Chronic Posttraumatic Stress Disorder Research Articles

Medical Cannabinoid Products in Children and Adolescents.

1. Kathleen K. Miller, MD* 2. Jonathan D. Klein, MD, MPH† 1. *Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, Minneapolis, MN 2. †University of Illinois at Chicago, Chicago, IL Cannabinoid-containing products have become increasingly ubiquitous worldwide, both through legalization of recreational marijuana and widespread use of cannabinoid derivatives in medical products. In the United States, the Centers for Disease Control and Prevention (CDC) reported that more than 1 in 3 adolescents said they have tried recreational marijuana in 2017. Pediatricians should be aware of the limitations of cannabinoids as medical treatments, and should knowledgeably counsel patients about their potential risks and benefits. Cannabinoids are derived from the cannabis plant, which contains a variety of metabolically active compounds, of which the most well-known are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is derived primarily from marijuana plants, and CBD primarily from hemp plants. THC is the primary psychoactive ingredient in marijuana and is responsible for the “high” associated with marijuana use. CBD, conversely, does not have psychoactive effects. In recent years, CBD has experienced a surge in popularity as an alternative treatment for a variety of ailments. Manufacturers have claimed that it has anxiolytic and anticonvulsant properties and that it can treat chronic pain, insomnia, and posttraumatic stress disorder. Recreational marijuana and plant derivatives of cannabis that can be smoked or ingested in edible forms contain THC in addition to other, less psychoactive cannabis-derived compounds. Only one cannabinoid derivative is Food and Drug Administration (FDA)–approved for use in children: dronabinol is approved for the treatment of nausea and vomiting induced by chemotherapy. Synthetic cannabinoids, also known as spice or K2, have neither therapeutic properties nor medical …

Case Series: Unilateral Amygdala Ablation Ameliorates Post-Traumatic Stress Disorder Symptoms and Biomarkers

Background Post-traumatic stress disorder is a severe psychobiological disorder associated with hyperactivity of the amygdala, particularly on the right side. Highly selective laser ablation of the amygdalohippocampal complex is an effective neurosurgical treatment for medically refractory medial temporal lobe epilepsy that minimizes neurocognitive deficits relative to traditional open surgery. Objective To examine the impact of amygdalohippocampotomy upon symptoms and biomarkers of post-traumatic stress disorder. Methods Two patients with well-documented chronic post-traumatic stress disorder who subsequently developed late-onset epilepsy underwent unilateral laser amygdalohippocampotomy. Prospective clinical and neuropsychological measurements were collected in patient 1. Additional prospective measurements of symptoms and biomarkers were collected pre- and post-surgery in patient 2. Results After laser ablation targeting the nondominant (right) amygdala, both patients experienced not only reduced seizures, but also profoundly abated post-traumatic stress symptoms. Prospective evaluation of biomarkers in patient 2 showed robust improvements in hyperarousal symptoms, fear potentiation of the startle reflex, brain functional magnetic resonance imaging responses to fear-inducing stimuli, and emotional declarative memory. Conclusion These observations support the emerging hypothesis that the right amygdala particularly perpetuates the signs and symptoms of post-traumatic stress disorder and suggests that focal unilateral amydalohippocampotomy can provide therapeutic benefit.

Posttraumatic stress disorder in urban women.

To provide an update of recent or relevant studies on posttraumatic stress disorder (PTSD) in urban women, with a special focus on biopsychosocial risk factors. Urbanization itself can increase the risk for PTSD due to the concentration of poverty, substance use and crime. Women are usually at a greater social and economic disadvantage and are victims of collective and domestic violence more often than men. Accordingly, urban women are more exposed to traumatic events that increase the prevalence of PTSD than rural women and both rural and urban men, especially those with lack of social and family protection and support (including refugees) and/or with a history of interpersonal violence. This type of events has sensitizing effects on the PTSD response to other traumatic experiences even if they are of a lesser magnitude, which may reflect women's biological susceptibility to PTSD, and could explain their higher risk of developing chronic PTSD. A complex interaction of biopsychological factors may contribute to the ultra-high-risk for PTSD among urban women. The socially modifiable factors involved highlight the importance of strategies focused on women's social development that could reduce their social suffering and its negative mental health outcomes.

PTSD as the second tsunami of the SARS-Cov-2 pandemic.

Since the first cases, the coronavirus disease (COVID-19) rapidly spread around the world, with hundred-thousand cases and thousands of deaths. Post-traumatic stress disorder (PTSD) is a common consequence of major disasters. Exceptional epidemic situations also promoted PTSD in the past. Considering that humanity is undergoing the most severe pandemic since Spanish Influenza, the actual pandemic of COVID-19 is very likely to promote PTSD. Moreover, COVID-19 was renamed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). With a poor understanding of viruses and spreading mechanisms, the evocation of SARS is generating a great anxiety contributing to promote PTSD. Quarantine of infected patients evolved to quarantine of 'infected' towns or popular districts, and then of entire countries. In the families of cases, the brutal death of family members involved a spread of fear and a loss of certainty, promoting PTSD. In the context of disaster medicine with a lack of human and technical resources, healthcare workers could also develop acute stress disorders, potentially degenerating into chronic PTSD. Globally, WHO estimates 30-50% of the population affected by a disaster suffered from diverse psychological distress. PTSD individuals are more at-risk of suicidal ideation, suicide attempt, and deaths by suicide - considering that healthcare workers are already at-risk occupations. We draw attention towards PTSD as a secondary effect of the SARS-Cov-2 pandemic, both for general population, patients, and healthcare workers. Healthcare policies need to take into account preventive strategy of PTSD, and the related risk of suicide, in forthcoming months.

Abnormal REM Sleep Atonia Control in Patients With Chronic Post-Traumatic Stress Disorder (1607)

Abnormal REM Sleep Atonia Control in Patients With Chronic Post-Traumatic Stress Disorder (1607)

Prevalence and Influencing Factors of Post-Traumatic Stress Disorder Among Survivors in the Hard-Hit Areas Ten Years After the Wenchuan Earthquake: A Cross-Sectional Study.

BackgroundPost-traumatic stress disorder (PTSD) is common psychological distress after natural disasters, which is persistent. Chronic PTSD leads to a heavy disease burden. The purpose of this study is to explore the prevalence and influencing factors of chronic PTSD among survivors in the hard-hit areas ten years after the Wenchuan earthquake.Materials and MethodsA cross-sectional survey was conducted on residents aged 16 or above in hard-hit areas through a multi-stage sampling approach ten years after the Wenchuan earthquake. The items of the questionnaire included demographic characteristics and earthquake exposure factors, and the PTSD Checklist-Civilian Version (PCL-C) was used to evaluate the PTSD of the respondents.ResultsA total of 1039 complete questionnaires were obtained. The median age of 1039 respondents was 60 years, 63.2% of whom were female, 70.2% were illiterate or had received primary education, and 58% had an annual household income of less than 20,000 yuan (US$ 2871.3). The rate of PTSD was 9.1% (95/1039). After controlling for confounding factors, it was found that higher income level and education level, and moving to concentrated rural settlement (CRS) after the earthquake might be protective factors for the long-term mental health of survivors in the hard-hit areas, and the loss of immediate families in the earthquake was an important risk factor.ConclusionEven though ten years have passed since the Wenchuan earthquake, the survivors in the hard-hit areas still have a serious mental disorder. The local government and health-care institutions should take appropriate measures to improve the mental health of residents.

Amygdala functional connectivity in the acute aftermath of trauma prospectively predicts severity of posttraumatic stress symptoms

Understanding neural mechanisms that confer risk for posttraumatic stress disorder (PTSD) is critical for earlier intervention, yet longitudinal work has been sparse. The amygdala is part of a core network consistently implicated in PTSD symptomology. Most neural models of PTSD have focused on the amygdala's interactions with the dorsal anterior cingulate cortex, ventromedial prefrontal cortex, and hippocampus. However, an increasing number of studies have linked PTSD symptoms to aberrations in amygdala functional connections with other brain regions involved in emotional information processing, self-referential processing, somatosensory processing, visual processing, and motor control. In the current study, trauma-exposed individuals (N = 54) recruited from the emergency department completed a resting state fMRI scan as well as a script-driven trauma recall fMRI task scan two-weeks post-trauma along with demographic, PTSD, and other clinical symptom questionnaires two-weeks and six-months post-trauma. We examined whether amygdala-whole brain functional connectivity (FC) during rest and task could predict six-month post-trauma PTSD symptoms. More negative amygdala-cerebellum and amygdala-postcentral gyrus FC during rest as well as more negative amygdala-postcentral gyrus and amygdala-midcingulate cortex during recall of the trauma memory predicted six-month post-trauma PTSD after controlling for scanner type. Follow-up multiple regression sensitivity analyses controlling for several other relevant predictors of PTSD symptoms, revealed that amygdala-cerebellum FC during rest and amygdala-postcentral gyrus FC during trauma recall were particularly robust predictors of six-month PTSD symptoms. The results extend cross-sectional studies implicating abnormal FC of the amygdala with other brain regions involved in somatosensory processing, motor control, and emotional information processing in PTSD, to the prospective prediction of risk for chronic PTSD. This work may contribute to earlier identification of at-risk individuals and elucidate potential intervention targets.

Post-Traumatic Stress Disorder Symptoms from Multiple Stressors Predict Chronic Pain in Cancer Survivors.

Background: Despite the association between chronic pain and post-traumatic stress disorder (PTSD), little is known about the longitudinal course of pain and PTSD during cancer treatment. Objectives: We examined the prevalence of PTSD and chronic pain at three time periods in veterans with a diagnosis of cancer, and the relationship between the experience of pain and PTSD. Methods: Participants (N = 123) with oral-digestive cancers were recruited from the Veterans Healthcare System (age M = 65.31 and SD = 9.13; 98.4% male) and completed face to face interviews at 6, 12, and 18 months post-diagnosis. Measures included the Post-traumatic Stress Disorder Checklist-Stressor-Specific version (PCL-S), Primary care PTSD (PC-PTSD), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Impact Scale. Results: About one-third (26.8%) of the sample had chronic pain, defined as elevated pain at two time periods. About one-fifth (20.3%) endorsed symptoms of combat-related PTSD at 6 months, and 22.8% endorsed symptoms of cancer-related PTSD, exceeding a clinical cutoff for older adults (12 months = 21.1%, 18 months = 23.1%). Changes over time were observed for cancer-related PTSD symptom clusters of hyperarousal (F = 3.85 and p = 0.023) and emotional numbing (F = 4.06 and p = 0.018) with a statistically significant quadratic function increasing at 18 months. In logistic regression, individuals with both combat and cancer-related PTSD symptoms at six months had 8.49 times higher odds of experiencing chronic pain (χ2 = 25.91 and p < 0.001; R2 = 0.28). Conclusions: Persisting pain may be a concern in veterans with cancer. Individuals who have experienced traumatic events with persisting PTSD symptoms may be at elevated risk for chronic pain. Veterans with PTSD symptoms from both cancer and combat are at the highest risk to experience chronic pain.

Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis.

Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010-2013 (n=381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91days) during the first-year postinjury. During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24-34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.

Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results.

To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone. Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial. Six Veterans Health Affairs clinics. Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain. Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain-PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist-Civilian score ≥41 at baseline. T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant. Veterans with the pain-PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.

Dynamic interplay between PTSD symptoms and posttraumatic growth in older military veterans

BackgroundPosttraumatic growth (PTG) refers to positive psychological changes that may occur after experiencing a traumatic event. While cross-sectional studies have suggested that posttraumatic stress disorder (PTSD) is associated with greater PTG, few longitudinal studies have evaluated interrelationships between PTSD and PTG. Further, little is known about which specific symptom clusters of PTSD and coping mechanisms may drive PTG over time. MethodsWe evaluated interrelationships between PTSD symptoms and PTG using data from a 4-year, nationally representative, prospective cohort study of 2,006 older trauma-exposed U.S. veterans. ResultsAutoregressive cross-lagged panel regression analyses revealed that greater severity of PTSD symptoms was associated with greater PTG over time. Specifically, greater severity of the avoidance and anxious arousal (e.g., hypervigilance) symptoms at Wave 1 predicted greater PTG at Wave 2; and greater severity of avoidance and lower severity of dysphoric arousal (e.g., sleep disturbance) at Wave 2 predicted greater PTG at Wave 3. Engagement in active coping and religious coping were associated with greater subsequent PTG above and beyond autoregressive associations between PTSD and PTG. LimitationsThe self-report nature of the assessments, discrete assessment periods assessed, and focus on older military veterans are study limitations. ConclusionsGreater severity of PTSD symptoms, particularly avoidance and hyperarousal symptoms, may contribute to and maintain PTG over time in older veterans. Interventions that promote deliberate, constructive attempts to manage chronic PTSD symptoms via active coping and religious coping may help veterans better manage PTSD symptoms and experience greater PTG in late-life.

Evaluating a screener to quantify PTSD risk using emergency care information: a proof of concept study

BackgroundPrevious work has indicated that post-traumatic stress disorder (PTSD) symptoms, measured by the Clinician-Administered PTSD Scale (CAPS) within 60 days of trauma exposure, can reliably produce likelihood estimates of chronic PTSD among trauma survivors admitted to acute care centers. Administering the CAPS is burdensome, requires skilled professionals, and relies on symptoms that are not fully expressed upon acute care admission. Predicting chronic PTSD from peritraumatic responses, which are obtainable upon acute care admission, has yielded conflicting results, hence the rationale for a stepwise screening-and-prediction practice. This work explores the ability of peritraumatic responses to produce risk likelihood estimates of early CAPS-based PTSD symptoms indicative of chronic PTSD risk. It specifically evaluates the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) as a risk-likelihood estimator.MethodsWe used individual participant data (IPD) from five acute care studies that used both the PDEQ and the CAPS (n = 647). Logistic regression calculated the probability of having CAPS scores ≥ 40 between 30 and 60 days after trauma exposure across the range of initial PDEQ scores, and evaluated the added contribution of age, sex, trauma type, and prior trauma exposure. Brier scores, area under the receiver-operating characteristic curve (AUC), and the mean slope of the calibration line evaluated the accuracy and precision of the predicted probabilities.ResultsTwenty percent of the sample had CAPS ≥ 40. PDEQ severity significantly predicted having CAPS ≥ 40 symptoms (p < 0.001). Incremental PDEQ scores produced a reliable estimator of CAPS ≥ 40 likelihood. An individual risk estimation tool incorporating PDEQ and other significant risk indicators is provided.ConclusionPeritraumatic reactions, measured here by the PDEQ, can reliably quantify the likelihood of acute PTSD symptoms predictive of chronic PTSD and requiring clinical attention. Using them as a screener in a stepwise chronic PTSD prediction strategy may reduce the burden of later CAPS-based assessments. Other peritraumatic metrics may perform similarly and their use requires similar validation.Trial registrationJerusalem Trauma Outreach and Prevention Study (J-TOPS): NCT00146900.

Multivariate classification of earthquake survivors with post-traumatic stress disorder based on large-scale brain networks.

The identification of post-traumatic stress disorder (PTSD) among natural disaster survivors is remarkably challenging, and there are no reliable objective signatures that can be used to assist clinical diagnosis and optimize treatment. The current study aimed to establish a neurobiological signature of PTSD from the connectivity of large-scale brain networks and clarify the brain network mechanisms of PTSD. We examined fifty-seven unmedicated survivors with chronic PTSD and 59 matched trauma-exposed healthy controls (TEHCs) using resting-state functional magnetic resonance imaging (rs-fMRI). We extracted the node-to-network connectivity and obtained a feature vector with a dimensionality of 864 (108 nodes×8 networks) to represent each subject's functional connectivity (FC) profile. Multivariate pattern analysis with a relevance vector machine was then used to distinguish PTSD patients from TEHCs. We achieved a promising diagnostic accuracy of 89.2% in distinguishing PTSD patients from TEHCs. The most heavily weighted connections for PTSD classification were among the default mode network (DMN), visual network (VIS), somatomotor network, limbic network, and dorsal attention network (DAN). The strength of the anticorrelation of FC between the ventral medial prefrontal cortex (vMPFC) in DMN and the VIS and DAN was associated with the severity of PTSD. This study achieved relatively high accuracy in classifying PTSD patients vs. TEHCs at the individual level. This performance demonstrates that rs-fMRI-derived multivariate classification based on large-scale brain networks can provide potential signatures both to facilitate clinical diagnosis and to clarify the underlying brain network mechanisms of PTSD caused by natural disasters.

Development of Ketamine Administration as a Treatment for Chronic PTSD

Posttraumatic stress disorder (PTSD) is a highly prevalent, chronic, and disabling condition for which currently available pharmacotherapies are insufficiently effective. Ketamine, which is a glutamate N-methyl-D-aspartate (NMDA) receptor antagonist, has emerged as a promising and rapid-acting novel treatment intervention for this disorder. Findings from a proof-of-concept, randomized, controlled crossover study of single-dose intravenous ketamine administration (compared to single-dose midazolam) in patients with chronic PTSD suggest that ketamine is associated with rapid improvement in core PTSD symptoms and comorbid depressive symptoms, and is generally well tolerated. Additional research is needed to confirm its efficacy and safety for patients with PTSD. Results from ongoing trials of repeated intravenous administration for PTSD are expected to yield more definitive evidence. Potential mechanisms of action as well as future research directions are discussed. [ Psychiatr Ann . 2020;50(2):68–76.]

Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: A 10-year follow-up study

Background: Maternal psychopathology can be an important factor associated with psychological adjustment of children. However, there is limited research on long-term impacts of maternal posttraumatic stress disorder (PTSD) on children's mental health. This study examined how PTSD trajectories of women exposed to the 2008 Wenchuan earthquake in China predicted their children's mental health symptoms 10 years after the earthquake. Methods: 410 dyads of mothers and their adolescent children who exposed to the Wenchuan earthquake were investigated at 12 and 18 months post-earthquake. While the mothers completed measures of earthquake exposure and PTSD symptoms, the children completed measures of earthquake exposure, PTSD, depression and anxiety symptoms. In the 10-year follow up, 257 out of the 410 children completed measures of PTSD, depression and anxiety symptoms. Data were analyzed using linear regression. Results: Four trajectories of maternal PTSD symptoms were identified: (a) chronic (9.5%); (b) resilient (66.3%); (c) delayed (7.6%); and (d) recovery (16.6%); More importantly, the findings demonstrated that children whose mothers experienced chronic PTSD reported higher level of PTSD and anxiety symptoms 10 years after the earthquake. Limitations: Only two waves of maternal PTSD were collected, self-reported tools other than clinical reviews were used to collect data, and a significant proportion of participants did not respond at the 10-year follow-up. Conclusions: This study identified maternal PTSD trajectories following the Wenchuan earthquake. Chronic PTSD symptoms in mothers were associated with increased risk of children's PTSD and anxiety 10 years after the earthquake.

Negative and positive emotional complexity in the autobiographical representations of sexual trauma survivors

This study examined the diversity of experienced positive and negative emotions – emodiversity – within two existing datasets involving female survivors of sexual abuse and assault, who all met criteria for chronic Posttraumatic Stress Disorder (PTSD) as well as a diversity of comorbid diagnoses. Study 1 investigated the structure of the self-concept and Study 2 explored the organization of past autobiographical knowledge. In each study, we measured emodiversity for positive and negative emotion constructs in the trauma sample, relative to healthy control participants with no history of sexual trauma or PTSD. Results confirmed our hypotheses that individuals with a severe sexual trauma history and resultant PTSD would show elevated negative emodiversity and reduced positive diversity across both the structure of the self-concept and the structure of the life narrative, relative to control participants. The current results differ from community studies where greater negative emodiversity is associated with better mental health but mirror those from a prior study with individuals with Major Depressive Disorder. This suggests that valence-based differences in emodiversity may result from chronic emotional disturbance.

Impact of Pre-Existing Migraine and Other Co-Morbid or Co-Occurring Conditions on Presentation and Clinical Course Following Deployment-Related Concussion.

To describe the clinical presentation and early clinical course of a sample of deployed U.S. military service members following concussion, underscoring the impact of pre-existing migraine and other co-occurring conditions. It is important to obtain a comprehensive clinical history to identify evidence of underlying migraine and other health conditions which may contribute to an individual's presenting symptoms influencing early management and outcomes following concussion. Early outcome measures assessed include headache treatment response and fitness for return to duty. Acute concussion is reported to result in an array of somatic, cognitive, and behavioral symptoms. It is well established that these symptoms are not specific for concussion and may result from exacerbation of pre-existing or underlying medical conditions and factors. Although most symptoms attributable to concussion resolve within days to weeks, there is evidence that persistent symptoms beyond that specific recovery time may be attributable to factors other than concussion. Military populations are at risk for a number of recognized co-morbid and co-occurring conditions, as well as special situational and psychosocial factors which may influence symptoms and clinical course following concussion. In addition, combat-related concussion frequently occurs in the setting of a blast or military vehicle accidents thus causing concurrent injuries where musculoskeletal injuries may contribute to the clinical presentation. The resultant acute stress reaction, secondary to the traumatic experience associated with concussion, may also cause or aggravate underlying psychological co-morbidities that may influence presenting symptoms. Prior studies identified co-morbidities associated with chronic post-concussive syndrome, which we find are also present during the early phase following deployment-related concussion, thereby influencing presentation and impacting recovery. This retrospective chart review was intended to demonstrate the presence and potential impact of co-morbid and co-occurring conditions contributing to symptoms following concussion, especially migraine due to its high prevalence among post-traumatic headaches. Retrospective chart review was performed by the treating neurologist of 40 service members following concussion in the deployed environment. Clinical symptoms and co-morbid and co-occurring conditions including evidence of pre-existing migraine identified during comprehensive neurologic evaluations were collected. Both pre-deployment/pre-traumatic and post-traumatic headache features supporting migraine and early instituted headache management and treatment response are described. Rates of return to duty in this sample were also tabulated. Headaches were the most frequently reported acute symptom following concussion in this deployed service member population (38/40 patients [98%]), followed by insomnia, tinnitus, impaired concentration, nausea, dizziness, anxiety, impaired balance, depression, and hearing loss. Co-occurring acute injuries, acute stress reaction, and recent onset medication overuse were the most frequent co-occurring conditions identified by the treating neurologist as potentially contributing to the service member's presentation. Chronic co-morbidities identified included chronic headache, anxiety/depression, insomnia, and post-traumatic stress disorder. Service members with 3 or more identified co-morbidities or co-occurring conditions were more likely to require evacuation from theater. Pre-deployment headaches were reported by 25/40 [63%] service members, with 5/40 [12.5%] reporting known prior personal history of migraine. Of those reporting pre-deployment headaches, 21/25 [84%] described migraine features and/or triggers, though most [(15/25) 60%] reported as infrequent. Daily post-traumatic headaches were frequent (26/38 [68%]) and associated with typical migraine features and/or triggers. Of those treated with triptans (16/40 patient [42%]), most (12/16 patient [75%]) showed positive treatment response. Concussion in the deployed settings does not occur in isolation, with co-morbid and co-occurring conditions being common. Presence of multiple co-morbidities appears to influence clinical course and overall recovery. Post-traumatic headaches are often phenotypically fully consistent with migraine, and appear related to pre-existing migraine if supported by detailed pre-deployment headache history suggesting same. Careful and comprehensive history taking and evaluation is invaluable in identifying associated conditions including migraine, potentially helping clinicians with more accurate symptom attribution, diagnoses, and improved clinical management following acute concussion.

The emergence of ketamine as a novel treatment for posttraumatic stress disorder.

A serious lack of effective pharmacotherapeutic interventions for posttraumatic stress disorder (PTSD) raises the urgent need for the development of novel treatments. Ketamine-a noncompetitive glutamate N-methyl-d-aspartate (NMDA) receptor antagonist in use for decades as an anesthetic and analgesic agent-has more recently been demonstrated to have rapid-onset antidepressant effects in patients with treatment-resistant depression (TRD). In the present review of ketamine as an emerging novel pharmacotherapeutic intervention for chronic PTSD, we discuss findings from the first proof-of-concept, randomized clinical trial (RCT) of single-dose intravenous ketamine in patients with chronic PTSD, as well as open-label studies and current practice. We introduce ongoing RCTs investigating the efficacy of repeated ketamine infusions in rapidly reducing symptoms and maintaining improvement in samples of individuals with PTSD stemming from civilian and military traumas. Additionally, we discuss mixed findings from published reports on ketamine administration in the acute aftermath of trauma. Studies in animal models of chronic stress have investigated molecular mechanisms underlying ketamine's effects, generating a shift in the conceptualization of PTSD as a disorder of impaired neural connectivity. We review animal studies examining the potential of ketamine to modify the expression of fear by altering memory reconsolidation or enhancing fear extinction, as well as others investigating ketamine administration prophylactically prior to stress exposure. We introduce the need for additional study in humans to evaluate whether ketamine might enhance the efficacy of psychotherapeutic interventions in individuals with chronic PTSD, harnessing a window of ketamine-induced neuroplasticity. While research on ketamine for PTSD is still in its early stages, it brings about the promise of novel and more effective treatments for this disabling condition.

The association between cognitive coping strategies and treatment outcomes in smokers with PTSD.

Numerous researchers have suggested that certain coping styles (e.g., maladaptive cognitive coping strategies) interfere with recovery from traumatic experiences and contribute to the onset/maintenance of posttraumatic stress disorder (PTSD). Further, given that individuals with PTSD have a high rate of smoking (e.g., Mahaffey et al., 2016) and that maladaptive coping strategies in general are associated with lower smoking quit rates, it is possible that use of maladaptive cognitive coping strategies are particularly problematic for the recovery of smokers with PTSD. The present study examined whether specific cognitive coping strategies are associated with poorer outcome among smokers with PTSD following an integrated treatment for both disorders. Patients with chronic PTSD and nicotine dependence (N = 142) received up to 12 sessions of smoking cessation counseling combined with varenicline or integrated prolonged exposure therapy and cessation counseling combined with varenicline. We hypothesized that greater maladaptive, and lower adaptive, cognitive coping strategies at baseline would moderate degree of improvement in smoking and PTSD outcomes through to follow-up. Multilevel modeling revealed that neither maladaptive nor adaptive cognitive coping strategies moderated smoking abstinence outcomes over the course of the study (ps ≥ .271). However, greater use of catastrophizing and lower use of positive reappraisal at baseline were associated with less improvement in the hyperarousal PTSD symptom cluster over the course of the study (ps ≤ .01). These findings suggest that maladaptive cognitive coping strategies are not necessarily a contraindication for overall outcomes in integrated PTSD and smoking treatment, although they may influence improvement in hyperarousal symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Positive and negative affect in the daily life of world trade center responders with PTSD: An ecological momentary assessment study.

The ability to experience positive affect (PA) has clinical and quality of life implications, particularly in vulnerable populations such as trauma-exposed disaster responders. Low PA is included in the diagnostic criteria for posttraumatic stress disorder (PTSD), however evidence for PA reduction in PTSD has been mixed. In contrast, negative affect (NA) has consistently been found to be elevated among individuals with PTSD. Multiday, ecological momentary assessment (EMA) can provide more ecologically valid evidence about experiences of affect; however, no such studies have been conducted in traumatized individuals with PTSD to date. World Trade Center (WTC) responders (N = 202) oversampled for the presence of PTSD were recruited from the WTC Health Program. Participants were administrated the Structured Clinical Interview for DSM-IV and the PTSD Checklist for DSM-5 at baseline, then completed EMA surveys of affect four times a day over seven consecutive days. Participants with current PTSD (19.3% of the sample) showed significantly higher levels of daily NA compared with those without PTSD. However, there was no group difference in daily PA, nor was PA associated with a dimensional measure of PTSD. Results suggest that for chronic PTSD among disaster responders, positive emotions are not inhibited across daily living. Such findings add to evidence suggesting that PA reduction may not be diagnostically relevant to PTSD, whereas NA remains an important target for therapeutic interventions. Moreover, results show that WTC responders can experience and benefit from positive emotion, even if they continue to have PTSD symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).