schizophrenia (SADS). From the information collected on the SADS, the subjects were given diagnoses based on Research Diagnostic Criteria. The results indicate a modest relationship between self-reported symptoms of depression and the diagnosis of a major or minor depression. However, the groups defined as "cases" by such reports also include many people with other diagnoses or with no diagnoses at all. Thus, symptom scales are useful for the screening of depressed persons in research studies but are only rough indicators of clinical depression in the community.

The authors suggest that the activity of neurotransmitter systems in the affective disorders and related psychiatric syndromes may be better understood as a reflection of a relative failure in their regulation, rather than as simple increases or decreases in their activity. A model organized around the concept of "dysregulation" posits that persistent impairment in one or more neurotransmitter homeostatic regulatory mechanisms confers a trait vulnerability to unstable or erratic neurotransmitter output. Evidence from clinical and animal model studies for dysregulation of the noradrenergic system in depression is examined with respect to criteria generated by such a general model, and a specific configuration of noradrenergic dysregulation in some forms of depression is proposed.

A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Following the 1980 Mount St. Helens volcanic eruption, psychiatric reactions were studied in the disaster area and in a control community. Using the new criterion-based diagnostic method for psychiatric epidemiologic research, the Diagnostic Interview Schedule, the authors found a significant prevalence of disaster-related psychiatric disorders. These Mount St. Helens disorders included depression, generalized anxiety, and posttraumatic stress reaction. There was a progressive "dose-response" relationship in the comparison of control, low-exposure, and high-exposure groups. The dose-response pattern occurred among both the bereaved and the property-loss victims.

A major problem for the practitioner is the lack of satisfactory guidelines as to how long continuation drug treatment of depressive episodes must be maintained to ensure that the episode is over. This often leads to either premature withdrawal of the drug and subsequent relapse or unnecessarily prolonged treatment. Results from a collaborative project of the National Institute of Mental Health provide the first study-derived guidelines on the length of continuation therapy. Findings indicate that withdrawal of such therapy is safe only after the patient has been free of significant symptoms for 16 to 20 weeks and that focusing on mild as well as severe symptoms is critical in this decision.

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

The authors investigated the pharmacological treatment of delusional depression by assigning patients on a random double-blind basis to amitriptyline alone, perphenazine alone, or a combination of the two. Fourteen (78%) of the 18 patients assigned to amitriptyline plus perphenazine were responders, compared with seven (41%) of 17 patients treated with amitriptyline alone and three (19%) of the 16 patients treated with perphenazine alone. The combination of amitriptyline and perphenazine was clearly superior (p less than .01).

In an earlier, separate study, the authors found that human aggression and suicide (a specific aggression-related behavior) were associated with lower levels of CSF 5-hydroxyindoleacetic acid (5-HIAA), a serotonin metabolite. That study focused on subjects with personality disorders without affective illness. In the present study they examine the life history of aggression and history of suicidal behavior in 12 subjects with borderline personality disorders without major affective disorder. Histories of aggressive behaviors and of suicide attempts were significantly associated with each other, and each was significantly associated with lower 5-HIAA levels. Altered serotonin metabolism may be a highly significant contributing factor to these behaviors in whatever diagnostic group they occur.

The authors examined the effects of wartime stressors in a sample of 69 Vietnam veterans who were psychiatric inpatients in a Veterans Administration hospital. Participation in atrocities and the cumulative exposure to combat stressors, each independently of the other, conferred a significant risk for posttraumatic stress disorder. In contrast, the effect of these war experiences on the onset of panic, major depression, and mania was not significant. The results indicate that extreme stressors are uniquely linked with posttraumatic stress disorder's characteristic cluster of symptoms but challenge DSM-III's implicit assumption that the reexperienced trauma is the stressor responsible for posttraumatic stress disorder.

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