Higher Levels Of Posttraumatic Stress Disorder Symptoms Research Articles

Posttraumatic Stress and the Comprehension of Everyday Activity.

People with Posttraumatic Stress Disorder (PTSD) often report difficulties with attention and memory on tasks that are unrelated to their trauma. One important component of everyday event comprehension is the segmentation of ongoing activity into meaningful events. The present study asked whether PTSD symptom severity was associated with impaired segmentation and memory for neutral, ongoing activity. A sample of 137 participants, ages 21-79, completed event segmentation and memory tasks, general cognitive functioning tasks, and questionnaires assessing PTSD symptom severity. People with higher levels of PTSD symptoms had poorer event segmentation and event memory performance. Hierarchical multiple regression analyses demonstrated that PTSD symptom severity explained unique variance in event segmentation performance, even after controlling for general cognitive function. These results suggest that interventions aimed at improving event comprehension may help compensate for memory disruptions in PTSD.

Test of the stress sensitization model in adolescents following the pipeline explosion

PurposeThe stress sensitization model states that early traumatic experiences increase vulnerability to the adverse effects of subsequent stressful life events. This study examined the effect of stress sensitization on development of posttraumatic stress disorder (PTSD) symptoms in Chinese adolescents who experienced the pipeline explosion. MethodsA total of 670 participants completed self-administered questionnaires on demographic characteristics and degree of explosion exposure, the Childhood Trauma Questionnaire (CTQ), and the Posttraumatic Stress Disorder Checklist—Civilian Version (PCL-C). Associations among the variables were explored using MANOVA, and main effects and interactions were analyzed. ResultsOverall MANOVA tests with the PCL-C indicated significant differences for gender (F=6.86, p=.000), emotional abuse (F=6.79, p=.000), and explosion exposure (F=22.40, p=.000). There were significant interactions between emotional abuse and explosion exposure (F=3.98, p=.008) and gender and explosion exposure (F=2.93, p=.033). ConclusionsBeing female, childhood emotional abuse, and a high explosion exposure were associated with high PTSD symptom levels. Childhood emotional abuse moderated the effect of explosion exposure on PTSD symptoms. Thus, stress sensitization influenced the development of PTSD symptoms in Chinese adolescents who experienced the pipeline explosion as predicted by the model.

Associations Between Childhood Abuse, Posttraumatic Stress Disorder, and Implicit Emotion Regulation Deficits: Evidence From a Low-Income, Inner-City Population

Objective: Childhood abuse is associated with a wide range of negative outcomes, including increased risk for development of emotion dysregulation and psychopathology, such as posttraumatic stress disorder (PTSD). The goal of the present study was to examine associations between child abuse, PTSD symptoms, and performance on an emotional conflict regulation task that assesses implicit emotion regulation abilities. Method: The sample consisted of 67 (94% African American) females recruited from a public, urban hospital. Childhood abuse was measured using the Childhood Trauma Questionnaire, and PTSD was measured using the modified PTSD Symptom Scale. Task accuracy and implicit emotion regulation were measured through an emotional conflict regulation behavioral task. Results: A multivariate analysis of covariance showed that exposure to moderate to severe childhood abuse was significantly related to worse emotional conflict regulation scores independent of current PTSD symptoms, depressive symptoms, and adult trauma exposure, suggesting a deficit in implicit emotion regulation. We also found an interaction between PTSD symptoms and abuse exposure in predicting accuracy on the behavioral task; high levels of PTSD symptoms were associated with poorer task accuracy among individuals who reported moderate to severe exposure to childhood abuse. However, no relationship between implicit emotion regulation abilities and overall PTSD symptom severity was found. Conclusions: This study provides preliminary evidence of an implicit emotion regulation deficit for individuals exposed to significant childhood abuse and further supports the growing evidence that addressing various aspects of emotion dysregulation, such as awareness of emotions and strategies to manage strong emotions, in the context of treatment would be valuable.

Pre-deployment differences in glucocorticoid sensitivity of leukocytes in soldiers developing symptoms of PTSD, depression or fatigue persist after return from military deployment.

Deployed soldiers are at risk of developing stress-related conditions, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and severe fatigue. We previously observed condition- and cell-specific differences in sensitivity of immune cells for regulation by glucocorticoids (GCs) pre-deployment between male soldiers with and without subsequent development of high levels of these stress-related symptoms. Here we investigated whether these pre-deployment dysregulations in GC-sensitivity of immune cells persisted after return from military deployment. In a prospective, longitudinal study including 721 male and female soldiers, the in vitro GC-sensitivity of monocytes and T-cells was assessed prior to deployment and one and six months post-deployment. Differences in the longitudinal course of sensitivity for regulation by dexamethasone (DEX) of LPS-stimulated TNF-α production and PHA-stimulated T-cell proliferation between soldiers with and without subsequent symptom development were investigated using linear mixed models. Within the whole group, DEX-sensitivity of monocytes was significantly decreased at six months post-deployment compared to the assessments pre-deployment and one month post-deployment. The DEX-sensitivity of T-cells did not significantly change over time. Participants developing high levels of PTSD symptoms showed high DEX-sensitivity of T-cells, while participants developing high levels of depressive symptoms showed low DEX-sensitivity of T-cells before deployment that persisted at the two time points after return. In addition, participants developing severe fatigue had low DEX-sensitivity of monocytes at all assessments. Our finding that the previously observed pre-deployment group differences in peripheral GC-sensitivity persisted until at least six months after return indicates that in vitro GC-sensitivity of T-cells and monocytes may represent a persistent biological vulnerability factor for development of stress-related conditions PTSD, depression and fatigue.

The effect of deployment to a combat zone on testosterone levels and the association with the development of posttraumatic stress symptoms: A longitudinal prospective Dutch military cohort study.

There is limited evidence on the association of the activity of HPG-axis with stress and symptoms of stress-related disorders. The aim of the current study was to assess the effect of deployment to a combat zone on plasma testosterone levels, and the possible association with the development of symptoms of posttraumatic stress disorder (PTSD). A total of 918 males were included in the study before deployment to a combat zone in Afghanistan. The effect of deployment on testosterone was longitudinally assessed; starting prior to deployment and follow-up assessments were preformed at 1 and 6 months after return. Furthermore, the association with PTSD symptoms reported at 1 and 2 years post-deployment was assessed. Plasma testosterone levels were significantly increased after deployment compared with pre-deployment levels. Although no difference was found between individuals reporting high or low levels of PTSD symptoms, pre-deployment testosterone levels predicted the development of PTSD symptoms at 1 and 2 years post-deployment. This study provides evidence that not the alterations in testosterone levels shortly after deployment, but the pre-deployment testosterone levels are associated with PTSD symptoms, which is of value in the identification of biological vulnerability factors for the development of PTSD.

Collaborative care intervention targeting violence risk behaviors, substance use, and posttraumatic stress and depressive symptoms in injured adolescents: a randomized clinical trial.

Violence and injury risk behaviors, alcohol and drug use problems, and posttraumatic stress disorder (PTSD) and depressive symptoms occur frequently among adolescents presenting to acute care medical settings after traumatic physical injury. To test the effectiveness of a stepped collaborative care intervention targeting this constellation of risk behaviors and symptoms in randomly sampled hospitalized adolescents with and without traumatic brain injury. A pragmatic randomized clinical trial was conducted at a single US level I trauma center. Participants included 120 adolescents aged 12 to 18 years randomized to intervention (n = 59) and control (n = 61) conditions. Stepped collaborative care intervention included motivational interviewing elements targeting risk behaviors and substance use as well as medication and cognitive behavioral therapy elements targeting PTSD and depressive symptoms. Adolescents were assessed at baseline before randomization and 2, 5, and 12 months after injury hospitalization. Standardized instruments were used to assess violence risk behaviors, alcohol and drug use, and PTSD and depressive symptoms. The investigation attained more than 95% adolescent follow-up at each assessment point. At baseline, approximately one-third of the participants endorsed the violence risk behavior of carrying a weapon. Regression analyses demonstrated that intervention patients experienced significant reductions in weapon carrying compared with controls during the year after injury (group × time effect, F3,344 = 3.0; P = .03). At 12 months after the injury, 4 (7.3%) intervention patients vs 13 (21.3%) control patients reported currently carrying a weapon (relative risk, 0.31; 95% CI, 0.11-0.90). The intervention was equally effective in reducing the risk of weapon carrying among injured adolescents with and without traumatic brain injury. Other treatment targets, including alcohol and drug use problems and high levels of PTSD and depressive symptoms, occurred less frequently in the cohort relative to weapon carrying and were not significantly affected by the intervention. Collaborative care intervention reduced the risk of adolescent weapon carrying during the year after the injury hospitalization. Future investigation should replicate this preliminary observation. If the finding is replicated, orchestrated investigative and policy efforts could systematically implement and evaluate screening and intervention procedures targeting youth violence prevention at US trauma centers. clinicaltrials.gov identifier: NCT00619255.

Trauma-related shame and guilt as time-varying predictors of posttraumatic stress disorder symptoms during imagery exposure and imagery rescripting—A randomized controlled trial

Objective: The specific aims of this study are to examine trauma-related shame and guilt as time-varying predictors of symptoms of posttraumatic stress disorder (PTSD). Method: Sixty-five patients were included in the statistical analyses and the multilevel modeling analyses supported three major findings. Results: (i) Patients with a higher level of shame and guilt at the start of treatment displayed a higher level of PTSD symptoms over the course of treatment compared to other patients. (ii) Time-specific change in shame and guilt predicted the level of PTSD symptoms 3 days later from session to session during treatment. (iii) No significant differences were evident between prolonged exposure (PE) and modified PE to include imagery rescripting in the within-person process of change in PTSD symptoms from session to session during therapy. Conclusions: This trial reports the first evidence that within-person change in shame and guilt predicts change in PTSD symptoms from session to session during treatment.

The presence of post‐traumatic stress disorder symptoms in earthquake survivors one month after a mudslide in southwest China

The psychological impact of a mudslide on survivors of the Wenchuan earthquake in China and the risk factors for development of disaster-related post-traumatic stress disorder (PTSD) were investigated. The study design was cross-sectional and included 1321 survivors who had endured both an earthquake and a mudslide. Participants filled out a self-report questionnaire. One month after the mudslide, the rate of PTSD symptoms was 18.7%. Females, the elderly, those with lower educational levels, those that lacked social support, those who did not take precautionary measures, those living with children below 6 years of age, and those who had higher exposure to traumatic events experienced a higher level of PTSD symptoms. Results indicated that timely rescue, abundant material help, and mental rehabilitation after a disaster play important roles in recovery, and that there are still some high-risk groups that need attention, care, and effective intervention from healthcare professionals and society.

Gaza Nurses After War: Are They Traumatized?

Studies related to trauma among nurses in Palestine are not available, but few studies about PTSD among Palestinian adolescents and other groups have been conducted. This study examines the relationship between exposure to war stress and posttraumatic symptoms among nurses in all Gaza hospitals after the Israeli war on Gaza. All available hospital nurses who were exposed to war stress (n=1130) were assessed for posttraumatic stress disorder (PTSD) symptoms one year after the war between Israel and Gaza erupted. Arabic version of Impact Event Scale-Revised (IES-R) was used in this study with a mean score of 35 as cut-off point for severe posttraumatic symptoms in nurses. High levels of PTSD symptoms were found in 69.4% of nurses. The most frequent symptoms of trauma subscales appears to be “Intrusion” (mean=15.5) followed by “Avoidance” (mean=14.9), and then “Hyper-arousal” (mean=11.4). These findings show that nurses suffered from severe posttraumatic symptoms after exposure to prolonged war stress. This level of trauma among nurses warrants intervention programs to reduce stress and trauma among Gaza nurses after the war.

The Effects of Alcohol Problems, PTSD, and Combat Exposure on Nonphysical and Physical Aggression Among Iraq and Afghanistan War Veterans.

Aggression among combat veterans is of great concern. Although some studies have found an association between combat exposure and aggressive behavior following deployment, others conclude that aggression is more strongly associated with symptoms of posttraumatic stress disorder (PTSD), and that alcohol misuse may influence this association. Many of these studies have assessed aggression as a single construct, whereas the current study explored both nonphysical aggression only and physical aggression in a sample of Iraq and Afghanistan war veterans (N = 337; 91% male). We found that alcohol problems interacted with PTSD symptom severity to predict nonphysical aggression only. At low levels of PTSD symptoms, veterans with alcohol problems were more likely to perpetrate nonphysical aggression only, as compared with no aggression, than veterans without an alcohol problem. There was no difference in the likelihood of nonphysical aggression only between those with and without alcohol problems at high levels of PTSD symptoms. The likelihood of nonphysical aggression only, as compared with no aggression, was also greater among younger veterans. Greater combat exposure and PTSD symptom severity were associated with an increased likelihood of perpetrating physical aggression, as compared with no aggression. Ethnic minority status and younger age were also associated with physical aggression, as compared with no aggression. Findings suggest that a more detailed assessment of veterans' aggressive behavior, as well as their alcohol problems and PTSD symptoms, by researchers and clinicians is needed in order to determine how best to intervene.

Posttraumatic stress in intensive care unit survivors – a prospective study

Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21%) had symptom levels indicating subclinical PTSD. Female, five illness factors: coma time, mechanical ventilation, sedation, benzodiazepine, pain relieving medication, and four psychological factors: symptoms of acute stress (T1), fear of death and/or feeling completely helpless and powerless in relation to the accident and/or ICU (T1), SOC (T1) and more external locus of control (T1) correlated significantly with PTSD symptoms at T2. In the linear regression analysis, female, length of sedation, dissociation (T1), hypervigilance (T1), and external locus of control predicted 58% of the variation of PTSD. Conclusions: High levels of PTSD symptoms occurred in 19.2% of respondents in six months following traumatic injury requiring ICU admission. Screening for the variables gender, length of sedation, dissociation, hypervigilance, and locus of control after ICU admission following traumatic injuries may help to predict who will develop PTSD.

Head Injury and Loss of Consciousness Raise the Likelihood of Developing and Maintaining PTSD Symptoms

Mild traumatic brain injury has been associated with higher prevalence of posttraumatic stress disorder (PTSD). The extent to which head injury or loss of consciousness predicts PTSD is unknown. To evaluate the contribution of head injury and loss of consciousness to the occurrence of PTSD, we made a longitudinal evaluation of 1,260 road accident survivors admitted to the emergency department with head injury (n = 287), head injury and loss of consciousness (n = 115), or neither (n = 858). A telephone-administered posttraumatic symptoms scale inferred PTSD and quantified PTSD symptoms at 10 days and 8 months after admission. The study groups had similar heart rate, blood pressure, and pain levels in the emergency department. Survivors with loss of consciousness and head injury had higher prevalence of PTSD and higher levels of PTSD symptoms, suggesting that patients with head injury and loss of consciousness reported in the emergency department are at higher risk for PTSD.

Dating Violence and Posttraumatic Stress Disorder Symptoms in Taiwanese College Students

This study has examined the effects that young adults' experience of dating-violence victimization can have on their manifestation of posttraumatic stress disorder (PTSD) symptoms. This study has also examined the possible roles that cultural beliefs can play in dating-violence experience, coping choices, and PTSD symptoms. This study has used self-reporting measures to collect data from a nationally stratified random sample of 1,018 college students in Taiwan. Results demonstrate that college students who had experienced dating-violence victimization reported higher levels of PTSD symptoms than those who had not. The results reveal that psychological-violence victimization and cultural beliefs have direct and indirect effects on PTSD symptoms via the mediation of young adults' use of emotion-focused coping strategies. Greater frequencies of psychological-violence victimization were associated with a greater use of emotion-focused coping, which was in turn associated with increases in PTSD symptoms. This study illustrates that traditional Chinese beliefs have played significant roles in exacerbating the risk for dating violence and PTSD, and in shaping victims' coping choices with dating violence.

A longitudinal study of demographic factors associated with stressors and symptoms in African refugees.

The objectives of this study were to assess differences in premigration, transit, and resettlement stressor exposure and post traumatic stress disorder (PTSD) symptoms as a function of demographic characteristics (i.e., gender, ethnicity, age, time in United States) and to examine the concurrent and longitudinal relations between stressor exposure and PTSD symptoms. The sample consisted of adult (18-78years) Somali and Oromo refugee men and women (N=437). Qualitative data regarding participants' self-nominated worst stressors collected at Time 2 (T2) informed the development of quantitative scales assessing premigration, transit, and resettlement stress created using items collected at Time 1 (T1). PTSD symptoms were measured at both T1 and T2. Quantitative analyses showed that levels of stressor exposure and PTSD symptoms differed as a function of refugee demographic characteristics. For example, Oromo, more recent, women, and older refugees reported more premigration and resettlement stressors. Oromo refugees and refugee men reported more PTSD symptoms in regression analyses with other factors controlled. Premigration, transit, and resettlement stressor exposure generally was associated with higher PTSD symptom levels. Results underscore the importance of assessing stress exposure comprehensively throughout the refugee experience and caution against overgeneralizing between and within refugee groups.

Traumatic Stressor Exposure and Post-Traumatic Symptoms in Homeless Veterans

To better understand potential risk factors for post-traumatic stress disorder (PTSD) and homelessness in veterans, we studied trauma exposure and responses in archival data on 115 homeless veterans. Rates of exposure to military and a variety of civilian high magnitude stressor (HMS) and persistent post-traumatic distress (PPD) events and symptoms of post-traumatic stress were assessed. The relationships between frequency of different trauma types and symptoms of post-traumatic stress were examined. Exposure to both HMS and PPD events were extremely high in this sample, with particularly high exposure to adult (82%) and childhood (62%) interpersonal violence HMS events and HMS events during military service (53%). Exposure to both military and civilian PPD events was associated with significantly higher levels of PTSD symptoms than exposure to no PPD events or only civilian PPD events, and almost all HMS event types were significantly correlated with both PTSD and dissociation symptoms. Post-traumatic symptoms and military and civilian traumatic stressors of all types should be assessed in homeless veterans because they may be contributing to poor social and occupational functioning.

Fear Extinction Requires Multipronged Intervention

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessFear Extinction Requires Multipronged InterventionAaron LevinAaron LevinSearch for more papers by this authorPublished Online:7 Jun 2013https://doi.org/10.1176/appi.pn.2013.6a22AbstractExtinction of conditioned fear in both civilian and military populations requires genetic, neuroendocrine, and psychophysiological components.A pile of trash burning in a field off an interstate highway in Georgia might seem unremarkable, but to a veteran traumatized by a roadside bomb blast, it’s another stimulus that brings back the fear he felt in Iraq, said Seth Norrholm, Ph.D., at the Eighth Annual Conference on the Amygdala, Stress, and PTSD, held April 23 at the Uniformed Services University of the Health Sciences in Bethesda, Md.An overload of fear can inhibit or delay fear extinction in patients with PTSD, said Emory University’s Seth Norrholm, Ph.D.Aaron LevinNorrholm, an assistant professor of psychiatry and behavioral sciences at Emory University School of Medicine, uses classical Pavlovian fear conditioning paradigms to study the physiological, neuroendocrine, and genetic factors that influence fear acquisition and extinction in both rodents and humans.To model these symptoms, he focuses on fear-potentiated startle, the exaggerated startle reaction to a stimulus that occurs when the subject (whether animal or human) is afraid.The model can also serve as a way of observing the effects of exposure-based extinction on how training reduces or eliminates the conditioned fear response.Norrholm, Kerry Ressler, Ph.D., and colleagues at Emory have been studying a cohort of more than 6,000 civilians who have been treated at Atlanta’s Grady Memorial Hospital. Most of them are low-income African Americans who have experienced severe trauma. The researchers have accumulated startle data on a subsample of 500 of those patients, comparing the patients with and without posttraumatic stress disorder (PTSD).Traumatized individuals with PTSD showed more fear-potentiated startle in fear-acquisition training.“There was no difference in cognitive awareness of fear and safety cues, but there was a difference at the level of the amygdala in fear acquisition,” he said. In the extinction phase, those with PTSD again had a much greater fear-potentiated startle than those without the disorder.Norrholm calls this difference “fear load,” a term that represents the much greater level of fear at the beginning of the extinction phase, which must be overcome in order to extinguish the fear-potentiated startle. It is the deficit the patient has to make up before achieving extinction.“Civilian PTSD patients show greater fear load at the time of extinction,” said Norrholm. He also found that among combat veterans of conflicts beginning with the Vietnam War, individuals with high re-experiencing symptoms had a higher fear load but were still able to extinguish fear.He divided a cohort of 168 veterans of the wars in Iraq and Afghanistan into those with high and low levels of PTSD symptoms. He found no difference in the acquisition of fear-potentiated startle. However, those with less-severe symptoms had a clear reduction in fear-potentiated startle, while those with higher symptom levels showed no reduction, indicating impairment.“Veteran PTSD patients displayed impaired within-session extinction of fear, an effect that is strongly associated with PTSD symptom severity,” he said.Epigenetic mechanisms also come into play in Norrholm’s research. DNA methylation silences genes, reducing protein expression and leading to behavioral effects. With the well-studied COMT gene, for example, the met/met allele renders individuals more susceptible to anxiety disorders, he said.“But the genotype alone is not significant, it’s the gene-by-environment interaction,” he said. The presence of the met/met allele in PTSD patients increases their fear load.His group also analyzed blood levels of the ADCYAP1 gene, which encodes the pituitary adenylate cyclase-activating polypeptide (PACAP) protein. In women with PTSD, but not in men, higher levels of the PACAP predict fear-potentiated startle response.Finally, pilot data from neuroendocrine studies of traumatized women indicate a role for estrogen as well. Women with PTSD and low estrogen levels appear to have lower levels of fear-potentiated startle than those with high estrogen levels.There may be initial clinical implications of Norrholm’s research, even at this early stage. “Fear-loaded patients may require a greater degree of intervention to overcome initial elevated levels of fear,” he said. ■More information on Seth Norrholm’s research is posted at http://www.frontiersin.org/Behavioral_Neuroscience/10.3389/fnbeh.2013.00030/abstract. ISSUES NewArchived

Controlled Trial of Psychotherapy for Congolese Survivors of Sexual Violence

BackgroundSurvivors of sexual violence have high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). Although treatment for symptoms related to sexual violence has been shown to be effective in high-income countries, evidence is lacking in low-income, conflict-affected countries.MethodsIn this trial in the Democratic Republic of Congo, we randomly assigned 16 villages to provide cognitive processing therapy (1 individual session and 11 group sessions) or individual support to female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms. One village was excluded owing to concern about the competency of the psychosocial assistant, resulting in 7 villages that provided therapy (157 women) and 8 villages that provided individual support (248 women). Assessments of combined depression and anxiety symptoms (average score on the Hopkins Symptom Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), PTSD symptoms (average score on the Harvard Trauma Questionnaire [range, 0 to 3, with higher scores indicating worse symptoms]), and functional impairment (average score across 20 tasks [range, 0 to 4, with higher scores indicating greater impairment]) were performed at baseline, at the end of treatment, and 6 months after treatment ended.ResultsA total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments. Mean scores for combined depression and anxiety improved in the individual-support group (2.2 at baseline, 1.7 at the end of treatment, and 1.5 at 6 months after treatment), but improvements were significantly greater in the therapy group (2.0 at baseline, 0.8 at the end of treatment, and 0.7 at 6 months after treatment) (P<0.001 for all comparisons). Similar patterns were observed for PTSD and functional impairment. At 6 months after treatment, 9% of participants in the therapy group and 42% of participants in the individual-support group met criteria for probable depression or anxiety (P<0.001), with similar results for PTSD.ConclusionsIn this study of sexual-violence survivors in a low-income, conflict-affected country, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms and improved functioning. (Funded by the U.S. Agency for International Development Victims of Torture Fund and the World Bank; ClinicalTrials.gov number, NCT01385163.)

A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. ( clinicaltrials.gov identifier: NCT00270959).

154. Glucocorticoid sensitivity of leukocytes predicts fatigue, depressive, and PTSD symptoms after military deployment

Posttraumatic stress disorder (PTSD), depression and severe fatigue may develop in response to severe stress and trauma. These conditions are associated with altered sensitivity of leukocytes to glucocorticoids (GCs). We investigated whether GC-sensitivity of T-cells and monocytes assessed before military deployment predicts high levels of fatigue, depressive, and/or PTSD symptoms 6 months after return from deployment. We included 523 male military personnel before deployment to Afghanistan. Logistic regression analysis was performed to predict fatigue, depressive, and PTSD symptoms 6 months after deployment based on sensitivity of LPS-induced TNF-alpha production and PHA-induced T-cell proliferation to dexamethasone (DEX)-inhibition before deployment. Severe fatigue 6 months after deployment was independently associated with low DEX-sensitivity of monocyte TNF-α production before deployment. A high level of depressive symptoms 6 months after deployment was independently associated with low DEX-sensitivity of T-cell proliferation. In contrast, a high level of PTSD symptoms after deployment was independently associated with high DEX-sensitivity of T-cell proliferation before deployment, but only in individuals who reported PTSD symptoms without depressive symptoms. DEX-sensitivity was not associated with childhood trauma, a known risk factor for development of fatigue, depressive and PTSD symptoms. GC-sensitivity of leukocytes prior to deployment predicts fatigue, depressive, and PTSD symptomatology in response to deployment. Notably, fatigue, depressive, and PTSD symptoms were differentially associated with GC-sensitivity of monocytes and T-cells and therefore may have specific biological underpinnings.

Distress Symptoms and High-Risk Behaviors Prospectively Associated With Treatment Use Among Returning Veterans

Distress symptoms and high-risk behaviors among Iraq and Afghanistan veterans were examined as predictors of treatment utilization. Veterans (N=618) completed self-report measures upon treatment enrollment (2005-2008). Two-year utilization data were obtained for five settings: primary care, mental health within primary care, outpatient mental health, emergency room, and inpatient psychiatric. Pain was associated with primary care use; depression, panic, posttraumatic stress disorder (PTSD), alcohol misuse, and aggression were associated with use of other settings. After adjustment for comorbidity, veterans with high levels of PTSD and depression symptoms had more treatment visits across several settings than veterans with lower levels. Specialty mental health utilization was low among those reporting elevated psychiatric symptoms (for example, a mean of 8.8 outpatient visits over two years). Symptoms and high-risk behaviors were differentially associated with treatment settings; PTSD and depression predicted greater treatment use. Veterans may have overutilized emergency care while underutilizing specialty mental health services.