A memory-based model of posttraumatic stress disorder: evaluating basic assumptions underlying the PTSD diagnosis.

In the mnemonic model of posttraumatic stress disorder (PTSD), the current memory of a negative event, not the event itself, determines symptoms. The model is an alternative to the current event-based etiology of PTSD represented in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The model accounts for important and reliable findings that are often inconsistent with the current diagnostic view and that have been neglected by theoretical accounts of the disorder, including the following observations. The diagnosis needs objective information about the trauma and peritraumatic emotions but uses retrospective memory reports that can have substantial biases. Negative events and emotions that do not satisfy the current diagnostic criteria for a trauma can be followed by symptoms that would otherwise qualify for PTSD. Predisposing factors that affect the current memory have large effects on symptoms. The inability-to-recall-an-important-aspect-of-the-trauma symptom does not correlate with other symptoms. Loss or enhancement of the trauma memory affects PTSD symptoms in predictable ways. Special mechanisms that apply only to traumatic memories are not needed, increasing parsimony and the knowledge that can be applied to understanding PTSD.

The reappearance hypothesis revisited: recurrent involuntary memories after traumatic events and in everyday life.

Recurrent involuntary memories are autobiographical memories that come to mind with no preceding retrieval attempt and that are subjectively experienced as being repetitive. Clinically, they are classified as a symptom of posttraumatic stress disorder. The present work is the first to systematically examine recurrent involuntary memories outside clinical settings. Study 1 examines recurrent involuntary memories among survivors of the tsunami catastrophe in Southeast Asia in 2004. Study 2 examines recurrent involuntary memories in a large general population. Study 3 examines whether the contents of recurrent involuntary memories recorded in a diary study are duplicates of, or differ from, one another. We show that recurrent involuntary memories are not limited to clinical populations or to emotionally negative experiences; that they typically do not come to mind in a fixed and unchangeable form; and that they show the same pattern regarding accessibility as do autobiographical memories in general. We argue that recurrent involuntary memories after traumas and in everyday life can be explained in terms of general and well-established mechanisms of autobiographical memory.

Flashbulb memories and posttraumatic stress reactions across the life span: age-related effects of the German occupation of Denmark during World War II.

A representative sample of older Danes were interviewed about experiences from the German occupation of Denmark in World War II. The number of participants with flashbulb memories for the German invasion (1940) and capitulation (1945) increased with participants' age at the time of the events up to age 8. Among participants under 8 years at the time of their most traumatic event, age at the time correlated positively with the current level of posttraumatic stress reactions and the vividness of stressful memories and their centrality to life story and identity. These findings were replicated in Study 2 for self-nominated stressful events sampled from the entire life span using a representative sample of Danes born after 1945. The results are discussed in relation to posttraumatic stress disorder and childhood amnesia.

Fear learning circuitry is biased toward generalization of fear associations in posttraumatic stress disorder.

Fear conditioning is an established model for investigating posttraumatic stress disorder (PTSD). However, symptom triggers may vaguely resemble the initial traumatic event, differing on a variety of sensory and affective dimensions. We extended the fear-conditioning model to assess generalization of conditioned fear on fear processing neurocircuitry in PTSD. Military veterans (n=67) consisting of PTSD (n=32) and trauma-exposed comparison (n=35) groups underwent functional magnetic resonance imaging during fear conditioning to a low fear-expressing face while a neutral face was explicitly unreinforced. Stimuli that varied along a neutral-to-fearful continuum were presented before conditioning to assess baseline responses, and after conditioning to assess experience-dependent changes in neural activity. Compared with trauma-exposed controls, PTSD patients exhibited greater post-study memory distortion of the fear-conditioned stimulus toward the stimulus expressing the highest fear intensity. PTSD patients exhibited biased neural activation toward high-intensity stimuli in fusiform gyrus (P<0.02), insula (P<0.001), primary visual cortex (P<0.05), locus coeruleus (P<0.04), thalamus (P<0.01), and at the trend level in inferior frontal gyrus (P=0.07). All regions except fusiform were moderated by childhood trauma. Amygdala-calcarine (P=0.01) and amygdala-thalamus (P=0.06) functional connectivity selectively increased in PTSD patients for high-intensity stimuli after conditioning. In contrast, amygdala-ventromedial prefrontal cortex (P=0.04) connectivity selectively increased in trauma-exposed controls compared with PTSD patients for low-intensity stimuli after conditioning, representing safety learning. In summary, fear generalization in PTSD is biased toward stimuli with higher emotional intensity than the original conditioned-fear stimulus. Functional brain differences provide a putative neurobiological model for fear generalization whereby PTSD symptoms are triggered by threat cues that merely resemble the index trauma.

Preditores de resiliência ao transtorno de estresse pós-traumático: uma metanálise

Ao contrário da maioria dos transtornos psiquiátricos, o transtorno de estresse pós-traumático (TEPT) apresenta uma fator causal necessário, embora não-suficiente: a exposição a um evento traumático (EPT). Em consequência deste evento desenvolvem-se três dimensões de sintomas: revivescência, esquiva/ entorpecimento emocional e hiperexcitabilidade. Um dos achados mais relevantes das pesquisas epidemiológicas de TEPT é que embora a maioria dos indivíduos seja exposta a um evento traumático em algum momento de sua vida, apenas uma minoria destes vai desenvolver o transtorno. Desta forma, a maior parte dos indivíduos expostos pode ser considerada resiliente. A resiliência consiste, portanto, na capacidade de adaptação eficaz diante de um distúrbio, estresse ou adversidade. Foi realizada uma revisão sistemática com metanálise de estudos longitudinais que investigaram fatores preditores de resiliência ao desenvolvimento de TEPT. A ausência de TEPT foi considerada proxy de resiliência. Em função do grande número de estudos identificados pela estratégia de busca, decidimos post hoc restringir as variáveis preditoras a apoio social (AS), personalidade, autoestima e eventos de vida potencialmente estressantes (EVPE). Apenas vinte artigos preencheram os critérios de elegibilidade. Treze estudos avaliaram apoio social, nove avaliaram personalidade e dois avaliaram EVPE. Nenhum dos trabalhos que pesquisou autoestima era elegível. Dezesseis dos vinte estudos incluídos nesta revisão avaliaram a associação de interesse na população geral. A maioria dos trabalhos avaliou a exposição de interesse após o EPT. Ainda que alguns destes tenham tentado captar a informação sobre a exposição antes do ocorrido, devido à natureza retrospectiva desta aferição, não há como se isentar o potencial efeito do trauma sobre resultado obtido. Além disso, foi observada grande heterogeneidade entre as pesquisas, limitando o número de estudos incluídos nas metanálises. Neuroticismo foi a única dimensão de personalidade avaliada por mais de um estudo. As medidas sumárias resultantes da combinação destes trabalhos revelaram que maior apoio social positivo prediz resiliência ao TEPT enquanto neuroticismo reduz a chance de resiliência. Os dois estudos que investigaram EVPE não puderam ser combinados. Um deles foi inconclusivo e o outro demonstrou associação entre menor número de EVPE e resiliência. Ressaltamos que as medidas sumárias devem ser interpretadas com cautela devido à grande heterogeneidade entre os estudos. Heterogeneidade na forma de avaliação dos fatores preditores de resiliência ao TEPT é compreensível devido à complexidade dos construtos avaliados. Todavia, a falta de padronização do método de operacionalização reduz a comparabilidade dos resultados.

Changes in neuroticism following trauma exposure.

Using longitudinal data, the present study examined change in midlife neuroticism following trauma exposure. Our primary analyses included 670 participants (M(age) = 60.55; 65.22% male, 99.70% Caucasian) who completed the NEO Personality Inventory at ages 42 and 50 and reported their lifetime exposure to traumatic events approximately 10 years later. No differences in pre- and post-trauma neuroticism scores were found among individuals who experienced all of their lifetime traumas in the interval between the personality assessments. Results were instead consistent with normative age-related declines in neuroticism throughout adulthood. Furthermore, longitudinal changes in neuroticism scores did not differ between individuals with and without histories of midlife trauma exposure. Examination of change in neuroticism following life-threatening traumas yielded a comparable pattern of results. Analysis of facet-level scores largely replicated findings from the domain scores. Overall, our findings suggest that neuroticism does not reliably change following exposure to traumatic events in middle adulthood. Supplemental analyses indicated that individuals exposed to life-threatening traumas in childhood or adolescence reported higher midlife neuroticism than individuals who experienced severe traumas in adulthood. Life-threatening traumatic events encountered early in life may have a more pronounced impact on adulthood personality than recent traumatic events.

The impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults.

The present study examined the impact of the developmental timing of trauma exposure on posttraumatic stress disorder (PTSD) symptoms and psychosocial functioning in a large sample of community-dwelling older adults (N = 1,995). Specifically, we investigated whether the negative consequences of exposure to traumatic events were greater for traumas experienced during childhood, adolescence, young adulthood, midlife, or older adulthood. Each of these developmental periods is characterized by age-related changes in cognitive and social processes that may influence psychological adjustment following trauma exposure. Results revealed that older adults who experienced their currently most distressing traumatic event during childhood exhibited more severe symptoms of PTSD and lower subjective happiness compared with older adults who experienced their most distressing trauma after the transition to adulthood. Similar findings emerged for measures of social support and coping ability. The differential effects of childhood compared with later life traumas were not fully explained by differences in cumulative trauma exposure or by differences in the objective and subjective characteristics of the events. Our findings demonstrate the enduring nature of traumatic events encountered early in the life course and underscore the importance of examining the developmental context of trauma exposure in investigations of the long-term consequences of traumatic experiences.

People who expect to enter psychotherapy are prone to believing that they have forgotten memories of childhood trauma and abuse.

We asked 1004 undergraduates to estimate both the probability that they would enter therapy and the probability that they experienced but could not remember incidents of potentially life-threatening childhood traumas or physical and sexual abuse. We found a linear relation between the expectation of entering therapy and the belief that one had, but cannot now remember, childhood trauma and abuse. Thus individuals who are prone to seek psychotherapy are also prone to accept a suggested memory of childhood trauma or abuse as fitting their expectations. In multiple regressions predicting the probability of forgotten memories of childhood traumas and abuse, the expectation of entering therapy remained as a substantial predictor when self-report measures of mood, anxiety, post-traumatic stress disorder symptom severity, and trauma exposure were included.

Confidence, not consistency, characterizes flashbulb memories.

On September 12, 2001, 54 Duke students recorded their memory of first hearing about the terrorist attacks of September 11 and of a recent everyday event. They were tested again either 1, 6, or 32 weeks later. Consistency for the flashbulb and everyday memories did not differ, in both cases declining over time. However, ratings of vividness, recollection, and belief in the accuracy of memory declined only for everyday memories. Initial visceral emotion ratings correlated with later belief in accuracy, but not consistency, for flashbulb memories. Initial visceral emotion ratings predicted later posttraumatic stress disorder symptoms. Flashbulb memories are not special in their accuracy, as previously claimed, but only in their perceived accuracy.

The effects of the Omagh bomb on adolescent mental health: a school-based study

Background: The main objective of this study was to assess psychiatric morbidity among adolescentsfollowing the Omagh car bombing in Northern Ireland in 1998.

Methods: Data was collected within schools from adolescents aged between 14 and 18 years via a selfcompletionbooklet comprised of established predictors of PTSD; type of exposure, initialemotional response, long-term adverse physical problems, predictors derived from Ehlers andClark’s (2000) cognitive model, a PTSD symptoms measure (PDS) and the General HealthQuestionnaire (GHQ).

Results:Those with more direct physical exposure were significantly more likely to meet caseness onthe GHQ and the PDS. The combined pre and peri trauma risk factors highlighted in previousmeta-analyses accounted for 20% of the variance in PDS scores but the amount of varianceaccounted for increased to 56% when the variables highlighted in Ehlers and Clark’scognitive model for PTSD were added.

Conclusions: High rates of chronic PTSD were observed in adolescents exposed to the bombing. Whilstincreased exposure was associated with increased psychiatric morbidity, the best predictors ofPTSD were specific aspects of the trauma (‘seeing someone you think is dying’), what youare thinking during the event (‘think you are going to die’) and the cognitive mechanismsemployed after the trauma. As these variables are in principle amenable to treatment theresults have implications for teams planning treatment interventions after future traumas.

Outlining new frontiers for the comprehension of obsessive-compulsive disorder: a review of its relationship with fear and anxiety

Anxiety is an important component of the psychopathology of the obsessive-compulsive disorder (OCD). So far, most interventions that have proven to be effective for treating OCD are similar to those developed for other anxiety disorders. However, neurobiological studies of OCD came to conclusions that are not always compatible with those previously associated with other anxiety disorders. OBJECTIVES: The aim of this study is to review the degree of overlap between OCD and other anxiety disorders phenomenology and pathophysiology to support the rationale that guides research in this field. RESULTS: Clues about the neurocircuits involved in the manifestation of anxiety disorders have been obtained through the study of animal anxiety models, and structural and functional neuroimaging in humans. These investigations suggest that in OCD, in addition to dysfunction in cortico-striatal pathways, the functioning of an alternative neurocircuitry, which involves amygdalo-cortical interactions and participates in fear conditioning and extinction processes, may be impaired. CONCLUSION: It is likely that anxiety is a relevant dimension of OCD that impacts on other features of this disorder. Therefore, future studies may benefit from the investigation of the expression of fear and anxiety by OCD patients according to their type of obsessions and compulsions, age of OCD onset, comorbidities, and patterns of treatment response.

Post-traumatic stress disorder in response to HIV infection

This study investigated the psychological impact of HIV infection through assessment of posttraumatic stress disorder in response to HIV infection. Sixty-one HIV-positive homosexual/bisexual men were assessed for posttraumatic stress disorder in response to HIV infection (PTSD-HIV) using a modified PTSD module of the DIS-III-R. Thirty percent met criteria for a syndrome of posttraumatic stress disorder in response to HIV diagnosis (PTSD-HIV). In over one-third of the PTSD cases, the disorder had an onset greater than 6 months after initial HIV infection diagnosis. PTSD-HIV was associated with other psychiatric diagnoses, particularly the development of first episodes of major depression after HIV infection diagnosis. PTSD-HIV was significantly associated with a pre-HIV history of PTSD from other causes, and other pre-HIV psychiatric disorders and neuroticism scores, indicating a similarity with findings in studies of PTSD from other causes. The findings from this preliminary study suggest that a PTSD response to HIV diagnosis has clinical validity and requires further investigation in this population and other medically ill groups. The results support the inclusion of the diagnosis of life-threatening illness as a traumatic incident that may lead to a posttraumatic stress disorder, which is consistent with the DSM-IV criteria.

The lived experience of post-traumatic stress disorder as described by motor vehicle accident victims in Jordan

Aim: To explore the lived experience of post-traumatic stress disorder (PTSD) as described by individuals who have been involved in a motor vehicle accident (MVA) in Jordan. Background: Motor vehicle accident (MVA) survivors who develop post-traumatic stress disorder (PTSD) have become an important health issue. The World Health Organisation (WHO) states that trauma resulting from MVAs is a phenomenon of increasing concern, with death from injuries projected to rise from 5.1 million in 1990 to 8.4 million in 2020 particularly in developing countries such as Jordan (WHO, 2002). The impact of trauma from MVAs inevitably compromises the victim’s quality of life (WHO, 2002; Blanchard & Hickling, 2007) resulting in psychological and emotional distress, occupational disability, family disintegration, and socio-economic difficulty (Jordan Ministry of Health, 2005). The development of PTSD as a result of an MVA is not limited to the individual, but also extends to the family, friends, and the health care team involved in the person's care and rehabilitation. Design: A descriptive phenomenological approach was used for this study. Method: This study was conducted in an orthopaedic unit in Amera Basma Hospital in Irbid Jordan. Fifteen (15) participants were voluntary recruited through the process of purposeful sampling. Data was collected by face-to-face in depth-interviews. Interviews were digitally recorded and transcribed verbatim. The process of analysis was undertaken using Colaizzi’s (1978) eight step approach with the addition of two extra steps. Findings: The process of analysis identified seven themes explicated from the participants’ transcripts of interview. The seven themes were: 1. Feeling frustrated at a diminishing health status 2. Struggling to maintain a sense of independence 3. Harbouring feelings of not being able to recover 4. Feeling discriminated against and marginalised by society 5. Feeling ignored and neglected by health care professionals 6. Feeling abandoned by family, and 7. Moving toward acceptance through having faith in Allah. Conclusion: The findings of this study have the potential to make a significant contribution to extant knowledge on the topic which can inform future nursing practice, education, policy development, and research initiatives in Jordan and internationally.

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)

BACKGROUND PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone. OBJECTIVES To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately. SEARCH STRATEGY Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned. SELECTION CRITERIA Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost. DATA COLLECTION AND ANALYSIS Two or three review authors independently selected trials, assessed their 'risk of bias' and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures. MAIN RESULTS Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported. AUTHORS' CONCLUSIONS There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

Post-Traumatic Stress Disorder (PTSD) and Its relationship with perinatal bereavement: definitions, reactions, adjustments, and grief.

A small percentage of women present with diagnosed PTSD post childbirth; however, though this an area of increasing research and clinical interest generally, little is known about PTSD in relation to perinatal bereavement. Health professionals must however be aware of the mechanisms and models of loss following perinatal bereavement in order to identify potential mental health phenomena which may be implicated in the development of PTSD symptomology. Understanding the predictive factors which may give early warning signs is an important component of the clinical evidence base. This chapter discusses mechanisms, models, and risk factors in relation to perinatal bereavement and the development of PTSD.