Posttraumatic Stress Disorder Symptoms In Patients Research Articles

Cancer and post-traumatic stress disorder: Diagnosis, pathogenesis and treatment considerations

The purpose of this article was to review the literature regarding diagnosis, pathogenesis, and treatment of post-traumatic stress disorder (PTSD) associated with cancer. We surveyed studies examining the validity of diagnostic scales commonly used to measure PTSD in patients with cancer. Neurobiological underpinnings of PTSD and cancer, including inflammation as the physiological mechanism linking these comorbidities, were examined. Psychopharmacologic and psychotherapeutic treatment of PTSD symptoms in patients with cancer was reviewed. In addition, potential drug-drug interactions between psychotropic medications commonly used to treat PTSD and anti-cancer agents were reviewed. Multiple studies demonstrated the validity of the PTSD Checklist Civilian Version (PCL-C) in diagnosing PTSD in patients with cancer. Research has shown that PTSD as defined in DSM-IV appears to be a better model for conceptualizing distress in patients with cancer than a generalized "distress" model. Epidemiologic studies have shown an increased incidence of PTSD associated with cancer; however, literature regarding characteristics of PTSD in patients with cancer is cross-sectional in nature. Future research focusing on longitudinal, prospective studies to identify patients at risk, determine causal or aggravating factors, and develop preventive interventions is needed. Further study of PTSD in patients with cancer may help increase recognition of this disorder, optimize treatment, and enhance the quality of life of these individuals.

Abstract 2388: Is Fatigue Associated With Symptoms Of Post Traumatic Stress Disorder In Subjects Following Stroke?

Introduction: Significant fatigue affecting quality of life is reported by up to 60% of stroke patients in the 6 months post event. We have previously reported an association between post fatigue and anxiety measured by Hospital Anxiety and Depression Score in stroke survivors. Stroke presents frequently as an unexpected potentially life threatening event with features similar to traumatic episodes such as accidents etc. Traumatic events may in turn be associated with development of the anxiety disorder Post Traumatic Stress Disorder (PTSD). We hypothesised that post-stroke fatigue may be related to a PTSD like phenomenon. Method: Independent patients (modified Rankin score <3) who were cognitively intact (AMTS >6) with a history of stroke attending a secondary prevention clinic were approached to participate in the study. All underwent a detailed 1-2 hour interview including assessment of fatigue using 2 tools, the Fatigue Assessment Scale (FAS) and the Fatigue Severity Score (FSS). PTSD severity was assessed using the Clinician Administered PTSD Scale (CAPS). The CAPS is a 30-item structured interview that corresponds to the DSM-IV criteria for PTSD. The CAPS is a standard criterion for the assessment and diagnosis of PTSD. Results: The study was terminated early after 18 patients completed assessments (15 male, median 70 years) due to unexpected distress experienced by some patients in completing the CAPS requiring referral to psychological support services. CAPS correlated strongly with FAS (r=0.72 (95%CI 0.39-0.89) p=0.0007). Seven subjects had a FAS score>20, of these 3 had symptoms of moderate to severe PTSD. No subjects with a FAS <21 had such symptoms (p=0.04, Fishers Exact test). The FSS also correlated with the CAPS but less strongly (r=0.50, p=0.03) Conclusion: Symptoms of PTSD are found in a proportion of patients following stroke. Although subject numbers are small there appears to be a strong correlation between fatigue severity and symptoms of PTSD in patients with stroke.

Reduced Amygdala Serotonin Transporter Binding in Posttraumatic Stress Disorder

The amygdala is a key site where alterations in the regulation of the serotonin transporter (5-HTT) may alter stress response. Deficient 5-HTT function and abnormal amygdala activity have been hypothesized to contribute to the pathophysiology of posttraumatic stress disorder (PTSD), but no study has evaluated the 5-HTT in humans with PTSD. On the basis of translational models, we hypothesized that patients diagnosed with PTSD would exhibit reduced amygdala 5-HTT expression as measured with positron emission tomography and the recently developed 5-HTT-selective radiotracer [(11)C]AFM. Fifteen participants with PTSD and 15 healthy control (HC) subjects without trauma history underwent a resting-state positron emission tomography scan. [(11)C]AFM binding potential (BP(ND)) within the combined bilateral amygdala region of interest was significantly reduced in the PTSD group compared with the HC group (p = .027; 16.3% reduction), which was largely driven by the between-group difference in the left amygdala (p = .008; 20.5% reduction). Furthermore, amygdala [(11)C]AFM BP(ND) was inversely correlated with both Hamilton Rating Scale for Anxiety scores (r = -.55, p = .035) and Montgomery-Åsberg Depression Rating Scale scores (r = -.56, p = .029). Our findings of abnormally reduced amygdala 5-HTT binding in PTSD and its association with higher anxiety and depression symptoms in PTSD patients support a translational neurobiological model of PTSD directly implicating dysregulated 5-HTT signaling within neural systems underlying threat detection and fear learning.

Structure of Posttraumatic Stress Disorder Symptoms in Pain and Pain-Free Patients Scheduled for Major Surgery

Factor-analytic studies of the structure of posttraumatic stress disorder (PTSD) symptoms have yielded inconsistent results. One of the reasons for the inconsistency may be that PTSD is highly comorbid with other disorders; the observed factor structure might depend on the particular comorbid disorder. One such disorder is chronic pain. The goal of the present study was to investigate whether PTSD symptom structure differs between pain and pain-free patients scheduled to undergo major surgery. Four hundred and forty-seven patients who were approached 7 to 10 days prior to scheduled surgery completed the PTSD Checklist-Civilian (PCL-C) Version and the Current Pain and Pain History Questionnaire; the latter was used to divide patients into pain (N = 175) and pain-free (N = 272) groups. Results showed that in pain-free patients, PTSD symptoms were best expressed as 2 symptom clusters (re-experiencing/avoidance; emotional numbing/hyperarousal) accounting for 52.4% of the variance. In pain patients, PTSD symptoms were best expressed as a single symptom cluster accounting for 51.1% of the variance. These results suggest different interrelationships among PTSD symptoms in these 2 populations. Results reflect the need for (1) controlling for pain in studies looking at PTSD-symptom expression and (2) further research on PTSD-symptom expression in pain populations. These results may have important implications for research on the comorbidity between PTSD and chronic pain, as well as for treatment of PTSD symptoms in patients presenting with pain problems.

Treatment of Acute Stress Disorder: A Randomized Controlled Trial

Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Intent-to-treat analyses indicated that at post-treatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD (Fig 3).

Prolonged Exposure Therapy Helps Ward off PTSD

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessProlonged Exposure Therapy Helps Ward off PTSDAaron LevinAaron LevinSearch for more papers by this authorPublished Online:4 Jul 2008https://doi.org/10.1176/pn.43.13.0013aPatients with acute stress disorder had fewer posttraumatic stress disorder (PTSD) symptoms at follow-up after a clinical trial of exposure-based therapy than did patients getting cognitive restructuring therapy or placed on a treatment waiting list, according to Australian psychologist Richard Bryant, Ph.D.More attention in recent years to early intervention following traumatic events has increased interest in what the primary therapeutic approach should be, wrote Bryant and colleagues in the June Archives of General Psychiatry.The researchers studied 90 patients who had experienced nonsexual assault or a motor vehicle crash and were diagnosed with acute stress disorder (ASD) from 2002 to 2006. They were randomized to receive five 90-minute sessions of either prolonged exposure therapy or cognitive restructuring therapy. A third group was placed on a wait list and told they would be reassessed after six weeks and then offered active treatment.Prolonged exposure patients were told to “verbalize reliving the trauma experience in a vivid manner that involved all perceptual and emotional details.” They were given homework exercises. Later sessions and homework included visualizing images of trauma exposure and real-life exposure to associations with their trauma. The last session included relapse-prevention strategies to help patients damp down PTSD symptoms if they recurred.Cognitive restructuring (CR) treatment involved identifying and monitoring maladaptive thoughts by “Socratic questioning, probabilistic reasoning, and evidence-based thinking.” Some homework and relapse prevention were included in this treatment too.Prolonged exposure showed large effect sizes, and cognitive restructuring showed moderate effect sizes, compared with the wait-list group. After six weeks, 33 percent of the exposure group met PTSD criteria compared with 63 percent of the cognitive restructuring patients, and 77 percent of those on the wait list.At the six-month follow-up, 37 percent of the exposure group met PTSD criteria while 63 percent of the cognitive restructuring group did. The researchers did not compare a combination of the two therapies with the single treatments.The effect was seen early in the course of exposure treatment, even as cognitive restructuring patients continued experiencing distress.Many therapists hesitate to use exposure therapy because it can cause distress and possibly drive patients away from therapy, according to the researchers. However, only five subjects reported adverse effects, all due to high distress, and dropped out of the study. Two subjects were in the exposure arm, and two were in the CR arm. Overall, patients getting exposure therapy reported less distress at the end of the last three sessions than did patients getting CR therapy.“Dropout rates in the present study were comparable to dropout rates across chronic PTSD studies,” wrote Bryant and colleagues.In a rigorous review of treatments for PTSD, the U.S. Institute of Medicine last fall said that the only treatment for PTSD supported by a strong evidence base was exposure therapy.“The current findings suggest that direct activation of trauma memories is particularly useful for prevention of PTSD symptoms in patients with ASD,” they wrote. “[A]daptation occurs when the individual repeatedly engages with trauma reminders and learns that there is no aversive outcome.”The study showed that not only was using prolonged exposure treatment beneficial, but also it did not result in more therapy dropouts or aversive responses than other approaches.For Bryant and colleagues, the conclusions are clear. “[T]here is a need to better educate mental health care providers about the use of [prolonged exposure] as a frontline intervention for ASD,” they said.“Treatment of Acute Stress Disorder: A Randomized Controlled Trial” is posted at<http://archpsyc.ama-assn.org/cgi/content/short/65/6/659>.▪ ISSUES NewArchived

Treatment of Acute Stress Disorder

Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Intent-to-treat analyses indicated that at posttreatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD.

(336/934): Clinical relationship between chronic pain and chronic combat related post traumatic stress disorder

Recent research and clinical practice suggest that there is strong interdependence between chronic pain and chronic post-traumatic stress disorder (PTSD), and there are several pathways by which both disorders may be involved in the escalation of symptoms and distress following trauma. The authors analysed the relationship between chronic pain and chronic combat-related PTSD among Croatian veterans. The 150 patients with chronic combat-related PTSD and chronic pain, who were treated at the Osijek University Clinical Hospital during year 2005, were selected as the sample for this study. On the base of clinical interviews, medical records and different self reported questionnaires (Mississippi Scale for combat-related PTSD, Mc Gill Pain Questionnaire, Pain Outcomes Questionnaire, Brief Pain Inventory, Beck Depression Inventory) the authors analysed the characteristics of chronic pain and PTSD, as well as pharmacological and non-pharmacological approaches that were used in the treatment. Combat veterans with PTSD reported in descending order back pain, headache pain, limb pain and torso pain. Intrusive symptoms of PTSD were significantly related to pain intensity and pain disability. Anxiety and depression were highly correlated to pain. All patients were treated with psychotropic drugs as well as with analgetics. The high levels of pain symptoms in PTSD patients suggests that pain is an important issue that needs to be recognized and treated by multidisciplinary approach. Rational polypharmacy may be essential to achieving and maintaining the full recovery of both disorders. But, pharmacotherapy alone is no sufficient to provide complete remission, and non-pharmacological methods have also very important place in the treatment of those patients.

Elevated Cerebrospinal Fluid Substance P Concentrations in Posttraumatic Stress Disorder and Major Depression

The authors tested the hypothesis that concentrations of the pain-transmitting neuropeptide substance P are elevated in the CSF of patients with major depression or posttraumatic stress disorder (PTSD), which have overlapping symptoms. The authors also sought to determine if CNS substance P concentrations change on provocation of symptoms in PTSD patients. The authors measured CSF substance P concentrations in medication-free patients with either major depression or PTSD and in healthy comparison subjects. Next, using a within-subject, crossover design, the authors sampled CSF for 6 hours through an indwelling subarachnoid catheter in PTSD patients before, during, and after exposure to a 60-minute traumatic or neutral videotape stimulus. Both depressed and PTSD patients had significantly elevated basal CSF substance P concentrations. In the challenge study, marked increases in CSF substance P concentrations were found only after precipitation of PTSD symptoms. CSF substance P concentrations increased by 169% and 90.6% of baseline levels at 10 and 70 minutes, respectively, after the start of the traumatic videotape but changed by only 1.1% and -8.1% of baseline levels 10 and 70 minutes after the start of the neutral videotape. These results suggest that elevated CNS substance P concentrations are involved in both major depression and PTSD. The marked increase in CSF substance P concentrations during and after the symptom-provoking stimulus, but not after the neutral stimulus, implicates CNS release of substance P in the mechanism of acute PTSD symptoms. These data also reveal that CNS substance P responds acutely to psychological stress in humans.

Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder

Background: Psychotic symptoms may be present in up to 40% of patients with combat-related posttraumatic stress disorder (PTSD). In this study, we hypothesized that severity of psychotic symptoms would also reflect severity of PTSD symptoms in patients with well-defined psychotic features. Methods: Forty-five Vietnam combat veterans with PTSD but without a primary psychotic disorder diagnosis underwent a Structured Clinical Interview for DSM-III-R with Psychotic Screen, and the Clinician Administered PTSD Scale (CAPS). Patients identified as having psychotic features (PTSD-P), ( n = 22) also received the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HDRS). Results: There was a significant positive correlation between the CAPS and PANSS global ratings ( p < .001) and the HDRS and PANSS ( p < .03) in the PTSD-P patients. Many CAPS and PANSS subscales also demonstrated significant intercorrelations; however, the CAPS-B subscale (reexperiencing) and the PANSS positive symptom scale were not correlated, suggesting that psychotic features may not necessarily be influenced or accounted for by more severe reexperiencing symptoms. Fifteen (68%) of the PTSD-P patients had major depression (MDD). Both CAPS and PANSS ratings were significantly higher in the PTSD-P patients with comorbid MDD. Conclusions: As postulated, patients with more severe psychosis ratings are likely to have more severe PTSD disease burden if psychotic features are present. This study further documents the occurrence of psychotic features in PTSD that are not necessarily due to a primary psychotic disorder, suggesting that this may be a distinct subtype; however, a significant interaction likely exists between PTSD, depression, and psychotic features.