Subsequent Psychopathology Research Articles

Psychiatric Disorders Among Adults Seeking Emergency Disaster Assistance After a Wildland-Urban Interface Fire

This study estimated the prevalence of psychopathology at a three-month follow-up among persons seeking emergency relief services after a wildfire and identified a practical screener for use in these disaster assistance settings to aid early identification of persons at risk of subsequent psychopathology. During the October 2003 California firestorm that occurred at the wildland-urban interface, 357 persons who were seeking assistance from adjacent American Red Cross and government relief centers were recruited for this study. Within days of mandatory evacuation, participants completed baseline self-administered questionnaires assessing demographic characteristics, initial subjective reactions, and degree of fire exposure. At the three-month follow-up, symptoms of posttraumatic stress disorder (PTSD) and major depression were measured via a mailed survey. At follow-up 33% showed evidence of probable major depression; 24% exhibited probable PTSD. On a bivariate basis, seven initial reaction and fire exposure items were significantly associated with subsequent psychopathology. Best-subsets logistic regression analyses revealed that property damage and physical injury were the best multivariate predictors of psychopathology at follow-up. No additional items provided a significant incremental improvement in prediction. Individuals seeking immediate emergency assistance related to the wildland-urban interface fire were at elevated risk of psychopathology in the weeks after the fire. A short, easily administered, two-item screener, composed of items assessing fire exposure severity, appears to hold promise for aiding early identification of persons at risk of postfire psychopathology. These findings may also have implications for other mass disasters.

Childhood Separation Anxiety and the Risk of Subsequent Psychopathology: Results from a Community Study

Objective: To examine the association between separation anxiety disorder (SAD) and mental disorders in a community sample and to evaluate whether separation anxiety is specifically related to panic disorder with and without agoraphobia. Method: The data come from a 4-year, prospective longitudinal study of a representative cohort of adolescents and young adults aged 14–24 years at baseline in Munich, Germany. The present analyses are based on a subsample of the younger cohort that completed baseline and two follow-up investigations (n = 1,090). DSM-IV diagnoses were made using the Munich Composite International Diagnostic Interview. Cox regressions with time-dependent covariates were used to examine whether prior SAD is associated with an increased risk for subsequent mental disorders. Results: Participants meeting DSM-IV criteria for SAD were at an increased risk of developing subsequent panic disorder with agoraphobia (PDAG) (HR = 18.1, 95% CI = 5.6–58.7), specific phobia (HR = 2.7, 95% CI = 1.001–7.6), generalized anxiety disorder (HR = 9.4, 95% CI = 1.8–48.7), obsessive-compulsive disorder (HR = 10.7, 95% CI = 1.7–66.1), bipolar disorder (HR = 7.7, 95% CI = 2.8–20.8), pain disorder (HR = 3.5, 95% CI = 1.3–9.1), and alcohol dependence (HR = 4.7, 95% CI = 1.7–12.4). Increased hazard rates for PDAG (HR = 4.2, 95% CI = 1.4–12.1), bipolar disorder type II (HR = 8.1, 95% CI = 2.3–27.4), pain disorder (HR = 1.9, 95% CI = 1.01–3.5), and alcohol dependence (HR = 2.1, 95% CI = 1.1–4.) were also found for subjects fulfilling subthreshold SAD. Conclusions: Although revealing a strong association between SAD and PDAG, our results argue against a specific SAD-PDAG relationship. PDAG was neither a specific outcome nor a complete mediator variable of SAD.

Broadening the definition of generalized anxiety disorder: Effects on prevalence and associations with other disorders in the National Comorbidity Survey Replication

Concerns have been raised that the DSM-IV requirements of 6-month duration, excessive worry, and three associated symptoms exclude a substantial number of people with clinically significant anxiety from a diagnosis of generalized anxiety disorder (GAD). We examined the implications of relaxing these three criteria for the estimated prevalence and predictive validity of GAD using nationally representative data from the US National Comorbidity Survey Replication. Relaxing all three criteria more than doubles the estimated prevalence of GAD. Broadly defined GAD significantly predicts the subsequent first onset of a wide range of temporally secondary disorders. The odds of secondary disorders are somewhat smaller for broadly defined than DSM-IV GAD, though few of these differences are statistically significant. Results suggest that subthreshold manifestations of GAD are significantly related to elevated risk of subsequent psychopathology. Further research is needed to determine whether broadening the current diagnostic criteria results in a more valid characterization of GAD.

Recent fear is resistant to extinction

In some individuals, fearful experiences (e.g., combat) yield persistent and debilitating psychological disturbances, including posttraumatic stress disorder (PTSD). Early intervention (e.g., debriefing) after psychological trauma is widely practiced and argued to be an effective strategy for limiting subsequent psychopathology, although there has been considerable debate on this point. Here we show in an animal model of traumatic fear that early intervention shortly after an aversive experience yields poor long-term fear reduction. Extinction trials administered minutes after aversive fear conditioning in rats suppressed fear acutely, but fear suppression was not maintained the next day. In contrast, delivering extinction trials 1 day after fear conditioning produced an enduring suppression of fear memory. We further show that the recent experience of an aversive event, not the timing of the extinction intervention per se, inhibits the development of long-term fear extinction. These results reveal that the level of fear present at the time of intervention is a critical factor in the efficacy of extinction. Importantly, our work suggests that early intervention may not yield optimal outcomes in reducing posttraumatic stress, particularly after severe trauma.

P.6.c.008 One year retention rates and outcomes methadone and buprenorphine maintenance treatments: a nationwide prospective-longitudinal study of 2694 patients

The concept of fearful spells (FS) denotes distressing spells of anxiety that might or might not qualify for criteria of panic attacks (PA). Few studies examined prospective-longitudinal associations of FS not meeting criteria for PA with the subsequent onset of mental disorders to clarify the role of FS as risk markers of psychopathology.A representative community sample of adolescents and young adults (N = 3021, age 14–24 at baseline) was prospectively followed up in up to 3 assessment waves over up to 10 years. FS, PA, anxiety, depressive, and substance use disorders were assessed using the DSM-IV/M-CIDI. Odds Ratios (OR) from logistic regressions were used to examine the predictive value of FS-only (no PA) and PA at baseline for incident disorders at follow-up.In logistic regressions adjusted for sex and age, FS-only predicted the onset of any subsequent disorder, any anxiety disorder, panic disorder, agoraphobia, GAD, social phobia, any depressive disorder, major depression, and dysthymia (ORs 1.54–4.36); PA predicted the onset of any anxiety disorder, panic disorder, GAD, social phobia, any depressive disorder, major depression, dysthymia, any substance use disorder, alcohol abuse/dependence, and nicotine dependence (ORs 2.08–8.75; reference group: No FS-only and no PA). Associations with psychopathology were slightly smaller for FS-only than for PA, however, differences in associations (PA compared to FS-only) only reached significance for any anxiety disorder (OR = 3.26) and alcohol abuse/dependence (OR = 2.26).Findings suggest that compared to PA, FS-only have similar predictive properties regarding subsequent psychopathology and might be useful for an early identification of high-risk individuals.

Immunological stress at the maternal–foetal interface: A link between neurodevelopment and adult psychopathology

Maternal infection during pregnancy is associated with a higher incidence of mental disorders, including schizophrenia, in the offspring in later life. Our recent attempt to study this link between prenatal immunological challenge and subsequent psychopathology has led to the establishment of a mouse model demonstrating the emergence of multiple psychotic-like phenotypes following immunological challenge on gestation day (GD) 9. However, little is known about the impact of similar in utero challenge at different times of pregnancy. Here, we compare the efficacy of identical maternal immune stimulation induced by the exposure to polyriboinosinic–polyribocytidilic acid (Poly(I:C)) at a dose of 5 mg/kg (i.v.) on distinct days of gestation (GD 6, 9, 13 or 17). The offspring derived were then compared to those collected from vehicle- and non-treated dams in two paradigms of selective associative learning: latent inhibition (LI) and the US-pre-exposure effect (USPEE). LI deficiency was observed in animals born to dams treated with Poly(I:C) on GD 6, 9 or 13, but not in those on GD17. In contrast, a loss of the USPEE was equivalently seen in all Poly(I:C) treatment groups, regardless of treatment times. Evaluation of the acute cytokine response in a separate cohort of pregnant dams receiving Poly(I:C) challenge on either GD9 or GD17 revealed that the ratio of interleukin-10/tumor necrosis factor-α was elevated in the GD17 relative to the GD9 group. The present report thus provides evidence that the acute cytokine reaction as well as the long-term pattern of behavioural sequelae of maternal immune challenge can be affected by its precise timing during pregnancy. The present study provides further support to the use of the prenatal Poly(I:C) model in the elucidation of mechanisms involved in the aetiology and disease process of immuno-precipitated neurodevelopmental mental diseases, including but not limited to, schizophrenia.

Psychological injury in the two World Wars: changing concepts and terms in German psychiatry

This paper describes how German psychiatrists in two World Wars treated psychologically injured soldiers, and the concepts of related illnesses which they developed. The literature is reviewed, and symptomatolgy of patients and therapeutic practice in the wars are compared. By 1916 German psychiatrists had already established a concept of illness that continued to be used until World War II and beyond, albeit with a changing terminology. The vague term 'war neurosis' was commonly used, but covered different, partly overlapping concepts. Psychiatrists considered the disorder as a psychogenetic reaction based on an individual predisposition and denied a causal link between the experience of war and subsequent psychopathology. It may be concluded that psychiatrists developed theoretical models and practical treatment methods in a manner that met the social and military requirements of the time.

Impact of child sexual abuse on mental health: prospective study in males and females.

The lack of prospective studies and data on male victims leaves major questions regarding associations between child sexual abuse and subsequent psychopathology. To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design. Children (n=1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period. Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v. 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v.10.2%). This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.

Attachment relationship experiences and childhood psychopathology.

Human infants form attachments to their caregivers gradually over the course of the first year of life. Qualitatively different types of attachments, which can be identified by the end of the first year, are broadly predictive of subsequent adaptive outcomes for young children. "Disorganized" patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment. Clinical disorders of attachment have been demonstrated to arise under conditions of social deprivation, such as institutionalization and maltreatment. An emotionally withdrawn/inhibited pattern and an indiscriminate/disinhibited pattern both have been described. Although these clinical types arise under similar conditions of environmental adversity, they tend to have different courses over time. We describe recent findings and highlight areas of emerging consensus and areas of continuing controversy regarding both disorganized patterns of attachment and clinical disorders of attachment in young children.

More on Adverse Childhood Experiences

Society is becoming aware of the important contributions of adverse childhood experiences to subsequent psychopathology. Two survey studies of unique

Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey.

This study examined the relationship between child sexual abuse (CSA) and subsequent onset of psychiatric disorders, accounting for other childhood adversities, CSA type, and chronicity of the abuse. Retrospective reports of CSA, other adversities, and psychiatric disorders were obtained by the National Comorbidity Survey, a nationally representative survey of the United States (n = 5877). Reports were analyzed by multivariate methods. CSA was reported by 13.5% of women and 2.5% of men. When other childhood adversities were controlled for, significant associations were found between CSA and subsequent onset of 14 mood, anxiety, and substance use disorders among women and 5 among men. In a subsample of respondents reporting no other adversities, odds of depression and substance problems associated with CSA were higher. Among women, rape (vs molestation), knowing the perpetrator (vs strangers), and chronicity of CSA (vs isolated incidents) were associated with higher odds of some disorders. CSA usually occurs as part of a larger syndrome of childhood adversities. Nonetheless, CSA, whether alone or in a larger adversity cluster, is associated with substantial increased risk of subsequent psychopathology.

The effect of prenatal cocaine exposure on the stress response of adult mice.

The neurotoxic consequences of intrauterine exposure to drugs of abuse, including cocaine, may include compromised fetal brain development with associated lasting behavioral alterations. Some infants exposed to cocaine in utero demonstrate impairments in reactivity and altered behavioral responses to stressful conditions. Alterations in arousal regulation can impact on socialization, adaptation, and educability. Moreover, such alterations may render cocaine-exposed children more vulnerable to the adverse developmental impact of stressful situations, with implications for subsequent behavior and psychopathology. Animal models facilitate the independent analysis and identification of genetic, intrauterine, and postnatal environmental factors in contributing to cocaine-induced alterations in behavioral and neurochemical responses to stressors. Utilizing a prenatal mouse model of gestational cocaine exposure we have identified a behavioral alteration evident as decreased duration of footshock-induced immobility termed "freezing" in cocaine-exposed adults as compared with controls. However, this attenuated behavioral response was not accompanied by demonstrable alterations in corticosterone response, nor was the corticosterone response altered in cocaine-exposed adults following a more protracted restraint-induced stress. The dissociation of these behavioral and neurochemical indices of altered response to stressors may provide insights regarding brain mechanisms underlying alterations in behavioral reactivity to stressful conditions following in utero cocaine exposure. In addition, this preclinical study may have implications for improved diagnostics and therapeutics for infants and children exposed to cocaine in the womb.

Parenting and adult mood, anxiety and substance use disorders in female twins: an epidemiological, multi-informant, retrospective study.

Although parenting has long been considered an important risk factor for subsequent psychopathology, most investigations of this question have studied a single informant, clinical populations, one or a few disorders and did not consider relevant covariates. Three dimensions of parenting (coldness, protectiveness and authoritarianism) were measured by combining the retrospective reports from adult female twins, their co-twins, and their mothers and fathers. We assessed by personal interview, lifetime history in the twins of eight common psychiatric and substance abuse disorders and a range of predictors of parenting. Analyses were performed using logistic regression. Examined individually, high levels of coldness and authoritarianism were modestly but significantly associated with increased risk for nearly all disorders, while the impact of protectiveness was more variable. These associations declined modestly when putative predictors of parenting were added as covariates. Maternal and paternal parenting were equally associated with outcomes in adult daughters. When coldness, protectiveness and authoritarianism were examined together, nearly all significant associations were seen solely with coldness. Few significant interactions were found between maternal and paternal parenting or between coldness, protectiveness and authoritarianism. The shared experience of these three dimensions of parenting predicts a quite small correlation in liability to these disorders in dizygotic twin pairs (e.g. r < 0.04). In women, parenting behaviour, especially levels of coldness, is probably causally related to risk for a broad range of adult psychiatric disorders. The impact of parenting on substance use disorders may be largely mediated through their co-morbidity with major depression, phobias and generalized anxiety disorder. In general population samples, the association of poor parenting with psychiatric illness is modest, largely non-specific and explains little of the observed aggregation of these disorders in families.

Recall of shame and favouritism in relation to psychopathology.

There is good evidence that early rearing experiences affect vulnerability to subsequent psychopathology. Recent research on memories of rearing style have been influenced by attachment theory and have focused primarily on domains of emotional warmth and control. However, early experiences of being shamed, criticized and made to feel inferior, together with believing one's sibling is favoured over oneself, are also likely to play a role in vulnerability. This study therefore explored recall of being shamed and sibling favouritism. A large community sample (N = 638) and a varied non-psychotic patient sample (N = 213) completed two recall of parent rearing scales (the PBI and EMBU). These gave measures of recall of emotional warmth, overprotection/control, being shamed and shown up, and self or sibling favouring. Participants also completed the SCL-90-R scale. Patients recalled less warmth, more control, more shame and more favouring of siblings than the community sample. The difference was greatest for shame, and following MANOVA analysis shame remained significantly different between the two groups even after controlling for emotional warmth and control. Similarly, recalling being less favoured than a sibling and shamed had robust associations with indicators of psychopathology and these were only marginally reduced when emotional warmth was controlled for. Moreover, hostility (as measured by the SCL-90-R) was specifically related to recall of being shamed but not emotional warmth. This study suggests that over and above issues of emotional warmth and control, recall of direct experiences of being shamed, feeling inferior and less favoured in a family, may be particularly pathogenic. They operate independently of warmth and may be especially important in proneness to hostile feelings. Given this, therapists may wish to specifically explore shame issues with patients.

Reported sexual abuse and subsequent psychopathology among women attending psychology clinics: the mediating role of dissociation.

While there is now a good clinical research base that outlines the links between reported sexual abuse and psychological symptoms and disorders, there is less of an understanding of the psychological processes mediating that relationship. This study assessed the role of dissociation as a mediator between reported sexual abuse and a range of psychopathological characteristics. A patient-series design was used. Participants were an unselected sample of 45 women attending clinical psychology services. Each woman was interviewed regarding a reported history of sexual abuse, and completed standardized measures of general psychopathology, borderline personality disorder characteristics and dissociation. Sexual abuse per se was associated with the extent of depression, somatization, compulsive behaviour, phobic symptoms and borderline personality disorder characteristics. In each case, dissociation served as a complete mediator in that link. However, the same mediating relationship was not found when attempting to explain the greater psychopathological impact of more 'severe' forms of abuse (childhood experiences; intra-familial abuse). These findings suggest that the effective of clinical work with these psychopathological features would be enhanced if dissociation symptoms were addressed in women with a reported history of sexual abuse. However, the importance of that therapeutic target may be unrelated to the severity of the psychological disturbance.

Discussion 5A

Several investigators have examined the relationship between a patient's premorbid personality and behavioral disturbances of dementia. Dr. Swearer described a study in which she examined whether premorbid personality was a predictor of disordered behaviors in dementia. Specifically, she considered whether premorbid aggression predicted subsequent aggressive behaviors, whether premorbid suspiciousness predicted disordered ideation, and whether premorbid restlessness predicted hyperkinesia. She found a relationship only between premorbid aggression and subsequent dementia-related aggressive behaviors. However, this finding appeared to be due to recall bias of caregivers of patients who were aggressive at the time of evaluation. This suggests that premorbid personality traits do not predispose to subsequent behavioral disturbances in dementia. On the other hand, in retrospective analyses, Drs. Whitehouse and Strauss and colleagues have found that premorbid personality predicts subsequent psychopathology.

Characteristics of childhood sexual abuse and adult psychopathology in female psychiatric patients.

The present study investigated the relationship of characteristics of childhood sexual abuse and subsequent psychopathology. Referrals to a female psychiatrist in private practice in an urban working class area provided 73 adult female subjects who reported having been sexually abused in childhood. Data were collected on age at onset, duration, physical invasiveness of the abuse, violence, and the number and relationship of abusers. Having had multiple abusers in childhood was significantly (p < 0.01) associated with every outcome measure of severe psychopathology: an initial Global Assessment Functioning score of 50 or below; both single and repeated incidents of deliberate self-harm; overdose; self-mutilation; and psychiatric hospital admission. Notably, having had multiple abusers was the only characteristic showing a reliable independent association with any of these measures. Subjects who had had multiple abusers were significantly more likely to have an earlier age of onset and longer duration of abuse, and to have experienced violent abuse.

Recent undesirable life events: their influence on subsequent psychopathology.

Life events appear to exert a range of effects on subsequent behaviour through their impact on affective-cognitive processes. Their effects on those physiological processes pertinent to psychopathology have yet to be investigated. Single events do not exert much risk for subsequent disorder. It is the pattern of adverse life experiences, of which recent life events is frequently a component, that determines the degree of risk and the mechanisms and processes that may lead to subsequent psychopathology. Recall of events that occurred in the recent past may be influenced independently by the age of the individual and a previous episode of psychiatric disorder. Longitudinal studies determining the impact of life events on subsequent behaviour will need to take these features into account. There remains no specificity between particular types of recent undesirable life events and anxious or depressive disorders. Future longitudinal research should employ modern methods of life event data collection and measurement. The goal of future longitudinal research should be to determine the relative contribution of undesirable and desirable recent life events in the presence and absence of other putative casual factors from different domains. This should necessarily include social (e.g. long-term difficulties), psychological (e.g, temperament (18) or self esteem) and physiological (e.g. hypercortisolaemia in adolescent major depression (14, 11) elements. It is only through this combination of longitudinal design, together with sensitive and concurrent multiple repeat measurements that a greater understanding of the mechanisms and processes that determine psychopathology over the course of development will occur.

Acute stress disorder, subsequent posttraumatic stress disorder and depression after a series of typhoons.

From August to November 1992, five typhoons struck the U.S. Pacific island territory of Guam. Three hundred and twenty subjects exposed to all five typhoons participated in a population survey measuring their acute stress symptoms and subsequent diagnoses of posttraumatic stress disorder (PTSD) and depression. A 23-item scale approximating the new DSM-IV diagnosis of acute stress disorder (ASD) was used to classify subjects into three groups based on their symptoms one week after the first typhoon: (1) probable ASD, (2) an early traumatic stress response (ETSR) of fear, intrusion, avoidance, and arousal, without dissociation, and (3) no acute diagnosis. A multi-dimensional measure of PTSD and the Zung Self-Rating Depression Scale were used to assess PTSD and depression 8 months after the first storm. The point prevalence of ASD at one week was 7.2%. An additional 15% of subjects had ETSR. Subjects with probable ASD at one week had significantly increased rates of PTSD and somewhat higher rates of depression at 8 months than those without ASD. In contrast, subjects with ETSR at one week did not have a poorer outcome than those with no acute diagnosis. These findings suggest that ASD is prognostically important, but also indicate that all acute stress symptoms do not have the same discriminative value. In this study, the acute dissociative symptoms of emotional numbing and derealization differentiated highly symptomatic subjects at risk for subsequent psychopathology (ASD) from others who were highly symptomatic at one week, but then had a more benign, posttraumatic course (ETSR).

A 50-year prospective study of the psychological sequelae of World War II combat

The authors took advantage of a 50-year prospective study of World War II veterans to examine the predictors and correlates of combat exposure, symptoms of posttraumatic stress disorder (PTSD), and trait neuroticism. The subjects were 107 veterans who had been extensively studied before and immediately after serving overseas in World War II. All served as members of the study until the present time, and 91 completed questionnaires of both PTSD symptoms and neuroticism. In this study group, variables associated with positive psychosocial health in adolescence and at age 65 predicted combat exposure. Combat exposure and number of physiological symptoms during combat stress--but not during civilian stress--predicted symptoms of PTSD in 1946 and 1988. Combat exposure also predicted early death and study attrition. Psychosocial vulnerability in adolescence and at age 65 and physiological symptoms during civilian stress--but not during combat stress--predicted trait neuroticism at age 65. Combat exposure predicted symptoms of PTSD but not nonspecific measures of psychopathology. Premorbid vulnerability predicted subsequent psychopathology but not symptoms of PTSD.