Following the 1st Conference of the Global Collaboration on Traumatic Stress, the consortium committed to systematically integrating sex and gender considerations in their endeavours, which aligns with the European Journal of Psychotraumatology's Gender Policy. This initiative is vital for understanding trauma's complex impacts, but also presents significant challenges in cross-cultural research. This letter, co-authored by researchers from across the globe, outlines these challenges and proposes mitigation strategies. First, definitions of sex and gender are provided from a Western perspective, while acknowledging cultural differences in these concepts. Second, the relevance of integrating sex and gender considerations in traumatic stress studies is briefly described. Third, cultural distinctions and legal contexts shaping the understanding and inclusion of these concepts, with non-Western and low-to-middle income regions facing significant legal and ethical obstacles are highlighted. Methodological challenges including measurement, recruitment, and statistical modelling are discussed, followed by recommendations including participatory approaches that involve members of the community, including sexual and gender minority individuals, as possible, throughout the research process, conducting risk analyses, employing sensitive quantitative and qualitative methods, and ensuring clear reporting and participant protection. To conclude, with this letter, we hope to instigate dialogue and foster innovative approaches to incorporating sex and gender considerations in cross-cultural studies of traumatic stress. Addressing these considerations is essential for ethical, meaningful research that respects and safeguards diverse experiences.

More than half of the UK’s frontline health and social care workers experienced a mental health disorder during the first COVID-19 lockdown, according to a study in the European Journal of Psychotraumatology. And more than a fifth of the staff, which included pharmacists, met the criteria for post-traumatic stress disorder (PTSD). Researchers at University College […]

ABSTRACTBackground: Women have a two to three times higher risk of developing post-traumatic stress disorder (PTSD) compared to men. Several factors are involved explaining this difference (Christiansen & Hansen, 2015). Both psychosocial and biological explanations (e.g. oxytocin related) have been suggested and will be reviewed in this paper. To date, we are still behind in gender- and sex-sensitive research and reporting.Prevalence and type of trauma: The lifetime prevalence of PTSD is about 10–12% in women and 5–6% in men. There are similar differences between the sexes for (comorbid) disorders such as major depression and anxiety disorders. PTSD subcluster scores have been found to be increased in women, e.g. for re-experiencing and anxious arousal (Charak et al., 2014). Men and women experience different types of trauma, both in private life and at work (e.g. police officers, Van der Meer et al., 2017), with women being exposed to more high-impact trauma (e.g. sexual trauma) than men, and at a younger age. Trauma early in life has more impact, especially when it involves type II trauma interfering with neurobiological development and personality. Traumatic stress affects different areas of the brains of boys and girls at different ages.Acute phase, stress-coping and psychotherapy: In the acute phase, women generally score higher than men on acute subjective responses, e.g. threat perception, peritraumatic dissociation and known predictors of PTSD. Women handle stressful situations differently and have evolved differentially to support these different behaviours. For instance, women in stressful situations may use a tend-and-befriend response rather than the fight-or-flight response that is often assumed. Emotion-focused, defensive and palliative coping are more prevalent in women, while problem-focused coping is higher in men. Women seek more social support, the lack of it being the most consistent predictor of negative outcome of trauma. Women have been shown to benefit more from psychotherapy then men in the reduction of PTSD symptoms.Psychobiological reactions and effects of oxytocin: Although only 2% of psychobiological research has been conducted in females (mainly rats), sex differences have been shown. Women appear to have a more sensitized hypothalamus–pituitary–axis than men, while men appear to have a sensitized physiological hyperarousal system. PTSD has consistently been associated with amygdala hyperactivity, ventromedial prefrontal cortex (vmPFC) hypoactivity and reduced communication (functional connectivity) between the vmPFC and amygdala, with the lower PFC control over the amygdala providing an explanation for the excessive fear response in PTSD. We hypothesized that the oxytocin system, which is associated with social support, fear and stress responses, was likely to play a sex-specific role in the stress response. In recently traumatized patients, we found that the effects of administration of oxytocin on amygdala reactivity to emotional stimuli depend on stimulus valence and sex (Frijling, 2017). In PTSD patients, we showed sex-specific routes for the effects of single oxytocin administration on the potential to diminish anxiety (fear learning) and fear expression by the amygdala: increased inhibitory control of the vmPFC over the centromedial nucleus in men and fewer excitatory dorsal anterior cingulate cortex projections to the basolateral nucleus in women. So, while our findings add to accumulating evidence that oxytocin administration could potentially enhance treatment response in PTSD, the routes in men and women differ (Frijling, 2017).Gender policy: In summary, all of these sex and gender differences in brain and behaviour together may explain why PTSD is more prevalent in women than in men. Clearly, we should not simplify. There are no male or female stereotypes, but some features are more common in women and others in men. To fully understand the differences, we need more gender- and sex-sensitive research as well as reporting (e.g. see the gender policy of the European Association of Science Editors). In 2016, the European Journal of Psychotraumatology was the first to implement a gender policy (Olff, 2016), i.e. authors are asked to: report the sex of research subjects, justify single-sex studies, discriminate between sex and gender (mostly for human research), analyse how sex or gender impact the results, and discuss sex and gender issues when relevant. This should not only apply to the field of psychotrauma, but deserves a much broader implementation. In doing so, we hope to obtain information that will improve sex- and gender-specific approaches to helping those affected by psychotrauma.

Back to table of contents Previous article Next article Communications and UpdatesFull AccessAddressing Sleep Impairment in Treatment Guidelines for PTSDAna Nectara Ticlea, M.D., Laura A. Bajor, D.O., and David N. Osser, M.D.Ana Nectara TicleaSearch for more papers by this author, M.D., Laura A. BajorSearch for more papers by this author, D.O., and David N. OsserSearch for more papers by this author, M.D.Published Online:1 Sep 2013https://doi.org/10.1176/appi.ajp.2013.13050641AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We reviewed Dr. Germain’s article (1) in the April issue with much interest. We would like to kindly correct Dr. Germain’s statement that no treatment guidelines have proposed that the initial treatment for posttraumatic stress disorder (PTSD) should focus on sleep impairment. The PTSD algorithm of the Psychopharmacology Algorithm Project at the Harvard South Shore Program (2), published in 2011, provides treatment guidelines that support exactly the idea that sleep evaluation and treatment should be the first step in assessing and treating PTSD. Notably, the first reference in the Psychopharmacology Algorithm Project article is to previous research by Dr. Germain and colleagues (3).From a psychopharmacological perspective, the availability of prazosin (4), which has demonstrated a much larger effect size than the selective serotonin reuptake inhibitors (SSRIs), a greater tolerability profile, and a shorter time to response, makes this approach possible. Many experts continue to promote SSRIs as a first-line treatment for this disorder, but the evidence—despite U.S. Food and Drug Administration approval of two SSRIs—remains not at all impressive (5, 6). SSRIs have a small effect size in ameliorating the range of PTSD symptoms, and they frequently exacerbate insomnia and nightmares. Furthermore, they often produce disabling sexual side effects.For many patients, sleep fragmentation may exacerbate daytime PTSD symptoms (hypervigilance, avoidance, and reexperiencing), and these symptoms may improve when sleep improves (7). The importance of sleep in regulating trauma-related memories and emotions has significant clinical implications, suggesting that prioritized interventions to correct sleep disturbances may facilitate the psychotherapeutic processing of traumatic events.From Harvard Medical School at the VA Boston Healthcare System, Brockton Division, Brockton, Mass.The authors report no financial relationships with commercial interests.References1 Germain A: Sleep disturbances as the hallmark of PTSD: where are we now? Am J Psychiatry 2013; 170:372–382Link, Google Scholar2 Bajor LA, Ticlea AN, Osser DN: The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on posttraumatic stress disorder. Harv Rev Psychiatry 2011; 19:240–258Crossref, Medline, Google Scholar3 Germain A, Buysse DJ, Nofzinger E: Sleep-specific mechanisms underlying posttraumatic stress disorder: integrative review and neurobiological hypotheses. Sleep Med Rev 2008; 12:185–195Crossref, Medline, Google Scholar4 Raskind MA, Peterson K, Williams T, Hoff DJ, Hart K, Holmes H, Homas D, Hill J, Daniels C, Calohan J, Millard SP, Rohde K, O'Connell J, Pritzl D, Feiszli K, Petrie EC, Gross C, Mayer CL, Freed MC, Engel C, Peskind ER: A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry 2013; 170:1003–1010 (Epub ahead of print: Jul 12, 2013)Link, Google Scholar5 National Collaborating Centre for Mental Health: Posttraumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. London; Leicester, UK, Gaskell and the British Psychological Society, 2005Google Scholar6 Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine: Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC, National Academies Press, 2008Google Scholar7 Thompson CE, Taylor FB, McFall ME, Barnes RF, Raskind MA: Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: response to prazosin. J Trauma Stress 2008; 21:417–420Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited bySleep, circadian system and traumatic stress28 September 2021 | European Journal of Psychotraumatology, Vol. 12, No. 1Traumatic stress and the circadian system: neurobiology, timing and treatment of posttraumatic chronodisruption27 November 2020 | European Journal of Psychotraumatology, Vol. 11, No. 1Multilevel Interactions of Stress and Circadian System: Implications for Traumatic Stress28 January 2020 | Frontiers in Psychiatry, Vol. 10Potential pleiotropic beneficial effects of adjuvant melatonergic treatment in posttraumatic stress disorder29 April 2016 | Journal of Pineal Research, Vol. 61, No. 1Current Opinion in Psychiatry, Vol. 27, No. 5 Volume 170Issue 9 September 2013Pages 1059-1059 Metrics PDF download History Accepted 1 June 2013 Published online 1 September 2013 Published in print 1 September 2013

Although European countries differ widely in their approach to psychotrauma and its consequences, with 20 years of European psychotraumatology in the form of the European Society for Traumatic Studies (ESTSS) there is now increasing dissemination of evidence-based care reaching more and more professionals and scholars in Europe. The society has moved forward to become a European umbrella organization serving many different European countries and cultures. This article describes the process of the restructuring and how ESTSS has grown from collaboration with other traumatic stress partners inside and outside Europe. The knowledge generated by The European Network for Traumatic Stress (TENTS) project has helped this process as well as the creation of an international open-access journal, the European Journal of Psychotraumatology (EJPT), for optimal dissemination of knowledge.

The Complexity of Complex PTSD

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.

Welcome to the European Journal of Psychotraumatology ! The European Journal of Psychotraumatology (EJPT) is a new peer-reviewed Open Access journal and the official organ of the European Society for Traumatic Stress Studies (ESTSS). It aims to serve the needs of both researchers and clinicians in the field of traumatic stress. EJPT is in line with ESTSS’s mission to advance and disseminate scientific knowledge about traumatic stress within Europe and internationally, and will publish original research papers as well as papers on evidencebased clinical practice. (Published: 6 December 2010) Citation: European Journal of Psychotraumatology 2010, 1: 5768 - DOI: 10.3402/ejpt.v1i0.5768 For the full text in other languages, please see Supplementary files in the column to the right (under Reading Tools).

The title of this editorial conveys one of the challenges for the launch of the European Journal of Psychotraumatology (EJPT) by the European Society for Traumatic Stress Studies (ESTSS): Abstracts of every article will appear in the major languages represented in our title. In adopting such a policy, EJPT and the ESTSS show they have faced the challenge head on and succeeded by virtue of adopting this policy in accommodating the needs of their intended readership. As well, while all articles will appear in English, authors may choose to also submit their paper in their own language, which will be made accessible as supplementary material directly from the English version. (Published: 6 December 2010) Citation: European Journal of Psychotraumatology 2010, 1 : 5746 - DOI: 10.3402/ejpt.v1i0.5746

Posttraumatic stress disorder (PTSD) is one of the few psychiatric conditions in which a subjective decrease in emotional range serves as a diagnostic criterion. In order to investigate whether veterans with chronic PTSD also experienced objective limitations in emotional perception, the authors administered the Aprosodia Battery to a group of 11 veterans with chronic PTSD, nine subjects with right hemisphere damage, seven subjects with left hemisphere damage, and 12 comparison subjects. The patients with PTSD displayed significant deficiencies in the comprehension and discriminative components of affective speech, similar in severity and performance profile on the Aprosodia Battery to the individuals with focal right hemisphere damage due to ischemic infarction.

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.

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.

This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. A principal-components analysis conducted on intake data (N = 82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.

The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

The authors examined the effect of patients' style of clinical presentation on primary care physicians' recognition of depression and anxiety. The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation of any psychiatric condition in the medical chart over the ensuing 12 months. The authors identified three progressively more persistent forms of somatic presentations, labeled "initial," "facultative," and "true" somatization. Of 215 patients with CES-D scores of 16 or higher, 80% made somatized presentations; of 75 patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, for psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number of lifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition.

The authors' objective was to explore aspects of trauma associated with severity of posttraumatic stress disorder (PTSD) in Vietnam veterans. Several ratings of stress exposure and symptom severity were administered to 40 patients with combat-related PTSD. A significant relationship was observed between exposure to atrocities and the impact of PTSD on veterans' lives, as measured by the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. Exposure to atrocities was also significantly correlated with current symptom severity. In contrast, combat exposure alone was not significantly associated with overall symptom severity. Both atrocity and combat exposure, however, were significantly related to reexperiencing symptoms. The data suggest that the enduring effect and severity of PTSD symptoms on an individual are associated more with exposure to brutal human death and suffering than the threat of death associated with combat.

Drs. Brown and Anderson and Dr. Sanders Reply

Seventeen definitions of the severely and persistently mentally ill have appeared in the literature over the past decade. These definitions have been used by 13 authors to formulate service programs and to estimate the prevalence of serious mental illness in the population. To test the applicability of these definitions, the authors operationalized each definition and applied it to a representative sample of 222 patients receiving services in one of Philadelphia's inner-city neighborhoods. The analysis showed estimates of prevalence of serious mental illness ranging from 4% to 88% of the treated population, depending on the definition applied. The NIMH (1987) definition was representative of the middle-range estimates of 45% to 55% arrived at by eight authors.

The authors evaluated changes in symptoms and levels of perceived distress of 21 Cambodian, 13 Hmong/Laotian, and 18 Vietnamese patients before and after a 6-month treatment period. Most of the patients improved significantly. Cambodians had the greatest and Hmong/Laotians had the least reductions in depressive symptoms. Although psychological symptoms improved, many somatic symptoms worsened. The authors conclude that refugee survivors of multiple traumata and torture can be aided by psychiatric care. They recommend investigations with larger samples and suitable control groups to further clarify the relative contributions of trauma, diagnosis, and acculturation stress to treatment outcome.

Dr. Herman and Associates Reply